Introduction

In November 2017, the Center for Medicare and Medicaid Services (CMS) finalized the 2018 Medicare Outpatient Prospective Payment System rule that removed total knee arthroplasty (TKA) procedures from the Medicare inpatient-only (IPO) list of procedures. This action had significant and unexpected consequences.

For several years, CMS has utilized a rule called the “Two-Midnight Rule” to define outpatient status for all procedures not on the IPO list. CMS made TKA subject to the “Two-Midnight Rule” in conjunction with the decision to move TKA off the IPO list. According to the “Two-Midnight Rule,” a hospital admission should be expected to span at least two midnights in order to be covered as an inpatient procedure. If it can be reliably expected that the patient will not require at least two midnights in the hospital, the “Two-Midnight Rule” suggests that the patient is considered an outpatient and is therefore subject to outpatient payment policies. Under prior guidance related to the “Two-Midnight Rule;” however, CMS also states that Medicare may treat some admissions spanning less than two midnights as inpatient procedures if the patient record contains documentation of medical need. The final rule was clear in stating CMS's expectation was that the great majority of TKAs would continue to be provided in an inpatient setting.

To evaluate the efficacy of VEPTR in preventing further progression of scoliosis without impeding spinal growth in the treatment of children with progressive early onset scoliosis (EOS) without rib abnormalities.

Prospective, multi-center, observational cohort study on patients with EOS treated with VEPTR with 2-year follow up. Data were analysed based on measurements done pre-implant, immediate post-op and at 2-yr f/u.

Sixty-three patients met inclusion: 35 males and 28 females. Mean age at time of implantation was 6.1±2.4 yrs. Etiologies included congenital (n=6), neuromuscular (n=36), syndromic (n=4), and idiopathic (n=17). Mean follow up was 2.2±0.4 yrs. Scoliosis (72o±18o) decreased after implant surgery (47o±17o) followed by slight increase at 2-yr f/u (57o±18o), p<0.0001.

At 2-yr f/u, VEPTR was effective in treating EOS without rib abnormalities with 86% of patients having an improvement in scoliosis and 94% of patients having an increased spinal height as compared to pre-operatively. VEPTR provided greater than 100% of expected age-matched spine growth and the instrumented spinal segment continued to grow during distraction phase. This large prospective, multicentre study demonstrated the ability of VEPTER to effectively treat EOS without rib abnormalities. Goals of preventing further scoliosis progression and of maintaining normal spine growth were achieved.

Introduction

Spinopelvic parameters describe the orientation, shape, and morphology of the spine and pelvis. In children without spinal deformity, these parameters change during the first 10 years of life; however, spinopelvic parameters need to be defined in children with significant early-onset scoliosis (EOS). The purpose of this study is to examine the effects of EOS on sagittal spinopelvic alignment. We hypothesise that sagittal spinopelvic parameters for patients with EOS will differ from age-matched children without spinal deformity. These values will act as a baseline for future studies and may predict postoperative complications such as proximal junctional kyphosis and implant failure in children being treated with growing systems.

Introduction

Many methods are available for distal anchoring of spine-based and rib-based growing rod systems for early-onset scoliosis. One of these methods, pelvic S-hooks, was initially recommended for patients with spina bifida or for those with severe thoracolumbar curves. No study has yet analysed the clinical and radiographic effects of S-hooks on patients with rib-based instrumentation. The purpose of this study is to retrospectively review the results of S-hook pelvic fixation in patients with rib-based instrumentation

Aims: The choice of the treatment of tibial plateau fractures remains a controversial topic in current traumatology practice. The best treatment must have three fundamental requirements: to be less invasive as possible, to result in a good reduction, to have a good stability.

Surgical approach with percutaneous indirect articular reduction by elevating,minimal osteosynthesis and the use of NORIAN Skeletal Repair System lets us reach three fundamental objectives stated before.

