BACKGROUND: Postoperative pain management after lumbar spine surgery often involves modest to high doses of opioids, which can contribute to the risk of dependence. Epidural analgesia has emerged as a promising opioid-sp...BACKGROUND: Postoperative pain management after lumbar spine surgery often involves modest to high doses of opioids, which can contribute to the risk of dependence. Epidural analgesia has emerged as a promising opioid-sparing alternative, but its efficacy compared with conventional opioid-based intravenous patient-controlled analgesia (IV-PCA) in a randomized trial has not been established in these patients. QUESTIONS/PURPOSES: We asked whether an opioid-sparing protocol, compared with conventional opioid-based IV-PCA, (1) provides superior pain control, (2) reduces opioid consumption, and (3) lowers the frequency of opioid-related adverse events. METHODS: In this multicenter, randomized, double-blind, parallel-group trial, we enrolled 98 patients undergoing single-level lumbar fusion or decompression. Eligible participants were adults age 20 to 80 years diagnosed with lumbar spinal stenosis or spondylolisthesis. Exclusion criteria included history of prior lumbar surgery, coagulation disorders, or opioid dependence. Patients were randomized to either the epidural opioid-free IV-PCA group (intraoperative single-shot epidural ropivacaine injection with opioid-free IV-PCA; epidural group) or the conventional opioid-based IV-PCA group (fentanyl-based IV-PCA; control group). In the epidural opioid-free group, fentanyl was administered solely as a rescue analgesic for breakthrough pain. All patients and outcome assessors were blinded to group allocation. In the fusion arm, 25 patients were randomized to the epidural group and 25 to the control group; data from all randomized patients (n = 25 in each group) were fully analyzed. In the decompression arm, 24 were randomized to the epidural group and 24 to the control group; data from all randomized patients (n = 24 in each group) were fully analyzed. Three patients (one in the fusion arm and two in the decompression arm) discontinued the intervention because of severe postoperative nausea and vomiting but were included in the final analysis based on the intention-to-treat principle, preventing differential loss to follow-up bias. There were no important differences between treatment and control groups in terms of baseline demographic or clinical data in either study arm. The minimum clinically important difference (MCID) for the numeric rating scale (NRS) pain score was defined as 2 points. The sample size was calculated to detect a 15% reduction in NRS scores (0.9 points), ensuring sensitivity to differences smaller than the MCID of 2 points. Secondary outcomes included total fentanyl consumption, rescue analgesic demand, and opioid-related adverse events. RESULTS: There were no clinically important differences between the epidural and control groups in either the decompression or the fusion arms of the study in terms of NRS pain scores at any time point (the largest difference was seen at 24 hours in the fusion group, but it was not clinically important: mean ± SD 2.7 ± 1.5 versus 4.4 ± 1.5 points of 10 total, mean difference -1.8 points [95% confidence interval (CI) -2.6 to -0.9]; p = 0.04). However, despite no important differences in pain control, fentanyl consumption was lower in the epidural groups than the control groups of both the fusion arm (122 ± 140 versus 1467 ± 481 µg, mean difference -1345 µg [95% CI -1550 to -1140]; p < 0.001) and the decompression arm (41 ± 51 versus 1046 ± 451 µg, mean difference -1005 µg [95% CI -1196 to -813]; p < 0.001). In the fusion arm of the study, postoperative urinary retention was less common in the epidural group (4% [1 of 25] versus 32% [8 of 25], relative risk 0.13 [95% CI 0.02 to 0.93]; p = 0.02); there were no differences in complications between the epidural and control groups in the decompression arm of the study. CONCLUSION: A single epidural ropivacaine injection with opioid-free IV-PCA provided effective pain control, reduced opioid consumption, and decreased urinary retention risk after single-level lumbar spine surgery. This protocol is a viable and effective opioid-sparing strategy. LEVEL OF EVIDENCE: Level I, therapeutic study.
