1
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Jackson ME, Galambas AK, Bauer JM. Intraoperative Neuromonitoring for Spines at Risk During Nonspine Surgery: A 9-Year Review. J Pediatr Orthop 2024; 44:e197-e202. [PMID: 37728105 DOI: 10.1097/bpo.0000000000002520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
BACKGROUND Patients with certain spinal anomalies are at risk for rare but devastating spinal cord injuries under anesthesia. We created a Spine at Risk (SAR) program to evaluate and recommend precautions for such patients, including intraoperative neuromonitoring (IONM) use for the highest-risk patients. We aimed to review all monitored nonspine procedures to determine rate of potential spinal cord injuries avoided in those who would otherwise have been unmonitored. METHODS We performed a retrospective review of our institutional SAR program from 2011 to 2019 to analyze the number of nonspine anesthetized procedures that were done under IONM, the characteristics of those that had an IONM alert; and the clinical outcomes. RESULTS Of the 3,453 patients flagged for SAR review, 1121 (33%) received a precaution recommendation, and 359 (10% of all flagged) were given IONM recommendations. Of those, 57 patients (16% of recommendations, 2% of all flagged) had a total of 102 nonspine anesthetized procedures done under IONM. Seven patients had a total of 10 cases with IONM alerts. Two cases were aborted when improved signals could not be obtained after working through a checklist; one of these patients woke with transient neurological deficits. Signals improved to baseline in 7 cases by working through a signal loss checklist. One case was aborted preoperatively when monitorable baseline signals could not be obtained. CONCLUSIONS In the highest-risk spinal anomaly patients, we monitored an average of 11.7 nonspine cases per year, with a 10% rate of IONM alerts, and no permanent neurological deficits. Although the majority of patients remain safe during procedures, in the most critical patients IONM allowed the team to identify and react to alerts that may have otherwise led to permanent neurological injury. This is the largest series of spinal cord-monitored nonspine pediatric cases. It is important for pediatric orthopedic surgeons to evaluate at-risk patients and recommend IONM where appropriate, to protect both patients and our procedural colleagues. LEVEL OF EVIDENCE Case series, level IV.
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Affiliation(s)
| | | | - Jennifer M Bauer
- Department of Orthopaedics and Sports Medicine, University of Washington
- Department of Orthopaedic Surgery, Seattle Children's Hospital, Seattle, WA
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2
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Salaün JP, Scholtes JL, Veyckemans F. Planning anesthesia of a child with a rare disease: useful tools. Anaesth Crit Care Pain Med 2023; 42:101284. [PMID: 37517687 DOI: 10.1016/j.accpm.2023.101284] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/12/2023] [Accepted: 07/19/2023] [Indexed: 08/01/2023]
Abstract
Up to 8,000 rare diseases are currently described in the scientific literature. The presence of a rare disease constitutes an additional challenge for the practitioner given its implications on the management of anesthesia. Moreover, it is not possible for an anesthesiologist to know them all especially as the sources of information are scattered. This narrative review aims at proposing pre-anesthetic evaluation clear tools to summarize the individual aspects of a known or suspected rare disease in a patient and to define an adapted anesthetic strategy. It also describes a decision-making process, called « the rare disease reflex », to guide the practitioner to quickly initiate diagnostic investigations in the presence of unusual perioperative clinical signs suggestive of an undiagnosed rare disease.
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Affiliation(s)
- Jean-Philippe Salaün
- Department of Anesthesiology and Critical Care Medicine, CHU Caen Normandie, Caen University Hospital, 14000 Caen, France; Normandie Univ, UNICAEN, INSERM, GIP Cyceron, Institut Blood and Brain @Caen-Normandie (BB@C), UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), Caen, France.
| | - Jean-Louis Scholtes
- Faculty of Medicine UCLouvain Medical School, Avenue Mounier 50, 1200 Brussels, Belgium
| | - Francis Veyckemans
- Faculty of Medicine UCLouvain Medical School, Avenue Mounier 50, 1200 Brussels, Belgium
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3
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Chan E, DeVile C, Ratnamma V. Osteogenesis imperfecta. BJA Educ 2023; 23:182-188. [PMID: 37124171 PMCID: PMC10140476 DOI: 10.1016/j.bjae.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 01/17/2023] [Indexed: 02/26/2023] Open
Affiliation(s)
- E. Chan
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - C. DeVile
- Great Ormond Street Hospital for Children, London, UK
| | - V.S. Ratnamma
- Great Ormond Street Hospital for Children, London, UK
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4
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Shafi K, Lovecchio F, Sava M, Steinhaus M, Samuel A, Carter E, Lebl D, Farmer J, Raggio C. Complications and Revisions After Spine Surgery in Patients With Skeletal Dysplasia: Have We Improved? Global Spine J 2023; 13:268-275. [PMID: 33596686 PMCID: PMC9972265 DOI: 10.1177/2192568221994786] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Retrospective case series. OBJECTIVE To report contemporary rates of complications and subsequent surgery after spinal surgery in patients with skeletal dysplasia. METHODS A case series of 25 consecutive patients who underwent spinal surgery between 2007 and 2017 were identified from a single institution's skeletal dysplasia registry. Patient demographics, medical history, surgical indication, complications, and subsequent surgeries (revisions, extension to adjacent levels, or for pathology at a non-contiguous level) were collected. Charlson comorbidity indices were calculated as a composite measure of overall health. RESULTS Achondroplasia was the most common skeletal dysplasia (76%) followed by spondyloepiphyseal dysplasia (20%); 1 patient had diastrophic dysplasia (4%). Average patient age was 53.2 ± 14.7 years and most patients were in excellent cardiovascular health (88% Charlson Comorbidity Index 0-4). Mean follow up after the index procedure was 57.4 ± 39.2 months (range). Indications for surgery were mostly for neurologic symptoms. The most commonly performed surgery was a multilevel thoracolumbar decompression without fusion (57%). Complications included durotomy (36%), neurologic complication (12%), and infection requiring irrigation and debridement (8%). Nine patients (36%) underwent a subsequent surgery. Three patients (12%) underwent a procedure at a non-contiguous anatomic zone, 3 (12%) underwent a revision of the previous surgery, and another 3 (12%) required extension of their previous decompression or fusion. CONCLUSIONS Surgical complication rates remain high after spine surgery in patients with skeletal dysplasia, likely attributable to inherent characteristics of the disease. Patients should be counseled on their risk for complication and subsequent surgery.
