Stuart L. Weinstein

Every aspect of our professional lives as orthopaedic surgeons, regardless of practice model, is affected by the policies and laws passed by the US Congress and implemented by the federal regulatory agencies. Similar dynamics play out at the state level for many other issues that affect orthopaedic practices. The United States spends 18% of our gross domestic product on health care, 2 to 3 times as much as the other developed countries in the world, with less-than-ideal outcomes for health metrics. Recognizing the challenges faced by the US healthcare system is fundamental to understanding the importance of advocacy in shaping the conversation on Capitol Hill. All healthcare advocacy is based on preserving the doctor-patient relationship, ensuring access to appropriate care, and improving the quality of that care. Advocating on behalf our patients is part of our physicians' contract with society. Physicians are the secondary beneficiary of effective patient advocacy. Understanding how practicing orthopaedic surgeons can have a positive effect on the decisions that are made at the federal and state level is of critical importance in the increasingly complex healthcare dynamic that affects our patient's lives and our profession.

Background: The severity of hip dysplasia is characterized by radiographic measurements that require user definition of the acetabular sourcil edge, a bony landmark for which the corresponding three-dimensional (3D) anatomy is not well defined in any imaging plane. Questions/purposes: To use digitally reconstructed radiographs to determine: (1) What 3D anatomy is contributing to the “acetabular sourcil” location used to make lateral center-edge angle (LCEA) and anterior center-edge angle (ACEA) measurements in standing AP and false-profile radiographic views, respectively? (2) How do intraobserver and interobserver agreement in LCEA and ACEA translate into agreement of the 3D anatomy being evaluated? (3) How distinct are regions around the acetabular rim circumference that are evaluated by LCEA and ACEA measurements on radiographs? Methods: Between January 2018 and May 2019, 72 patients were indicated for periacetabular osteotomy to treat hip dysplasia or acetabular retroversion at our institution. From these patients, a series of 10 patients were identified of the first 12 patients in 2018 who were treated with periacetabular osteotomy, excluding two with missing or low-quality clinical imaging. A second series of 10 patients was identified of the first 11 patients in 2019 who were treated with periacetabular osteotomy and concurrent hip arthroscopy, excluding one who was missing clinical imaging. Pelvis and femoral bone surface models were generated from CT scans of these two series of 10 patients. There were 15 female and five male patients, with a median patient age of 18 years (IQR 17 to 23 years), a preoperative LCEA of 22° (IQR 18° to 24°), and a preoperative ACEA of 23° (IQR 18° to 27°). Exclusion criteria included missing preoperative CT or standard clinical radiographic imaging or severe joint incongruity. To address our first study question, digitally reconstructed radiographs matching each patient’s standing AP and false-profile clinical radiographs were created from the segmented CT volumes. A board-certified orthopaedic surgeon and three trained researchers measured LCEA and ACEA on the digitally reconstructed radiographs, and the selected sourcil points were projected back into coordinates in the 3D anatomic space. To address our second study question, intraobserver and interobserver agreement in radiographic coverage angles were related to variations in 3D coordinates of the selected bony anatomy. Lastly, to address our third study question, 3D locations around the acetabular rim identified as contributing to the lateral and anterior sourcil points were summarized across patients in a clockface coordinate system, and statistical analysis of the “time” separating the 3D acetabular contributions of the sourcil edges was performed. Results: The 3D anatomy contributing to the lateral sourcil was a variable length (27 mm [IQR 15 to 34 mm]) span of the laterosuperior acetabular edges, with contributions by the anterior inferior iliac spine in 35% (7 of 20) of hips. The anterior sourcil reflected a 28-mm (IQR 25 to 31 mm) span of bone from the medial ilium (posterior-medial to the anterior-inferior iliac spine and anterior-lateral to the arcuate line) to the anterior and lateral edges of the acetabulum. Interobserver variability was good for LCEA (intraclass correlation coefficient [ICC] 0.82 to 0.83) and moderate to good for ACEA (ICC 0.73 to 0.79), whereas the agreement in identified 3D sourcil locations varied widely (ICC 0.32 to 0.95). The acetabular edge of the 3D anatomy contributing to the anterior sourcil overlapped the circumferential range of the acetabular rim contributing to the lateral sourcil. Conclusion: Projection of two-dimensional radiographic landmarks contributing to the diagnosis of structural hip deformity into 3D allowed for the identification of the overlapping bony anatomy contributing to radiographically visible anterior and lateral sourcil edges. Clinical Relevance: This work leveraging digitally reconstructed radiographs and 3D pelvis anatomy has found that bone outside the joint contributes to the radiographic appearance of the sourcil and may variably confound estimates of joint coverage. Furthermore, the substantial overlap between the acetabular bone contributing to measurement of the LCEA and ACEA would indicate that these angles measure similar acetabular deformity, and that additional measures are needed to assess anterior coverage independent of lateral coverage.

Background: Severe adolescent idiopathic scoliosis (AIS) can be treated with instrumented fusion, but the number of anchors needed for optimal correction is controversial. Methods: We conducted a multicenter, randomized study that included patients undergoing spinal fusion for single thoracic curves between 45° and 65°, the most common form of operatively treated AIS. Of the 211 patients randomized, 108 were assigned to a high-density screw pattern and 103, to a low-density screw pattern. Surgeons were instructed to use ≥1.8 implants per spinal level fused for patients in the high-implant-density group or ≤1.4 implants per spinal level fused for patients in the low-implant-density group. The primary outcome measure was the percent correction of the coronal curve at the 2-year follow-up. The power analysis for this trial required 174 patients to show equivalence, defined as a 95% confidence interval (CI) within a ±10% correction margin with a probability of 90%. Results: In the intention-to-treat analysis, the mean percent correction of the coronal curve was equivalent between the high-density and low-density groups at the 2-year follow-up (67.6% versus 65.7%; difference, −1.9% [95% CI: −6.1%, 2.2%]). In the per-protocol cohorts, the mean percent correction of the coronal curve was also equivalent between the 2 groups at the 2-year follow-up (65.0% versus 66.1%; difference, 1.1% [95% CI: −3.0%, 5.2%]). A total of 6 patients in the low-density group and 5 patients in the high-density group required reoperation (p = 1.0). Conclusions: In the setting of spinal fusion for primary thoracic AIS curves between 45° and 65°, the percent coronal curve correction obtained with use of a low-implant-density construct and that obtained with use of a high-implant-density construct were equivalent. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

With Americans living longer, many physicians and surgeons have extended their medical and surgical practice life beyond the traditional 65-year-old retirement age. As retirement is inevitable, planning for that eventuality, which in early practice years appears unnecessary, is in fact an exercise which will pay dividends at the time of retirement. Two senior orthopaedic surgeons provide insight on the 2 main issues concerning retirement: how to prepare for retirement while in active practice, and factors to consider as to the timing of that major life event.

An abstract is unavailable. This article is available as a PDF only.

An abstract is unavailable. This article is available as a PDF only.