BACKGROUND: Simulator-based training addresses a pressing need to move surgical skill acquisition from the operating room to the laboratory, reducing patient risk associated with traditional trial-and-error training meth...BACKGROUND: Simulator-based training addresses a pressing need to move surgical skill acquisition from the operating room to the laboratory, reducing patient risk associated with traditional trial-and-error training methods. The Core Requisites of Orthopedic Wire Navigation Skills (CROWNS) curriculum employs a hybrid reality simulator to teach surgeons the foundational skill of placing a guidewire in bone via fluoroscopic imaging. Simulator-based training has already been shown to improve subsequent operating room performance, but objective benchmarks to assess skill proficiency are lacking. QUESTIONS/PURPOSES: The objective of this study was to measure and compare expert and novice performance on a simulated hip wire navigation task as a basis to define candidate proficiency training benchmarks. METHODS: This study was designed as an experimental assessment of a surgical simulation platform to differentiate between skill levels during a proctored examination. In all, 113 surgeons participated, including 68 orthopaedic residents (novices) and 45 experts (28 Orthopaedic Trauma Association fellows and 17 practicing orthopaedic surgeons). To achieve the primary objective of measuring and comparing expert and novice performance, all participants performed a simulated hip wire navigation task replicating guide wire placement for intertrochanteric fracture fixation. Experts completed three simulated patient scenarios: one represented a straightforward case with clear imaging and a typical femoral neck-shaft angle (∼ 135°), another required a steeper guidewire trajectory to match an increased neck-shaft angle, and another involved a slightly malreduced fracture with an imperfect lateral view, requiring greater judgment to determine appropriate wire placement. Novices completed only the straightforward case scenario. Performance metrics included tip-apex distance (TAD), fluoroscopic image count, time, decision errors, the angle of off-target adjustments, and the previously reported Image-based Decision Error Analysis (IDEA) composite score. The IDEA score is normalized, meaning that a participant's score reflects the number of SDs above or below the mean performance across a large resident cohort. Assuming a normal distribution of scores, 95% of participants would be expected to score between -2 and +2. Higher values indicate better performance generally associated with more surgical experience. The score combines three normalized components-TAD, angle error, and decision errors-where lower TAD and smaller or fewer errors yield a more positive score. Statistical analyses compared novice and expert cohorts to help inform proficiency benchmark recommendations. The expert cohort's simulator-based IDEA scores were then compared with prior intraoperative IDEA scores from residents. RESULTS: The expert cohort completed all three simulated patient scenarios with a mean ± SD time of 117 ± 60 seconds, using 17 ± 8 images, and achieving a TAD of 13 ± 5 mm. The expert cohort had 5 ± 4 decision errors, angle errors of 1.4° ± 1.8°, and an IDEA score of 0.65 ± 0.4. The novice cohort completed their single patient scenario with a time of 207 ± 88 seconds, using 22 ± 10 images, and achieving a TAD of 20 ± 7 mm. The novice cohort had 14 ± 7 decision errors, angle errors of 3.2° ± 3.0°, and an IDEA score of -0.21 ± 0.7. When comparing the performance of the expert and novice cohorts in the single shared case scenario, the expert cohort achieved a substantially higher IDEA score (0.62 ± 0.3 and -0.21 ± 0.7, respectively, mean difference 0.83 [95% confidence interval 0.58 to 1.07]; p < 0.001). Based on prior research linking simulator performance to actual surgical experience, the expert IDEA mean score of 0.65 was roughly comparable to a performance expected in novices after their first 11 completed wire navigation surgical cases. An IDEA score of 0.5 is proposed as a balanced proficiency benchmark, achieved by 75% of experts but only 13% of novices. CONCLUSION: The CROWNS simulator and IDEA composite score reliably distinguished expert from novice performance, underscoring the need for deliberate practice and targeted feedback to close the novice-expert gap. A benchmark IDEA score of 0.5 offers a rigorous yet attainable goal for residents, representing readiness for safe and efficient operating room participation. CLINICAL RELEVANCE: Objective, simulation-based proficiency standards-such as attaining an IDEA score of 0.5 for hip fracture pinning-can guide competency-based progression, ensuring that residents achieve the technical skill required for safe operating room performance. Future research should evaluate how such benchmarks translate to real-world outcomes and whether they can be optimized to further improve surgical training and patient safety.