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Affiliation(s)
- Karim Shafi
- Hospital for Special Surgery, New York,
NY, USA
| | | | - Maria Sava
- Hospital for Special Surgery, New York,
NY, USA
| | | | | | - Erin Carter
- Hospital for Special Surgery, New York,
NY, USA
| | - Darren Lebl
- Hospital for Special Surgery, New York,
NY, USA
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5
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Tofts LJ, Armstrong JA, Broley S, Carroll T, Ireland PJ, Koo M, Langdon K, McGregor L, McKenzie F, Mehta D, Savarirayan R, Tate T, Wesley A, Zankl A, Jenner M, Eyles M, Pacey V. Australian guidelines for the management of children with achondroplasia. J Paediatr Child Health 2023; 59:229-241. [PMID: 36628540 PMCID: PMC10107108 DOI: 10.1111/jpc.16290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 10/14/2022] [Accepted: 10/23/2022] [Indexed: 01/12/2023]
Abstract
Achondroplasia is the most common form of skeletal dysplasia. In addition to altered growth, children and young people with achondroplasia may experience medical complications, develop and function differently to others and require psychosocial support. International, European and American consensus guidelines have been developed for the management of achondroplasia. The Australian focused guidelines presented here are designed to complement those existing guidelines. They aim to provide core care recommendations for families and clinicians, consolidate key resources for the management of children with achondroplasia, facilitate communication between specialist, local teams and families and support delivery of high-quality care regardless of setting and geographical location. The guidelines include a series of consensus statements, developed using a modified Delphi process. These statements are supported by the best available evidence assessed using the National Health and Medicine Research Council's criteria for Level of Evidence and their Grading of Recommendations Assessment, Development and Evaluation (GRADE). Additionally, age specific guides are presented that focus on the key domains of growth, medical, development, psychosocial and community. The guidelines are intended for use by health professionals and children and young people with achondroplasia and their families living in Australia.
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Affiliation(s)
- Louise J Tofts
- Department of Health Sciences, Macquarie University, Sydney, New South Wales, Australia.,Kids Rehab, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Jennifer A Armstrong
- Department of Health Sciences, Macquarie University, Sydney, New South Wales, Australia.,Department of Orthopaedics, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Stephanie Broley
- Genetic Services of Western Australia, King Edward Memorial Hospital, Perth, Western Australia, Australia.,Undiagnosed Diseases Program, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Theresa Carroll
- Queensland Paediatric Rehabilitation Service, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Penelope J Ireland
- Queensland Paediatric Rehabilitation Service, Queensland Children's Hospital, Brisbane, Queensland, Australia.,School of Health and Rehabilitation Sciences, University of Queensland, Brisbane, Queensland, Australia
| | - Minna Koo
- Kids Rehab, The Children's Hospital at Westmead, Sydney, New South Wales, Australia.,The Children's Hospital at Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Katherine Langdon
- Kids Rehab WA, Perth Children's Hospital, Perth, Western Australia, Australia.,Telethon Kids Institute, Perth, Western Australia, Australia
| | - Lesley McGregor
- Paediatric and Reproductive Genetics Unit, Women's and Children's Hospital, Adelaide, Australia
| | - Fiona McKenzie
- Genetic Services of Western Australia, King Edward Memorial Hospital, Perth, Western Australia, Australia.,School of Paediatrics and Child Health, University of Western Australia, Perth, Western Australia, Australia
| | - Divyesh Mehta
- Curtin University, Perth, Western Australia, Australia.,Child and Adolescent Health Services, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Ravi Savarirayan
- Skeletal Therapies, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,University of Melbourne, Melbourne, Victoria, Australia
| | - Tracy Tate
- Kids Rehab, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Alison Wesley
- Kids Rehab, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Andreas Zankl
- The Children's Hospital at Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia.,Department of Clinical Genetics, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Maree Jenner
- Medical Advisory Board, Short Statured People of Australia, Melbourne, Victoria, Australia
| | - Marta Eyles
- Medical Advisory Board, Short Statured People of Australia, Melbourne, Victoria, Australia
| | - Verity Pacey
- Department of Health Sciences, Macquarie University, Sydney, New South Wales, Australia.,The Children's Hospital at Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
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6
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Anaesthesia-Relevant Disease Manifestations and Perianaesthetic Complications in Patients with Mucolipidosis—A Retrospective Analysis of 44 Anaesthetic Cases in 12 Patients. J Clin Med 2022; 11:jcm11133650. [PMID: 35806935 PMCID: PMC9267794 DOI: 10.3390/jcm11133650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 06/17/2022] [Accepted: 06/17/2022] [Indexed: 02/04/2023] Open
Abstract
Mucolipidosis (ML) type II, intermediate, and III are lysosomal storage disorders with progressive multiorgan manifestations predisposing patients to a high risk of perioperative morbidity. The aims of the study were to systematically assess disease manifestations relevant to anaesthesia as well as anaesthesia-related complications. This retrospective study includes ML patients who underwent anaesthesia in two centres between 2008 and 2022. We reviewed patients’ demographics, medical history, disease manifestations, as well as procedure- and outcome-related data. A total of 12 patients (7 MLII, 2 ML intermediate, 3 MLIII) underwent 44 anaesthesia procedures (per patient: median 3, range 1–11). The median age was 3.3 years (range 0.1–19.1). At least one complication occurred in 27.3% of the anaesthesia procedures. The vast majority of complications (94%) occurred in children with MLII and ML intermediate. A predicted difficult airway was found in 100% and 80% of the MLII and ML intermediate patients, respectively. Accordingly, most complications (59%) occurred during the induction of anaesthesia. Altogether, respiratory complications were the most frequent (18%), followed by difficult airway management (14%). The risk for anaesthesia-related complications is alarmingly high in patients with ML, particularly in those with MLII and ML intermediate. Multidisciplinary risk–benefit analysis and thoughtful anaesthesia planning are crucial in these patients.
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7
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Galambas AK, Krengel WF, Parker CE, Kolenko AM, Browd SR, White KK, Bauer JM. The pediatric "Spine at Risk" program: 9-year review of a novel safety screening tool. Spine Deform 2022; 10:327-334. [PMID: 34705253 DOI: 10.1007/s43390-021-00430-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 10/16/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE We implemented an EMR-based "Spine at Risk" (SAR) alert program in 2011 to identify pediatric patients at risk for intraoperative spinal cord injury (SCI) and prompt an evaluation for peri-operative recommendations prior to anesthetic. SAR alerts were activated upon documentation of a qualifying ICD-9/10 diagnosis or manually entered by providers. We aimed to determine the frequency of recommended precautions for those auto-flagged by diagnosis versus by provider, the frequency of precautions, and whether the program prevented SCIs during non-spinal surgery. METHODS We performed a retrospective chart review of patients from 2011 to 19 with an SAR alert. We recorded how the chart was flagged, recommended precautions, and reviewed data for SCIs at our institution during non-spinal operations. RESULTS Of the 3453 patients with an SAR alert over the 9-year study period, 1963 were auto-flagged by diagnosis and 1490 by manual entry. Only 38.7% and 24.3% of the patients in these respective groups were assigned precaution recommendations, making the auto-flag 62.8% better than providers at identifying patients needing precautions. Cervical spine positioning precautions were needed most frequently (86.7% of diagnosis-flagged; 30.0% of provider-flagged), followed by intraoperative neuromonitoring (IONM) (25.2%; 6.1%), thoracolumbar positioning restrictions (16.1%; 7.9%), and fiberoptic intubation (13.9%; 5.7%). There were no SCIs in non-spinal procedures during the study. CONCLUSION EMR-based alerts requiring evaluation by a Neurosurgeon or Orthopaedic surgeon prior to anesthesia can prevent SCIs during non-spinal procedures. The majority of identified patients are not found to be at risk, and will not require special precautions. LEVEL OF EVIDENCE III.
