Derek Moore, MD

Orthopedic Spine Surgeon & Founder of @Orthobullets

[Derek Moore, MD @Derekwmooremd]

@orthobullets @ratnayakemd @drmikeselby @TheSpineSurgeon @DrNTheodore @DrFehlings @dominick_tuason @CraigLouer @nishantspine @antoniowebbmd @dougbeall Such a great case with so many ways to approach. The interesting thing is the auto-fusion at L5-S1.

I am curious, would people get scoliosis films to measure sagittal parameters?

[Derek Moore, MD @Derekwmooremd]

I wanted to see how good the AI is reading xrays. I uploaded this Xray and gave this prompt: What is the Anderson Orthopaedic Research Institute (AORI) Classification?

What do people think of the response.

Femur: AORI Type 1 – metaphyseal bone stock globally preserved, intact cortical rims, no large cavitary or segmental defects; long cemented stem not clearly bridging a major metaphyseal void.

Tibia: AORI Type 2A – proximal metaphyseal bone loss predominantly on one side with thinning/osteolysis, but overall cortical rim preserved and remaining metaphyseal bone capable of supporting a stemmed component.

Overall: AORI femur 1 / tibia 2A, based on AP view only; final classification subject to confirmation with lateral and intra-operative findings.

#orthotwitter, Would you agree with this assessment?

[Derek Moore, MD @Derekwmooremd]

@itius @orthobullets @Nemours @traumaticum @anklefootmd @FootAndAnkleMD @Vishal21975 @Drlyndonmason @DrAJ26001405 @DrFraneNicholas @clareau @ChrisWi19030624 @southNJscoli "External rotation stress test showing stability of the syndesmosis (no significant widening of the medial clear space or the distal tib/fib joint, when compared to contralateral)"

[Derek Moore, MD @Derekwmooremd]

Unfortunately we made a copy/paste mistake on a key image when posting today. . Where we talked about a CT scan of cervical spine, it was meant to say:

"External rotation stress test showing stability of the syndesmosis (no significant widening of the medial clear space or the distal tib/fib joint, when compared to contralateral)"

Here is the corrected image. Important for this case.

[Derek Moore, MD @Derekwmooremd]

@jointdocShields @orthobullets @HMethodistMD @BennerKneeMD @MrSimonTalbot @txsportsdoc @centerofhip @huddleston_md @generalorthomd @KevinParkMD @bonesmith_ @drgsreddy lol - ya lets talk infection prevention. if this patient had a prior intra-articular steroid injection, how long would you wait prior to proceeding with a TKA?

[Derek Moore, MD @Derekwmooremd]

@BennerKneeMD @orthobullets @DanielLiechtiMD @emplifyttown @RachelFrankMD @Lafi_KhalilMD @DrBryanSaltzman @txsportsdoc @schulte_ss @DrDerekOchiai @MDMillerMDUVA @BenMayoMD @H2O_SportsMD Rodney, why have you stuck with the inside out repairs and not use the all inside devices?

[Derek Moore, MD @Derekwmooremd]

@MDMillerMDUVA @orthobullets @DanielLiechtiMD @emplifyttown @RachelFrankMD @Lafi_KhalilMD @DrBryanSaltzman @txsportsdoc @schulte_ss @DrDerekOchiai @BenMayoMD @H2O_SportsMD @BennerKneeMD it sounds like you continue to do inside out repairs? Did you ever adopt the all inside repair gadgets?

Also, when you do an inside-out repair, are you making safety incision?

[Derek Moore, MD @Derekwmooremd]

@MDMillerMDUVA @orthobullets @DanielLiechtiMD @emplifyttown @RachelFrankMD @Lafi_KhalilMD @DrBryanSaltzman @txsportsdoc @schulte_ss @DrDerekOchiai @BenMayoMD @H2O_SportsMD @BennerKneeMD Mark, thanks for the great comment. When you say early operative repair, how early do you mean? Considering the knee is locked in flexion, and you already have an MRI, would you take him to surgery urgently the same day or is within a few days OK?

[Derek Moore, MD @Derekwmooremd]

Does anybody know any other good studies looking at femoral neck fractures in patients on anticoagulants - to delay or not to delay? Upcoming journal club.

https://t.co/4MMd8Citcf

[Derek Moore, MD @Derekwmooremd]

@orthobullets @PEvansMDPhD @CleveClinicFL @Grant_Garrigues @MDiPaolaMD @londonarmdoc @dave_cloke @DrRobHartzler @CowlingSurgeon @NickGarbis @DrNickColyvas @surg4shoulders @Shoulder2LeanOn Here is the only article on distal biceps ruptures that was included in ABOS WLA.