NORIAN S.R.S, used to fill the bone gap resulting from the traumatic collapse of the metaphyseal bone, with its mechanical strength allows the stabilization of the joint fragments, the reduction and the relative ostheosyntesis, thus greatly shortening the functional recovery time.

Methods: We reviewed 70 patients affected by tibial plateau fractures, treated with this percutaneous technique using the mineral bone substitute 56 fractures were uni-condylar, 21 type 41-B2 and 35 type 41-B3 (according to AO/OTA classificaction); 14 fractures were bicondylar (AO/OTA 41-C3).

The minimum follow-up was 1 year. We used for clinical evaluation the Hohl assessment form, for the radiographs the criteria of Rasmussen.

X-rays.

Results: The final conclusions, resulting from integrated analysis of the clinical data and X-ray data, can be simplified and represented as follows: 52 cases could be considered excellent-good (74%), 14 fair (20%), and 4 poor (6%).

Conclusions: We can claim that the recostruction of the tibial plateau by minimal invasive surgery such as the percutaneous indirect reduction by elevating minimal osteosyintesis and mechanical stability assured by NORIAN SRS, is a good improvement in order to cut-down the functional recovery time.

Mobilization is allowed the day after surgery and weight-bearing within the first week in B2 e B3 fracture type and within four weeks in C3 type reducing to the minimum knee posthraumatic stiffness.

The choice of the treatment of tibial plateau fractures remains a controversial topic in current traumatology practice. The best treatment must have three fundamental requirements: to be less invasive as possible, to result in a good reduction, to have a good stability.

Surgical approach with percutaneous indirect articular reduction by elevating,minimal osteosynthesis and the use of NORIAN Skeletal Repair System lets us reach three fundamental objectives stated before.

NORIAN S.R.S, used to fill the bone gap resulting from the traumatic collapse of the metaphyseal bone, with its mechanical strength allows the stabilization of the joint fragments, the reduction and the relative ostheosyntesis, thus greatly shortening the functional recovery time.

We reviewed 70 patients affected by tibial plateau fractures, treated with this percutaneous technique using the mineral bone substitute Norian:

56 fractures were unicondylar, 21 type 41-B2 and 35 type 41-B3 (according to AO/OTA classificaction); 14 fractures were bicondylar (AO/OTA 41-C3).

The minimum follow-up was 1 year. We used for clinical evaluation the Hohl assessment form, for the radiographs the criteria of Rasmussen. X-rays. The final conclusions, resulting from integrated analysis of the clinical data and X-ray data, can be simplified and represented as follows: 52 cases could be considered excellent-good (74%), 14 fair (20%), and 4 poor (6%).

We can claim that the recostruction of the tibial plateau by minimal invasive surgery such as the percutaneous indirect reduction by elevating minimal osteosyintesis and mechanical stability assured by NORIAN SRS, is a good improvement in order to cutdown the functional recovery time. Mobilization is allowed the day after surgery and weight-bearing within the first week in B2 e B3 fracture type and within four weeks in C3 type reducing to the minimum knee posthraumatic stiffness.

Introduction: While bracing may improve the natural history of patients with adolescent idiopathic scoliosis with moderate curves, little attention has been paid to the potential impact of brace treatment on their quality of life. We hypothesized that bracing has a negative affect on the physical and psychosocial health of affected adolescents.

Methods: Quality of life (QOL) data was collected from patients with adolescent idiopathic scoliosis and a spinal curvature greater than 10 degrees at our institution. The Child Health Questionnaire (CHQ) and the American Academy of Orthopaedic Surgeons Pediatric Outcomes Data Collection Instrument (PODCI) were administered to parents to measure their children’s QOL. Multivariate analyses were conducted to determine the effect of gender and treatment on QOL.