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Affiliation(s)
| | - Walter F Krengel
- Department of Orthopaedics and Sports Medicine, Department of Orthopaedic Surgery, Seattle Children's Hospital, University of Washington, 4800 Sand Point Way NE, Seattle, WA, 98105, USA
| | - Cheryl E Parker
- Department of Orthopaedic Surgery, Seattle Children's Hospital, Seattle, WA, USA
| | - Ana Maria Kolenko
- Department of Orthopaedic Surgery, Seattle Children's Hospital, Seattle, WA, USA
| | - Samuel R Browd
- Department of Neurosurgery, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Klane K White
- Department of Orthopaedics and Sports Medicine, Department of Orthopaedic Surgery, Seattle Children's Hospital, University of Washington, 4800 Sand Point Way NE, Seattle, WA, 98105, USA
| | - Jennifer M Bauer
- Department of Orthopaedics and Sports Medicine, Department of Orthopaedic Surgery, Seattle Children's Hospital, University of Washington, 4800 Sand Point Way NE, Seattle, WA, 98105, USA.
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8
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Savarirayan R, Ireland P, Irving M, Thompson D, Alves I, Baratela WAR, Betts J, Bober MB, Boero S, Briddell J, Campbell J, Campeau PM, Carl-Innig P, Cheung MS, Cobourne M, Cormier-Daire V, Deladure-Molla M, Del Pino M, Elphick H, Fano V, Fauroux B, Gibbins J, Groves ML, Hagenäs L, Hannon T, Hoover-Fong J, Kaisermann M, Leiva-Gea A, Llerena J, Mackenzie W, Martin K, Mazzoleni F, McDonnell S, Meazzini MC, Milerad J, Mohnike K, Mortier GR, Offiah A, Ozono K, Phillips JA, Powell S, Prasad Y, Raggio C, Rosselli P, Rossiter J, Selicorni A, Sessa M, Theroux M, Thomas M, Trespedi L, Tunkel D, Wallis C, Wright M, Yasui N, Fredwall SO. International Consensus Statement on the diagnosis, multidisciplinary management and lifelong care of individuals with achondroplasia. Nat Rev Endocrinol 2022; 18:173-189. [PMID: 34837063 DOI: 10.1038/s41574-021-00595-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/29/2021] [Indexed: 12/31/2022]
Abstract
Achondroplasia, the most common skeletal dysplasia, is characterized by a variety of medical, functional and psychosocial challenges across the lifespan. The condition is caused by a common, recurring, gain-of-function mutation in FGFR3, the gene that encodes fibroblast growth factor receptor 3. This mutation leads to impaired endochondral ossification of the human skeleton. The clinical and radiographic hallmarks of achondroplasia make accurate diagnosis possible in most patients. However, marked variability exists in the clinical care pathways and protocols practised by clinicians who manage children and adults with this condition. A group of 55 international experts from 16 countries and 5 continents have developed consensus statements and recommendations that aim to capture the key challenges and optimal management of achondroplasia across each major life stage and sub-specialty area, using a modified Delphi process. The primary purpose of this first International Consensus Statement is to facilitate the improvement and standardization of care for children and adults with achondroplasia worldwide in order to optimize their clinical outcomes and quality of life.
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Affiliation(s)
- Ravi Savarirayan
- Murdoch Children's Research Institute, Royal Children's Hospital, University of Melbourne, Parkville, Victoria, Australia.
| | - Penny Ireland
- School of Health and Rehabilitation Sciences, University of Queensland, Brisbane, Queensland, Australia
| | - Melita Irving
- Evelina London Children's Hospital, Guys & St Thomas' NHS Foundation Trust, London, UK
| | - Dominic Thompson
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Inês Alves
- ANDO Portugal / ERN BOND, Évora, Portugal
| | | | - James Betts
- Centre for Nutrition, Exercise & Metabolism, Department for Health, University of Bath, Bath, UK
| | - Michael B Bober
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | | | - Jenna Briddell
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Jeffrey Campbell
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | | | | | - Moira S Cheung
- Evelina London Children's Hospital, Guys & St Thomas' NHS Foundation Trust, London, UK
| | - Martyn Cobourne
- Centre for Craniofacial and Regenerative Biology, King's College London, London, UK
| | | | | | | | | | - Virginia Fano
- Paediatric Hospital Garrahan, Buenos Aires, Argentina
| | | | - Jonathan Gibbins
- Evelina London Children's Hospital, Guys & St Thomas' NHS Foundation Trust, London, UK
| | - Mari L Groves
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Therese Hannon
- Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Julie Hoover-Fong
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Greenberg Center for Skeletal Dysplasias, Johns Hopkins University, Baltimore, MD, USA
| | | | | | - Juan Llerena
- National Institute Fernandes Figueira, Rio de Janeiro, Brazil
| | | | | | | | - Sharon McDonnell
- Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | | | - Klaus Mohnike
- Universitätskinderklinik, Otto-von-Guericke Universität, Magdeburg, Germany
| | - Geert R Mortier
- Antwerp University Hospital and University of Antwerp, Antwerp, Belgium
| | - Amaka Offiah
- Sheffield Children's Hospital, Sheffield, UK
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Keiichi Ozono
- Graduate School of Medicine, Osaka University, Osaka, Japan
| | | | - Steven Powell
- Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Yosha Prasad
- Evelina London Children's Hospital, Guys & St Thomas' NHS Foundation Trust, London, UK
| | | | - Pablo Rosselli
- Fundación Cardio infantil Facultad de Medicina, Bogota, Colombia
| | - Judith Rossiter
- University of Maryland St. Joseph Medical Center, Towson, MD, USA
| | | | | | - Mary Theroux
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Matthew Thomas
- Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | - David Tunkel
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Colin Wallis
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Michael Wright
- Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | - Svein Otto Fredwall
- TRS National Resource Centre for Rare Disorders, Sunnaas Rehabilitation Hospital, Nesodden, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
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9
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Groves ML, Kashanian A, Danielpour M, Stadler JA. Neurosurgical Evaluation and Management of Adults with Achondroplasia. Neurosurg Clin N Am 2021; 33:25-35. [PMID: 34801139 DOI: 10.1016/j.nec.2021.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Much of the current medical discussion for within centers for skeletal dysplasia and specifically patients with achondroplasia focuses on infancy and early childhood. Most neurosurgical concerns arise due to a defect in the endochondral ossification, resulting on early fusion of the synchondrosis. As patients age, the neurosurgical focus shifts from primarily cranial to spinal concerns. Often pediatric neurosurgeons may continue to follow their patients with skeletal dysplasia. However, general adult neurosurgeons and orthopedic surgeons may see these graduated adults in their practice. This article provides a review of the common neurosurgical concerns for patients with achondroplasia.