They found "Distal biceps repair is associated with a 7.5% major complication rate and 4.5% reoperation rate."

Is this consistent with everyone's experience?

https://t.co/YarJ7m4LGI

[Derek Moore, MD @Derekwmooremd]

I agree, the end goal is “patient care”excellence. But in my opinion, the most important way to optimize good patient care is to create a happy, content career. To do that, you need to learn smart, not hard. A medical student spending the night in the hospital is low educational value. Instead they should be at home and get “called in” if a unique educational opportunity presents itself.

[Derek Moore, MD @Derekwmooremd]

@AleksiReito

As you can see, this patient had an excellent result. I don't know how long it will last, and there could be a lot of other variables as to why there was a delta improvement from pre-op to post-op.

Question for you: when applying the literature, how do you accommodate the outliers, the individual patient factors, and the fact that there are always 1 in 10,000 that have an "outlier" outcome?

As a spine surgeon, I have the sad situation of often being the first to diagnose metastatic cancer with lesions to the spine. For these patients, I would never say the literature says there is no hope and you are going to die.

I say there are always exceptions; there are clear examples of "miracle cancer survivors." While you have to be realistic for family planning reasons, you also have to "believe" that there is a chance that you will be the "one miracle survivor."

Clinical studies apply "averages" to individuals. Patient care needs to be tailored to the individual. I am not saying don't follow the evidence and literature, I am just saying that following it alone is not the whole solution for being a good "healer".

[Derek Moore, MD @Derekwmooremd]

That is my point. It sounds like you are a strong scientist with experience in research and publishing. So it is easy for you to filter out what can be trusted and what can not be. For guys like me, without a strong background in statistics, it isn't very easy to know what to trust.

Couple that with the fact that the journal and the scientific publication industry are essentially a "pay for self-promotion and marketing yourself and your hospital" enterprise; the vast majority of published material is low quality and not to be trusted.

[Derek Moore, MD @Derekwmooremd]

@KevinParkMD are you at a point where you think steroid injections for the presumed diagnosis of trochanteric bursitis should be avoided until after an MRI is done and confirms that there is not an underlying abductor tendon tear and that the pathology is in the trochanteric bursa?

[Derek Moore, MD @Derekwmooremd]

@KevinParkMD @orthotraumamd @orthobullets @StephenJIncavo @HMethodistMD @drsebheaven @ChrisGraysonMD1 @tdd340 @jointdocShields @yoon_rs @schulte_ss @DrFraneNicholas @stevemchale @itius @shaunpat1 @KevinParkMD

How often have you gone back in months later to repair a abductor tear in a hip fx s/p CMN?

[Derek Moore, MD @Derekwmooremd]

@AleksiReito @orthobullets @StephenJIncavo @HMethodistMD @drsebheaven @ChrisGraysonMD1 @tdd340 @jointdocShields @yoon_rs @schulte_ss @DrFraneNicholas @stevemchale @itius @KevinParkMD I think the real question is - what is the liklihood they heal?

Do we need a RoHI index score for hip abductor tears?

https://t.co/LbuZ1ErX6Y

[Derek Moore, MD @Derekwmooremd]

@orthobullets @atmghn A.T, how are you tackling these in Switzerland these days? Navigation? Expandable cages?

[Derek Moore, MD @Derekwmooremd]

@orthobullets @AliBaajMD @BannerHealth @atmghn @AmitJainSpine @KhoiThanMD @drericksonspine @SpineNeuro @thejuansuribe @MichaelYangMD @geofreyngetich @JohnHShinMD @AliBaajMD, what are you doing in the intervertebral space? Anything special to prepare the endplates like microfracture holes? BMP? DBM? Local bone from the pars resection if you did one?

[Derek Moore, MD @Derekwmooremd]

@orthobullets @AliBaajMD @drmikeselby

What are the key questions you ask DS patients to understand how the neurogenic claudication is impacting their lives?

How many epidural injections do you do before you call it quits and proceed with surgery?

[Derek Moore, MD @Derekwmooremd]

This is a great basic teaching case. In terms of doing the operation, there are many different options, and the discussion falls under the bucket of “there are many ways to skin the cat."

I think the more important discussion is when to offer surgery versus continuing with nonoperative management. As somebody who’s had one hip replaced already, and what I've learned from the arthroplasty literature, the treatment of degenerate spondylolisthesis and neurogenic claudication should really be focused on improving walking enjoyment and duration.

The key questions to ask his patient are things like:

Do you no longer play golf like you used to because of pain in your buttocks?

Have you stopped walking with friends due to pain in your buttocks that makes you want to sit down?

Do you enjoy shopping or is it an unpleasant experience because you always want to sit down?