Background: Anatomic variation in the relationship between the lumbar spine and sacrum was first described in the literature nearly a century ago and continues to play an important role in spine deformity, low back pain (LBP), and pelvic trauma. This review will focus on the clinical and surgical implications of abnormal lumbosacral anatomy in the context of sacroiliac joint (SIJ) disease, spine deformity, and pelvic trauma. Methods: A PubMed search using the keywords ''lumbosacral transitional vertebrae,'' ''LSTV,'' ''transitional lumbosacral vertebrae,'' ''TLSV,'' and ''sacral dysmorphism'' was performed. The articles presented here were evaluated by the authors. Clinical Significance: The prevalence of LSTV varies widely in the literature from 3.9-% to 35.6% in the spine literature, and sacral dysmorphism is described in upwards of 50% of the population in the trauma literature. The relationship between LSTV and LBP is well established. While there is no agreed-on etiology, the source of pain is multifactorial and may be related to abnormal biomechanics and alignment, disc degeneration, and arthritic changes. Surgical Implications: Understanding abnormal lumbosacral anatomy is crucial for preoperative planning of SIJ fusion, spine deformity, and pelvic trauma surgery. LSTV can alter spinopelvic parameters crucial in planning spine deformity correction. Traditional safe zones for sacroiliac screw placement do not apply in the first sacral segment in sacral dysmorphism and risk iatrogenic nerve injury. Conclusions: LSTV and sacral dysmorphism are common anatomic variants found in the general population. Abnormal lumbosacral anatomy plays a significant role in clinical evaluation of LBP and surgical planning in SIJ fusion, spine deformity, and pelvic trauma. Further studies evaluating the influence of abnormal lumbosacral anatomy on LBP and surgical technique would help guide treatment for these patients.

Introduction: The current COVID-19 disease pandemic has delayed nonurgent orthopaedic procedures to adequately care for those affected by the severe acute respiratory syndrome coronavirus 2, resulting in a backlog in orthopaedic surgical care. As the capacity for orthopaedic surgeries expands or contracts, allocation of limited resources in a manner that adequately reflects medical necessity and urgency is paramount. An orthopaedic surgery-specific prioritization schema with proven reliability is lacking. The primary aim of this study was to assess the reliability of a newly developed prioritization list used for the phased reinstatement of orthopaedic surgical procedures during the COVID-19 pandemic and afterward. The secondary aim was to report its implementation. Methods: A consensus-based, orthopaedic surgery-specific, tiered prioritization list reflecting various levels of urgency was created by a committee of orthopaedic surgeons covering all subspecialties and representing academic, multispecialty, and private community practices. Reliability was tested for 63 randomized cases representing all orthopaedic subspecialties. Four raters evaluated the cases independently at two separate time points, at least one week apart. Fleiss kappa was used to assess intrarater and interrater agreement. Implementation were assessed by surveying both surgeons and the surgery scheduling administrative personnel at each surgical facility within a large health system for any adoption issues. Results: Case distributions within tiers 1, 2, 3, and 4 were 35%, 14%, 27%, and 24%, respectively. Interrater agreement ranged from 0.63 (95% confidence interval [CI] 0.57 to 0.69) to 0.72 (95% CI 0.66 to 0.78) for the ratings. Intrarater reliability ranged from 0.62 to 1.0. The highest levels of agreement were in tiers 1, 4, and the subspecialties oncology and foot/ankle. The time from development to full scale adoption and implementation by all orthopaedic surgeons was rapid. Discussion: This tiered prioritization list for orthopaedic procedures is both adoptable and reliable during the phased reinstatement of procedures during the COVID-19 pandemic and afterward. Further refinements may enhance utility. Levels of Evidence: Reliability study: Level I (Evid Based Spine Care J 2014 October;5(2):166. doi: 10.1055/s-0034-1394106).

objective measure of parasol rib deformity from spine X-rays; 2) compare efficacy of rib-based instrumentation (RBI) versus spine-based instrumentation (SBI) to improve parasol rib deformity and pulmonary function. Methods: A retrospective review of 2 multicenter databases was conducted to identify patients with hypotonic neuromuscular scoliosis treated by growth-friendly RBI or SBI with greater than 1 year follow-up. Preoperative and final spine X-rays were assessed for parasol rib collapse, as well as measures of spine asymmetry (Cobb and kyphosis) and thoracic deformity (RVA at apex scoliosis, thoracic, and hemithoracic widths at T6 and T12, maximum thoracic width, and pelvic inlet width). Multivariable analysis was performed on combinations of these measurements to identify the best descriptor of parasol rib deformity. Using this measurement, the ability of RBI versus SBI to correct and/or prevent parasol rib deformity was then compared. Assisted ventilation rating (AVR) before surgery and at final follow-up was also compared between the 2 groups. Results: A total of 23 patients treated with RBI (average age, 6.7 years; average follow-up, 3.3 years) were compared with 22 patients treated with SBI (average age, 7.7 years; average follow-up, 2.9 years). The equation Parasol Score 5 (T6 width convex hemithorax / T6 width concave hemithorax) Â (T6 thoracic width / T12 thoracic width) was the most accurate descriptor rib collapse (area under the curve 5 0.927 with receiver operating characteristic analysis). The parasol score was correlated with AVR. It did not significantly change over time for patients treated with SBI but it had a tendency to worsen for patients treated with RBI. The AVR did not change significantly in either group from before surgery to final follow-up. Cobb angle and kyphosis angle were better corrected using SBI. Conclusions: In children with hypotonic neuromuscular scoliosis, parasol rib deformity, measured by Parasol Score 5 (T6 width convex hemithorax / T6 width concave hemithorax) Â (T6 thoracic width / T12 thoracic width), did not improve after treatment with RBI or SBI. The AVR did not change significantly in either group.Introduction: Early-onset scoliosis commonly results in decreased thoracic volume and can cause severely compromised cardiopulmonary function. Yet little research has evaluated the effect of early-onset scoliosis treatments on thoracic volume. Thoracic volume may be estimated using computed tomographic (CT) scans or surrogate measures such as T1eS1 height, but neither is optimal because of safety concerns from recurrent radiation exposure from CT scans and limited accuracy of surrogates. The authors have developed a novel methodology to obtain patient-specific thoracic volumes from conventional orthogonal radiographs using opensource 3-dimensional (3D) graphics and animation software (Blender 2.71). The software allows manipulation of rib and vertebral elements to fit radiographs in coronal and sagittal planes, creating 3D thorax models. A validation study has demonst...

Mean postoperative length of stay (LOS) was significantly longer for the control group (20.2 AE 11.2 hours) than the ketorolac group (13.5 AE 8.8 hours, P < .001). There was no difference in the 90-day complication rate between patients in the ketorolac group and the control group (P ¼ .905). Summary Points:There is a need for improved narcotic stewardship in orthopedic surgery. The complementary administration of ketorolac reduces postoperative pain and opioid use in children with displaced supracondylar humerus fractures. Ketorolac use reduces length of stay following CRPP for supracondylar humerus fractures and offers an opportunity for cost savings.