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Affiliation(s)
- Mari L Groves
- Division of Pediatric Neurosurgery, Johns Hopkins Hospital, 600 N Wolfe Street, Phipps 556, Baltimore, MD 21287, USA.
| | - Alon Kashanian
- Maxine Dunitz Neurosurgical Institute, Cedars-Sinai Medical Center, 127 South San Vicente Boulevard, 6th Floor #A6600, Los Angeles, CA 90048, USA. https://twitter.com/AlonKashanian
| | - Moise Danielpour
- Maxine Dunitz Neurosurgical Institute, Cedars-Sinai Medical Center, 127 South San Vicente Boulevard, 6th Floor #A6600, Los Angeles, CA 90048, USA. https://twitter.com/m_danielpour
| | - James A Stadler
- Department of Neurological Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI 53792, USA. https://twitter.com/stadler_md
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10
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Tunkel DE, Gough E, Bober MB, Hashmi SS, Hecht JT, Legare JM, Little ME, Modaff P, Pauli RM, Rodriguez-Buritica D, Serna ME, Smid CJ, Hoover-Fong JE. Otolaryngology Utilization in Patients With Achondroplasia: Results From the CLARITY Study. Laryngoscope 2021; 132:1548-1554. [PMID: 34708868 DOI: 10.1002/lary.29915] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 09/22/2021] [Accepted: 10/10/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVES/HYPOTHESIS To quantify otolaryngologic surgery utilization in patients with achondroplasia, and to identify any changes in utilization over the past four decades. STUDY DESIGN Retrospective cohort study. METHODS A retrospective cohort study of 1,374 patients with achondroplasia enrolled in the CLARITY retrospective cohort study at four centers of multi-specialty care for patients with achondroplasia. Otolaryngologic surgeries are presented by birth cohort decade. The main outcomes were number of primary and additional otolaryngologic procedures; age at surgery; likelihood of repeated surgery; temporal trends in surgical utilization. RESULTS In this cohort of 1,374 patients with achondroplasia, 620 (45.1%) had pharyngeal surgery at least once, 150 (10.9%) had pharyngeal surgery on more than one occasion, and patients who had adenoidectomy first were 2.68 times more likely to require a second pharyngeal surgery than those who had adenotonsillectomy. Seven hundred and seventy-nine (56.7%) had tympanostomy tubes placed at least once, and 447 (32.5%) had tympanostomy tubes placed more than one time. Age at first pharyngeal surgery decreased by 1.2 years per birth cohort decade, and age at tympanostomy tube placement decreased by 1.1 years per decade. CONCLUSIONS Patients with achondroplasia often require otolaryngologic surgery, particularly adenoidectomy and/or tonsillectomy as well as tympanostomy tube placement. Such surgery is performed now more frequently and at younger ages than in earlier decades. While otolaryngologic disease associated with achondroplasia is now recognized earlier and treated more frequently, long-term outcome studies are needed. LEVEL OF EVIDENCE 3 Laryngoscope, 2021.
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Affiliation(s)
- David E Tunkel
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, U.S.A
| | - Ethan Gough
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, U.S.A
| | - Michael B Bober
- Division of Medical Genetics, Nemours/AI duPont Hospital for Children, Wilmington, Delaware, U.S.A
| | - S Shahrukh Hashmi
- Department of Pediatrics, McGovern Medical School, University of Texas Health Science Center, Houston, Texas, U.S.A
| | - Jacqueline T Hecht
- Department of Pediatrics, McGovern Medical School, University of Texas Health Science Center, Houston, Texas, U.S.A
| | - Janet M Legare
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, U.S.A
| | - Mary Ellen Little
- Division of Medical Genetics, Nemours/AI duPont Hospital for Children, Wilmington, Delaware, U.S.A
| | - Peggy Modaff
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, U.S.A
| | - Richard M Pauli
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, U.S.A
| | - David Rodriguez-Buritica
- Department of Pediatrics, McGovern Medical School, University of Texas Health Science Center, Houston, Texas, U.S.A
| | - Maria Elena Serna
- Department of Pediatrics, McGovern Medical School, University of Texas Health Science Center, Houston, Texas, U.S.A
| | - Cory J Smid
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, U.S.A
| | - Julie E Hoover-Fong
- Greenberg Center for Skeletal Dysplasias, Department of Genetic Medicine, Johns Hopkins University, Baltimore, Maryland, U.S.A
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11
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Dikova M, Nikolova ST, Loukanov A. Preoperative Microbiological Screening in Pediatric Assessment of Skeletal Dysplasias Cases Before Planned Orthopedic Surgery. Open Access Maced J Med Sci 2021. [DOI: 10.3889/oamjms.2021.5851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
We report the preoperative microbiological screening of gram positive bacteria as a promising diagnostic approach for precise pediatric assessment of children with skeletal dysplasias who have undergone planned orthopedic surgery within a period of 10 years. The study was conducted on children with 29 different clinical diagnoses with preoperatively measured haemoglobin, platelets, blood glucose, serum glutamic-oxaloacetic transaminase, serum glutamic-pyruvic transaminase, serum creatinine, total protein, and fibrinogen. The performed preoperative microbiological screening involved the examination of nasal and throat secretions aiming to detect carrier and/or colonization of potentially pathogenic microflora in these upper respiratory tract niches. The documented statistical data demonstrated that 50.8 % of the cases had normal microflora, however the rest 49.2 % of the patients had potentially pathogenic bacteria. Among them, S. aureus was identified in 39.3% (as methicillin-susceptible or MSSA) and in 3.3% of the children (as methicillin-resistant or MRSA). The other predominant gram-positive bacteria were S. pneumoniae, S. pyogenes, M. catarrhalis, and C. albicans in 1.6, 0.8, 2.4 and 2.4 %, respectively. The infected patients have been at significantly higher risk for staph infections after surgical procedures than those with normal microflora. The presented microbiological screening proves the need for obligatory preoperative eradication of MRSA from nose niche, oral preoperative treatment of Streptococcus pyogenes and personalized preoperative antibacterial prophylaxis.