BACKGROUND: In the United States, approximately 2.3 million people live with limb loss, of whom about 91% have undergone lower extremity amputation. Despite these numbers, relatively few studies have evaluated outcomes a...BACKGROUND: In the United States, approximately 2.3 million people live with limb loss, of whom about 91% have undergone lower extremity amputation. Despite these numbers, relatively few studies have evaluated outcomes after elective transtibial amputation. In particular, we do not know whether the outcomes after amputation for intractable neurogenic pain such as complex regional pain syndrome (CRPS) are comparable to outcomes after late amputations (6 weeks or more after limb salvage) performed for other reasons such as recurrent infection, soft tissue problems, recalcitrant nonunion, poor function, and chronic nonneurogenic pain. QUESTIONS/PURPOSES: (1) Did patients who underwent late amputation for CRPS or neuropathic pain have inferior Patient-Reported Outcomes Measurement Information System (PROMIS) scores at follow-up compared with patients who had nonneurogenic elective amputation? (2) Did patients who underwent late amputation for CRPS or neuropathic pain have more pain, use more pain medication, or wear prosthetics less often than patients who have undergone nonneurogenic elective amputation? (3) Were patients who underwent late amputation for CRPS or neuropathic pain more likely to be revised to a higher level of amputation or express decision regret than patients undergoing nonneurogenic elective amputation? METHODS: This retrospective comparative study examined 70% (50 of 71) of patients who underwent elective (that is, scheduled, nonurgent) transtibial amputation between July 2006 and September 2019 at least 6 weeks after lower extremity trauma (median [range] 2 years [6 weeks to 15 years]). Most patients were men (94% [47 of 50]) and active duty service members who sustained combat-related trauma (74% [37 of 50]). Patients with CRPS (defined using the Budapest criteria diagnostic guidelines, which requires ongoing disproportionate pain plus signs in four categories: sensory, vasomotor, sudomotor/edema, and motor/trophic changes, n = 10) and other forms of neuropathic pain (n = 10) were compared with a control group of patients who had nonneurogenic elective amputation (n = 30). Demographic characteristics among cohorts were not different given the numbers available. The median (range) follow-up was 9 years (3 to 16) after amputation. The primary outcome was the PROMIS pain interference score. Secondary outcomes included other PROMIS metrics, VAS pain, and patient-reported medication and prosthetic use as well as revision to a higher level of amputation and decision regret. RESULTS: With the numbers available, we found no difference in PROMIS pain interference scores for patients with transtibial amputations performed for neurogenic pain compared with other causes of late amputation (median [range] 57 [45 to 64] versus 56 [39 to 72]; p = 0.81). There were likewise no differences with the numbers available in PROMIS physical function, mobility, life satisfaction, and severity of substance use. Amputations performed for neurogenic pain resulted in more pain reduction than late amputations for other causes (median ΔVAS -5 [-9 to -1] versus median Δ VAS -3 [-8 to 7]; p = 0.02). Both groups reported a reduction in opioid use (100% reduction in median frequency of opioid administrations for both groups; p < 0.001). Prosthetic use was not different with the numbers available among all cohorts. No patients in the CRPS plus neuropathic pain cohort were revised to a higher level of amputation compared with 2 patients in the nonneurogenic elective amputation cohort. No patients expressed definitive decision regret. CONCLUSION: Patients undergoing elective transtibial amputations for intractable neurogenic pain experienced clinically meaningful improvement in pain. Our findings support the use of transtibial amputation for treatment-resistant neurogenic pain, and they provide reasonable, but generally favorable, expectations for patients considering this irreversible procedure that are generally comparable to outcomes from patients undergoing late amputations for other indications. LEVEL OF EVIDENCE: Level III, therapeutic study.