Results: Our cohort consisted of 214 patients, who were mostly female, with an average curve of 28 degrees and an average age of 13.7 years. One hundred thirty four patients were observed (average curve 25 degrees), while 80 patients were treated with bracing (average curve 34 degrees). There were no significant differences in QOL between these two treatment groups, using the Bonfer-roni multiple comparison test. There were no gender-related differences in QOL. Among 15 children with pre- and intra-bracing data, there were no significant differences in QOL between these two time points.

Discussion and conclusion: Our patients who were treated with spinal bracing did not seem to have significantly different health-related QOL, as compared with patients in the observation group. These findings are contrary to our initial hypotheses and merit further study.

Introduction: The surgical correction of idiopathic scoliosis is a technically complex procedure that requires significant surgical expertise and highly specialized support. The current study examines practice patterns for the surgical treatment of scoliosis over a 5-year period in the State of California, with particular attention to the effect of payer status on surgical outcomes. Given the significant disparity in reimbursement for scoliosis surgery between patients with different payment sources (i.e. Medicaid versus private insurance), the potential exists for different management of disease and patient outcomes.

Methods: Using the California Office of Statewide Health Planning and Development (OSHPD) hospital discharge database, data for all surgical discharges between 1993 and 1997 for children ages 10–18 years old with a primary diagnosis of idiopathic scoliosis were reviewed. 1614 children were discharged from 99 hospitals over this period, and form the basis for this report. Outcomes of interest included length of stay (LOS), readmission, death, and need for surgical reoperation. Results: The mean age at admission of patients was 13.97 years (SD=1.89). The mean LOS was 7.38 days (SD=5.63) and mean readmission rate was 4.5%. Death (n=2) and reoperation (n=4) were extremely uncommon, making it impossible to use these as primary endpoints. Patients insured by Medi-Cal did not have significantly higher readmission rates, but did have a significantly longer length of hospital stay than patients with other payment sources (p< 0.001) and had a greater proportion of cases of extreme severity (p< 0.05), according to DRG severity code. Patients insured by Medi-Cal also incurred significantly higher hospital charges than patients with other sources of payment (p< 0.001).

Discussion and conclusions: The current study highlights the significant disparity in reimbursement rates for scoliosis surgery for patient insured by Medicaid versus private insurance in California. While this study does not address the issue of “unmet need” among the underinsured segment of the population, review of administrative data suggests that patients with Medicaid are more likely to have a higher severity of illness when presenting for surgery, and perhaps as a result, a longer length of stay. Future investigations will seek to reanalyze this dataset in patients with neurogenic scoliosis, where higher mortality and morbidity may allow for a more sensitive analysis of predictors of outcome.

Introduction: The goal of surgical equalization of leg length discrepancy (LLD) is to improve the quality of life (QOL) of affected individuals by improving function and appearance. While many surgeons utilize a cut off point of 2cm as a treatment guide, little attention has been focused on the effect of LLD on QOL. The purpose is to determine the critical cut off size for the effect of LLD on QOL. Such information may help refine the surgical indications of leg length equalization in these patients.

Methods: QOL and scanogram data were collected from children diagnosed with LLD at our institution. QOL was assessed using the parent short-form of the Child Health Questionnaire (CHQ). QOL scores from this group were compared to normative data. Correlation analyses and independent t-tests were conducted to assess the relationship between size of LLD and QOL.

Results: Our cohort consists of 41 patients (50 observations) with an average LLD of 2.05cm. Compared to norms, LLD patients scored significantly lower on four CHQ domains. Correlation analyses revealed a negative relationship between size of LLD and several psychosocial domains. Independent t-test revealed that children with LLD greater than or equal to 2cm scored significantly (p< 0.05) higher in six domains than children with LLD> 2cm: General Health, Parental Impact-Emotional Scale, Parental Impact-Time Scale, Family Activities, Family Cohesion, Psychosocial Summary Score.

Discussion and conclusion: With increasing LLD, differences in psychosocial health become especially apparent. This study suggests that children with LLD> 2 cm experience perturbations in QOL, supporting the use of this cut off as a guideline for intervention.