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Continuous Spinal Anaesthesia for Intertrochanteric Femur Fracture in a Patient with Skeletal Dysplasia. Case Rep Anesthesiol 2021; 2021:6644894. [PMID: 33953987 PMCID: PMC8057902 DOI: 10.1155/2021/6644894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 03/08/2021] [Accepted: 04/03/2021] [Indexed: 11/17/2022] Open
Abstract
The practice of continuous spinal anaesthesia is not common. Though underutilised, it offers significant advantage when compared to the single-shot technique nonetheless. Time and again, it has proven its worth in patients with advanced cardiac illness, spinal deformities, and obesity. We here successfully employed this neuraxial anaesthetic technique in a sixty-two-year-old male patient with skeletal dysplasia, who presented for surgical fixation of intertrochanteric fracture of the femur. With short stature, anticipated difficult airway, and poor pulmonary status complicating the anaesthetic plan, we opted for continuous spinal anaesthesia. The procedure was carried out uneventfully with 8 mg of hyperbaric bupivacaine used in titration to anaesthetic needs. Patients with skeletal dysplasia present with wide array of clinical conditions that pose a formidable challenge to anaesthesiologists. Continuous spinal anaesthesia can be safely practiced in such patients as it provides a titratable form of neuraxial blockade with reduced dose of local anaesthesia. This, in turn, ensures a predictable block and, thus, hemodynamic stability.
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13
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Sponer P, Korbel M, Kucera T. Total Knee Arthroplasty in Spondyloepiphyseal Dysplasia with Irreducible Congenital Dislocation of the Patella: Case Report and Literature Review. Ther Clin Risk Manag 2021; 17:275-283. [PMID: 33833516 PMCID: PMC8020459 DOI: 10.2147/tcrm.s294876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 02/17/2021] [Indexed: 11/23/2022] Open
Abstract
Background Spondyloepiphyseal dysplasia is the clinical term applied to a group of rare genetic disorders with primary involvement of the vertebrae and epiphyses, predisposing the afflicted individuals toward the premature development of osteoarthritis. There are few reports concerning joint replacement therapy in these patients, particularly describing the role of total hip arthroplasty. In this report, we describe the anatomical and technical aspects of spondyloepiphyseal dysplasia that must be considered during surgical planning and performance of total knee arthroplasty. Case Presentation A 49-year old woman with a history of spondyloepiphyseal dysplasia suffered from severe osteoarthritis of the knee and irreducible congenital dislocation of the patella. After careful preoperative evaluations and planning, the knee joint deformity was solved by knee joint replacement with realignment of the extensor mechanism using quadricepsplasty. After 2 years of surgery, the patient showed no pain and was able to walk with the help of elbow crutches. The Hospital for Special Surgery knee score increased from preoperative 51 points to 85 points during the final follow-up. The postoperative range of motion increased to final flexion of 0–115°. Conclusion The advances made so far in the medical care for patients with skeletal dysplasia have improved their overall survival during adulthood. The case report described herein demonstrates the numerous challenges and technical aspects of a successful total knee arthroplasty in cases of spondyloepiphyseal dysplasia, highlighting the need to consider skeletal and soft tissue abnormalities of skeletal dysplasia during the planning and performance of joint replacement surgery.
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Affiliation(s)
- Pavel Sponer
- Department of Orthopedic Surgery, Charles University, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Martin Korbel
- Department of Orthopedic Surgery, Charles University, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Tomas Kucera
- Department of Orthopedic Surgery, Charles University, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic
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Scott-Warren VL, Walker R. Perioperative management of patients with Mucolipidosis II and III: Lessons from a case series. Paediatr Anaesth 2021; 31:260-267. [PMID: 33247997 DOI: 10.1111/pan.14090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 11/14/2020] [Accepted: 11/20/2020] [Indexed: 01/22/2023]
Abstract
Mucolipidosis (ML) II and III are complex lysosomal storage disorders characterized by progressive multisystem pathology which can pose challenges to the anesthetist and increase the risks associated with general anesthesia. We sought to review the management of patients with ML II and III undergoing anesthesia in our institution in order to better define recommendations for the preoperative assessment and optimization of these children. We further elected to analyze the conduct of anesthesia, intraoperative management, and perioperative complications that our patients had experienced in order to allow improved informed consent and anesthetic planning. We performed a retrospective examination of the medical notes of those patients who had undergone anesthesia in our institution to identify their clinical features, anesthetic technique, airway management, and perioperative complications. Five children underwent 11 episodes of anesthesia. Fiber-optic or videolaryngoscopy was utilized in six out of seven intubations, with four out of seven requiring a change from the method initially chosen to enable intubation. Four of the five patients had an abnormal echocardiogram. Three patients had radiological evaluation of their cervical spine, with two demonstrating abnormalities. One patient had changes suggesting instability at the atlantoaxial junction. Children and babies with ML II and III present multisystem challenges to the anesthetist. Multidisciplinary planning and assessment, followed by a discussion of risk, should proceed any elective surgery. These complex children should undergo elective anesthesia delivered by an experienced (pediatric) anesthetist in an appropriate tertiary center with on-site pediatric ENT and critical care support.
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Affiliation(s)
- Victoria Louise Scott-Warren
- Department of Anaesthesia, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Rob Walker
- Department of Anaesthesia, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
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Savarirayan R, Tunkel DE, Sterni LM, Bober MB, Cho TJ, Goldberg MJ, Hoover-Fong J, Irving M, Kamps SE, Mackenzie WG, Raggio C, Spencer SA, Bompadre V, White KK. Best practice guidelines in managing the craniofacial aspects of skeletal dysplasia. Orphanet J Rare Dis 2021; 16:31. [PMID: 33446226 PMCID: PMC7809733 DOI: 10.1186/s13023-021-01678-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 01/05/2021] [Indexed: 02/08/2023] Open
Abstract
Background Recognition and appropriate management of the craniofacial manifestations of patients with skeletal dysplasia are challenging, due to the rarity of these conditions, and dearth of literature to support evidence-based clinical decision making. Methods Using the Delphi method, an international, multi-disciplinary group of individuals, with significant experience in the care of patients with skeletal dysplasia, convened to develop multi-disciplinary, best practice guidelines in the management of craniofacial aspects of these patients. Results After a comprehensive literature review, 23 initial statements were generated and critically discussed, with subsequent development of a list of 22 best practice guidelines after a second round voting. Conclusions The guidelines are presented and discussed to provide context and assistance for clinicians in their decision making in this important and challenging component of care for patients with skeletal dysplasia, in order standardize care and improve outcomes.