BACKGROUND: Although patients with THA may increase their use of hip flexion to compensate for loss of spinal motion after lumbar fusion, no studies have directly examined this relationship. Furthermore, the association...BACKGROUND: Although patients with THA may increase their use of hip flexion to compensate for loss of spinal motion after lumbar fusion, no studies have directly examined this relationship. Furthermore, the association between the number of fused levels on postoperative compensatory hip motion is not clear, making it difficult to anticipate these changes prior to lumbar fusion. QUESTIONS/PURPOSES: (1) Is lumbar fusion after THA associated with resting spinopelvic alignment or compensatory changes at the hip? (2) Is the number of fused spinal segments associated with an increase in hip compensatory motion? (3) Can this increase in hip compensatory motion be anticipated prior to lumbar spine fusion? METHODS: Between January 2017 and December 2023, we retrospectively identified 109 patients with lumbar fusion after THA. The minimum follow-up time after lumbar fusion was set at 6 months to account for implant stabilization and early dislocation events. Of these patients, 59% (64) were excluded because of incomplete questionnaires (17% [19 of 109]), neuromuscular disease (3% [3 of 109]), unavailable or obscured functional lateral radiographs before and/or after lumbar fusion (36% [39 of 109]), or lumbar fusion performed within 6 months after THA (3% [3 of 109]), leaving 41% (45 of 109) of patients for analysis. Among the included patients, 82% (37 of 45) were female, with a mean ± SD age of 74 ± 8 years. Functional lateral radiographs were obtained in three postures (free-standing, relaxed-seated, and flexed-seated) before and after lumbar fusion surgery. From these radiographs, spinopelvic alignment parameters were measured, including pelvic incidence, L1-S1 lumbar lordosis, sacral slope, pelvic tilt, pelvic-femoral angle (PFA), and pelvic incidence minus lumbar lordosis (PI-LL). The hip angle was defined as the PFA value calibrated for pelvic incidence. Lumbar, pelvic, and hip motion were assessed based on the degree of change between each posture. Multivariable regression analysis was performed to examine the association between the number of fused levels and the change in PFA in the flexed-seated position before and after lumbar fusion. RESULTS: After lumbar fusion, mean ± SD Oswestry Disability Index (ODI) total scores were lower (44% ± 18% versus 22% ± 16%, mean difference -21% [95% confidence interval (CI) -29% to -14%]; p < 0.001). Median (range) ODI item Q1 (back pain) scores were also lower (3 [0 to 5] versus 1 [0 to 3], median difference -2 points [95% CI -3 to -2]; p < 0.001). In the standing position, L1-S1 lumbar lordosis was larger (29° ± 22° versus 34° ± 14°, mean difference 6° [95% CI 1° to 10°]; p = 0.01) and PI-LL was smaller (19° [-13° to 76°] versus 11° [-12° to 76°], median difference -4° [95% CI -9° to 0°]; p = 0.02), while other standing parameters were no different. In the flexed-seated position, L1-S1 lumbar lordosis, PFA, and hip angle were larger after lumbar fusion (L1-S1 lumbar lordosis: -8° ± 14° versus 8° ± 14°, mean difference 16° [95% CI 11° to 22°]; p < 0.001; PFA: 83° ± 17° versus 97° ± 16°, mean difference 14° [95% CI 10° to 17°]; p < 0.001; hip angle: 93° [51° to 127°] versus 106° [87° to 132°], mean difference 13° [95% CI 10° to 16°]; p < 0.001), indicating greater compensatory hip flexion. The number of fused levels was associated with the magnitude of increase in PFA in the flexed-seated position after lumbar fusion (standardized β = 0.39 [95% CI 0.15 to 0.62]; p = 0.002) after accounting for age, BMI, and preoperative hip angle in the flexed-seated position. Using the multivariable model, the anticipated magnitude of postoperative increase in PFA in the flexed-seated position could be described based on the number of fused levels and the preoperative hip angle in the flexed-seated position (R 2 = 0.43; p < 0.001). The following regression equation was described to anticipate the increase in compensatory motion after lumbar fusion: ΔPFA flexed-seated = (-0.39 × preoperative flexed-seated hip angle) + (2.44 × number of fused levels) + 44.7. CONCLUSION: Our findings suggest that obtaining flexed-seated radiographs preoperatively in patients with prior THA who are scheduled to undergo lumbar fusion may be helpful. This information may assist spine surgeons in communicating the potential risk of postoperative dislocation with patients and hip surgeons and support shared decision-making before lumbar fusion. Future studies using three-dimensional imaging or motion-capture techniques will be necessary to determine how loss of lumbar motion is associated with multiplanar hip motion and dislocation risk during functional activities, particularly when considering acetabular and femoral component placement. LEVEL OF EVIDENCE: Level III, therapeutic study.