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Affiliation(s)
- Ravi Savarirayan
- Victorian Clinical Genetics Services, Murdoch Children's Research Institute, University of Melbourne, Parkville, VIC, 3052, Australia. .,Department of Radiology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA.
| | - David E Tunkel
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Laura M Sterni
- Eudowwod Division of Pediatric Respiratory Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael B Bober
- Division of Orthogenetics - Nemours/ A.I. duPont Hospital for Children, Wilmington, DE, USA
| | - Tae-Joon Cho
- Division of Pediatric Orthopaedics, Seoul National University Children's Hospital, Seoul, South Korea
| | - Michael J Goldberg
- Department of Orthopedics and Sports Medicine, Seattle Children's Hospital, Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA, USA
| | - Julie Hoover-Fong
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Melita Irving
- Department of Clinical Genetics Guy's, St Thomas NHS, London, UK
| | - Shawn E Kamps
- Department of Orthopedics and Sports Medicine, Seattle Children's Hospital, Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA, USA
| | - William G Mackenzie
- Department of Orthopedic Surgery - Nemours/ A.I. duPont Hospital for Children, Wilmington, DE, USA
| | - Cathleen Raggio
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Samantha A Spencer
- Department of Orthopedic Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Viviana Bompadre
- Department of Orthopedics and Sports Medicine, Seattle Children's Hospital, Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA, USA
| | - Klane K White
- Department of Orthopedics and Sports Medicine, Seattle Children's Hospital, Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA, USA
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Pargas C, Franzone JM, Rogers KJ, Artinian F, Santana A, Shah SA, McGreal CM, Kruse RW, Bober MB. Cervical kyphosis: A predominant feature of patients with osteogenesis imperfecta type 5. Bone Rep 2020; 13:100735. [PMID: 33304945 PMCID: PMC7718132 DOI: 10.1016/j.bonr.2020.100735] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 11/03/2020] [Accepted: 11/18/2020] [Indexed: 10/26/2022] Open
Abstract
Objectives Osteogenesis imperfecta (OI) is a heterogeneous group of genetic disorders of connective tissue that cause skeletal fragility and extra-skeletal manifestations. Classically, four different types of OI were distinguished. Type 5 OI was added due to its distinct clinical and radiographic features. In 2012, two independent groups identified a recurrent heterozygous c.-14C>T mutation in IFITM5 as the responsible genetic change for this type of OI. To our knowledge, cervical kyphosis has not been identified in the literature as a finding in type 5 OI patients. This is a retrospective review of a cohort of patients with type 5 OI and a description of associated cervical spine deformity. Methods After institutional review board approval, a retrospective review identified 13 patients with type 5 OI. Clinical, radiologic, and genetic data from 2002 to 2020 were reviewed. Results We identified 13 patients with clinical diagnosis of type 5 OI. Twelve had molecular confirmation and the classic IFITM5, c.14C>T gene mutation was identified. The remaining individual did not undergo genetic testing. Dentinogenesis imperfecta was observed in one patient, while blue sclerae or hearing loss were not present. All patients had at least one fracture and four underwent intramedullary rodding. Radiologic features included subphyseal metaphyseal radiodense line in 12/13 patients (92%), interosseous membrane calcification in seven of 13 patients (54%) (more commonly noted in the upper extremities), and hypertrophic callus in six of 13 patients (46%). Thoracolumbar spinal deformities were seen in six of 13 patients (46%) with two of these individuals requiring surgery. Cervical kyphosis was noted in nine of 13 individuals (69%) ranging in age from 3 months to 22 years. Anterior wedging of the cervical vertebral bodies was noted in the absence of any fractures. Six of nine individuals demonstrated listhesis of C2-C3 or C3-C4 segment. Magnetic resonance imaging studies were performed and reviewed in patients with cervical kyphosis and subluxation; three patients showed narrowing of spinal canal without cervical cord compression and one asymptomatic patient showed impingement of the spinal cord. Conclusions Cervical kyphosis appears to be a common feature of type 5 OI. It can be a presenting and apparently life-long association and does not appear to be caused by vertebral body fractures. Evaluation for cervical kyphosis should be performed in patients with a suspected or confirmed diagnosis of type 5 OI. Furthermore, if cervical kyphosis is noted in an individual with OI, type 5 OI should be considered.Level of evidence: IV.
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Affiliation(s)
- Carlos Pargas
- Department of Orthopaedic Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Jeanne M Franzone
- Department of Orthopaedic Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Kenneth J Rogers
- Department of Orthopaedic Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Frank Artinian
- Department of Orthopaedic Surgery, Akron Children's Hospital, Akron, OH, USA
| | - Adolfredo Santana
- Department of Orthopaedic Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Suken A Shah
- Department of Orthopaedic Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Cristina M McGreal
- Division of Orthogenetics, Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Richard W Kruse
- Department of Orthopaedic Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Michael B Bober
- Division of Orthogenetics, Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
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17
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Beethe AR, Bohannon NA, Ogun OA, Wallace MJ, Esposito PW, Lockhart TJ, Hamlin RJ, Williams JR, Goeller JK. Neuraxial and regional anesthesia in surgical patients with osteogenesis imperfecta: a narrative review of literature. Reg Anesth Pain Med 2020; 45:993-999. [DOI: 10.1136/rapm-2020-101576] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 08/11/2020] [Accepted: 08/15/2020] [Indexed: 01/03/2023]
Abstract
Background and objectivesRegional and neuraxial anesthesia techniques have become instrumental in the perioperative period yet have not been well described in patients with osteogenesis imperfecta (OI), a congenital connective tissue disorder characterized by skeletal dysplasia and fragility. Patients with skeletal dysplasia present unique perioperative challenges that warrant consideration of these techniques despite their relative contraindication in this population due to reports of increased bleeding with surgery, skeletal fragility concerns with positioning, and risk of spinal cord injury with continuous neuraxial catheters. The aim of this narrative review was to evaluate literature describing the use of regional and neuraxial techniques in patients with OI and any associated clinical outcomes.MethodsAll available literature from inception to July 2020 was retrieved, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, from MEDLINE, Embase, Google Scholar and The Cochrane Library. Three authors reviewed all references for eligibility, abstracted data, and appraised quality.ResultsOf 412 articles initially identified, 42 met our inclusion criteria, yielding 161 cases with regional and/or neuraxial techniques described. In 117 (72.6%) of the 161 cases, neuraxial technique was performed, including 76 (64.9%) epidural, 7 (5.9%) caudal, 5 (4.2%) combined spinal epidural, and 29 (24.7%) spinal procedures. In 44 (27.4%) of the 161 cases, the use of regional anesthesia was described. Our review was confounded by incomplete data reporting and small sample sizes, as most were case reports. There were no randomized controlled trials, and the two single-center retrospective data reviews lacked sufficient data to perform meta-analysis. While complications or negative outcomes related to these techniques were not reported in any of the cases, less than half specifically discuss outcomes beyond placement and immediate postoperative course.ConclusionsThere is insufficient evidence to validate or refute the potential risks associated with the use of regional and neuraxial techniques in patients with OI. This review did not uncover any reports of negative sequelae related to the use of these modalities to support relative contraindication in this population; however, further research is needed to adequately assess clinically relevant outcomes such as complications and opioid-sparing effect.
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18
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Raggio CL, Yonko EA, Khan SI, Carter EM, Citron KP, Bostrom MPG, Figgie MP. Joint Replacements in Individuals With Skeletal Dysplasias: One Institution's Experience and Response to Operative Complications. J Arthroplasty 2020; 35:1993-2001. [PMID: 32386881 DOI: 10.1016/j.arth.2020.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 02/14/2020] [Accepted: 04/03/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Skeletal dysplasias are a heterogeneous group of >400 genetic disorders characterized by abnormal bone growth. Many individuals experience joint pain and limitation, coming to require joint replacement much earlier than the average-statured population. In addition, prosthesis survival rate is less in the dysplastic population. The purpose of this study is to identify risk factors for surgery and provide recommendations to improve surgical outcomes. METHODS This a retrospective review of 29 individuals with a skeletal dysplasia who had 64 joint replacements between April 1985 and January 2019 at a single institution. We collected demographics, physical examination, medical history, imaging studies, surgical indication, and complications. RESULTS Spondyloepiphyseal dysplasia was the most common skeletal dysplasia (7), followed by pseudoachondroplasia (4) and multiple epiphyseal dysplasia (4). Average age of the cohort was 40.6 years (range 14-64). Hip arthroplasty (34) was the most commonly performed surgery. The majority of arthroplasties (75%) required custom components. Complication rate was 37.3%, most commonly pulmonary embolism (3) and pneumonia (3). Most complications (81.8%) occurred in individuals with either a pre-existing cardiopulmonary comorbidity or lumbar/sacral deformity. Body mass index did not correlate with complication severity (R = -0.042, P = .752) or rate (R = 0.006, P = .963). CONCLUSION Surgical complications are highest in patients with pre-existing cardiopulmonary conditions. Body mass index does not predict complications in this cohort. Preoperative evaluations for individuals with skeletal dysplasias should include comprehensive work-up of spine issues and extraskeletal systems that present an operative risk. Intraoperative protocol should include special consideration for placement on the table, airway maintenance, and spinal cord monitoring in select cases.
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Affiliation(s)
- Cathleen L Raggio
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Elizabeth A Yonko
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Sobiah I Khan
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Erin M Carter
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Kate P Citron
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Mathias P G Bostrom
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Mark P Figgie
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
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19
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White KK, Bober MB, Cho TJ, Goldberg MJ, Hoover-Fong J, Irving M, Kamps SE, Mackenzie WG, Raggio C, Spencer SA, Bompadre V, Savarirayan R. Best practice guidelines for management of spinal disorders in skeletal dysplasia. Orphanet J Rare Dis 2020; 15:161. [PMID: 32580780 PMCID: PMC7313125 DOI: 10.1186/s13023-020-01415-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Accepted: 05/20/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Disorders of the spine present a common and difficult management concern in patients with skeletal dysplasia. Due to the rarity of these conditions however, the literature, largely consisting of small, single institution case series, is sparse in regard to well-designed studies to support clinical decision making in these situations. METHODS Using the Delphi method, an international, multi-disciplinary group of individuals, with significant experience in the care of patients with skeletal dysplasia, convened to develop multi-disciplinary, "best practice" guidelines in the care of spinal disorders in patients with skeletal dysplasia. RESULTS Starting with 33 statements, the group a developed a list of 31 "best practice" guidelines. CONCLUSIONS The guidelines are presented and discussed to provide context for clinicians in their decision making in this often-challenging realm of care.
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Affiliation(s)
- Klane K White
- Department of Orthopedics and Sports Medicine, Seattle Children's Hospital, 4800 Sand Point Way, OA.9.120, Seattle, Washington, 98105, USA. .,Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA, USA.
| | - Michael B Bober
- Division of Orthogenetics, Nemours/ A.I. duPont Hospital for Children, Wilmington, DE, USA
| | - Tae-Joon Cho
- Division of Pediatric Orthopaedics, Seoul National University Children's Hospital, Seoul, South Korea
| | - Michael J Goldberg
- Department of Orthopedics and Sports Medicine, Seattle Children's Hospital, 4800 Sand Point Way, OA.9.120, Seattle, Washington, 98105, USA.,Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA, USA
| | - Julie Hoover-Fong
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Melita Irving
- Department of Clinical Genetics Guy's and St Thomas NHS, London, UK
| | - Shawn E Kamps
- Department of Radiology, Seattle Children's Hospital, Seattle, WA, USA.,Department of Radiology, University of Washington, Seattle, WA, USA
| | - William G Mackenzie
- Department of Orthopedic Surgery, Nemours/ A.I. duPont Hospital for Children, Wilmington, DE, USA
| | - Cathleen Raggio
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Samantha A Spencer
- Department of Orthopedic Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Viviana Bompadre
- Department of Orthopedics and Sports Medicine, Seattle Children's Hospital, 4800 Sand Point Way, OA.9.120, Seattle, Washington, 98105, USA
| | - Ravi Savarirayan
- Victorian Clinical Genetics Services, Murdoch Children's Research Institute, University of Melbourne, Parkville, Victoria, Australia
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Abstract
Achondroplasia is the most common short-stature skeletal dysplasia, additionally marked by rhizomelia, macrocephaly, midface hypoplasia, and normal cognition. Potential medical complications associated with achondroplasia include lower extremity long bone bowing, middle-ear dysfunction, obstructive sleep apnea, and, more rarely, cervicomedullary compression, hydrocephalus, thoracolumbar kyphosis, and central sleep apnea. This is the second revision to the original 1995 health supervision guidance from the American Academy of Pediatrics for caring for patients with achondroplasia. Although many of the previously published recommendations remain appropriate for contemporary medical care, this document highlights interval advancements in the clinical methods available to monitor for complications associated with achondroplasia. This document is intended to provide guidance for health care providers to help identify individual patients at high risk of developing serious sequelae and to enable intervention before complications develop.
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Affiliation(s)
- Julie Hoover-Fong
- Greenberg Center for Skeletal Dysplasias, McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland;
| | - Charles I Scott
- Nemours/Alfred I. duPont Hospital for Children and Sidney Kimmel Medical College, Thomas Jefferson University, Wilmington, Delaware; and
| | - Marilyn C Jones
- Department of Pediatrics, University of California, San Diego and Rady Children's Hospital, San Diego, California
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21
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Defining the clinical phenotype of Saul-Wilson syndrome. Genet Med 2020; 22:857-866. [PMID: 31949312 PMCID: PMC7205587 DOI: 10.1038/s41436-019-0737-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 12/16/2019] [Accepted: 12/17/2019] [Indexed: 11/29/2022] Open
Abstract
Purpose: Four patients with Saul-Wilson syndrome were reported between 1982 and 1994, but no additional individuals were described until 2018, when the molecular etiology of the disease was elucidated. Hence, the clinical phenotype of the disease remains poorly defined. We address this shortcoming by providing a detailed characterization of its phenotype. Methods: Retrospective chart reviews were performed and primary radiographs assessed for all 14 individuals. Four individuals underwent detailed ophthalmologic examination by the same physician. Two individuals underwent gynecologic evaluation. Z-scores for height, weight, head circumference and BMI were calculated at different ages. Results: All patients exhibited short stature, with sharp decline from the mean within the first months of life, and a final height Z-score between −4 and −8.5 standard deviations. The facial and radiographic features evolved over time. Intermittent neutropenia was frequently observed. Novel findings included elevation of liver transaminases, skeletal fragility, rod-cone dystrophy, and cystic macular changes. Conclusion: Saul-Wilson syndrome presents a remarkably uniform phenotype, and the comprehensive description of our cohort allows for improved understanding of the long-term morbidity of the condition, establishment of follow-up recommendations for affected individuals, and documentation of the natural history into adulthood for comparison with treated patients, when therapeutics become available.
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22
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Mamaril ME. Preoperative Risk Factors Associated With PACU Pediatric Respiratory Complications: An Integrative Review. J Perianesth Nurs 2020; 35:125-134. [PMID: 31911088 DOI: 10.1016/j.jopan.2019.09.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 09/19/2019] [Accepted: 09/21/2019] [Indexed: 12/01/2022]
Abstract
PURPOSE This article reviews state of the science of preoperative risk factors associated with postanesthesia care unit (PACU) pediatric respiratory complications. DESIGN An integrative review. METHODS A search of PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, Scopus, Cochrane, and Joanna Briggs Institute databases was performed. Thirty-one articles, published between 2006 and 2018, were appraised for quality and the level of evidence using the Johns Hopkins Nursing Evidence-Based Practice Model. FINDINGS These articles were grouped into the following categories: age, American Society of Anesthesiologists status, gender, airway comorbidities, syndromes, anomalies, pulmonary comorbidities, ethnicity, obesity, neurologic comorbidities, and cardiac comorbidities. CONCLUSIONS Evidence identified significant preoperative and anesthesia risk factors that are associated with PACU pediatric respiratory complications. This article reveals the importance for the perioperative team to identify, assess for, communicate, and develop a management plan for pediatric respiratory complications.
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Affiliation(s)
- Myrna E Mamaril
- Perioperative Services Department, The Johns Hopkins Hospital, Baltimore, MD.
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23
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Anaesthesia and orphan disease: Tracheal reconstruction in two children with Morquio disease. Eur J Anaesthesiol 2020; 37:132-137. [PMID: 31913934 DOI: 10.1097/eja.0000000000001109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Tyagi A, Dass C, Rao NT, Soni KD. Emergency anesthetic management of an achondroplastic elderly gravida with polytrauma. Int J Crit Illn Inj Sci 2019; 9:191-193. [PMID: 31879607 PMCID: PMC6927133 DOI: 10.4103/ijciis.ijciis_56_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 09/05/2019] [Accepted: 10/16/2019] [Indexed: 11/26/2022] Open
Abstract
A 42-year-old pregnant female, diagnosed with achondroplasia, presented to our trauma center with multiple injuries after being involved in a motor vehicle accident. During her hospitalization, she underwent multiple surgeries and required admission in the intensive care unit. We describe the emergency anesthetic management of this patient, highlighting the effects of skeletal dysplasia on airway, cardiorespiratory system, and ventilatory mechanics. These effects, when superimposed upon with physiological changes of pregnancy, can lead to an unanticipated ventilatory challenge as we describe in this report.
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Affiliation(s)
- Abhay Tyagi
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Christopher Dass
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Nageswara Tangirala Rao
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Kapil Dev Soni
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
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25
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Castelein RM, Hasler C, Helenius I, Ovadia D, Yazici M. Complex spine deformities in young patients with severe osteogenesis imperfecta: current concepts review. J Child Orthop 2019; 13:22-32. [PMID: 30838072 PMCID: PMC6376432 DOI: 10.1302/1863-2548.13.180185] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
The severity of osteogenesis imperfecta (OI), the associated reduced quality and quantity of collagen type I, the degree of bone fragility, ligamentous laxity, vertebral fractures and multilevel vertebral deformities all impair the mechanical integrity of the whole spinal architecture and relate to the high prevalence of progressive kyphoscoliotic deformities during growth. Bisphosphonate therapy may at best slow down curve progression but does not seem to lower the prevalence of deformities or the incidence of surgery. Brace treatment is problematic due to pre-existing chest wall deformities, stiffness of the curve and the brittleness of the ribs which limit transfer of corrective forces from the brace shell to the spine. Progressive curves entail loss of balance, chest deformities, pain and compromise of pulmonary function and eventually require surgical stabilization, usually around puberty. Severe vertebral deformities including deformed, small pedicles, highly brittle bones and chest deformities, short deformed trunks and associated issues like C-spine and cranial base abnormalities (basilar impressions, cervical kyphosis) as well as deformed lower and upper extremities are posing multiple peri- and intraoperative challenges. Hence, an early multidisciplinary approach (anaesthetist, pulmonologist, paediatric orthopaedic spine surgeon) is mandatory. This paper was written under the guidance of the Spine Study Group of the European Paediatric Orthopaedic Society. It highlights the most pertinent information given in the current literature and various practical aspects on surgical care of spine deformities in young OI patients based on the personal experience of the contributing authors.
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Affiliation(s)
- R. M. Castelein
- Department of Orthopaedic Surgery, University Medical Center Utrecht, The Netherlands
| | - C. Hasler
- Orthopaedic Department, Children’s Hospital, University of Basel, Switzerland, Correspondence should be sent to C. Hasler, Orthopaedic Department, Children’s Hospital, University of Basel, Spitalstrasse 33, 4056 Basel, Switzerland. E-mail:
| | - I. Helenius
- Department of Paediatric Orthopaedic Surgery, University of Turku and Turku University Hospital, Turku, Finland
| | - D. Ovadia
- Department of Paediatric Orthopaedic Surgery, Dana Dwek Children’s Hospital, Tel Aviv Sourasky Medical Center, Affilated to Tel Aviv University Sackler School of Medicine, Tel Aviv, Israel
| | - M. Yazici
- Hacettepe University, Faculty of Medicine, Dept of Orthopaedics Ankara, Turkey
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Savarirayan R, Bompadre V, Bober MB, Cho TJ, Goldberg MJ, Hoover-Fong J, Irving M, Kamps SE, Mackenzie WG, Raggio C, Spencer SS, White KK. Best practice guidelines regarding diagnosis and management of patients with type II collagen disorders. Genet Med 2019; 21:2070-2080. [PMID: 30696995 DOI: 10.1038/s41436-019-0446-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 01/16/2019] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Skeletal dysplasias comprise a heterogeneous group of inherited disorders of development, growth, and maintenance of the human skeleton. Because of their relative rarity and wide phenotypic variability, patients should be accurately identified, uniformly assessed, and managed by clinicians who are aware of their potential complications and possess the knowledge and resources to treat them effectively. This study presents expert guidelines developed to improve the diagnosis and management of patients with type II collagen skeletal disorders to optimize clinical outcomes. METHODS A panel of 11 multidisciplinary international experts in the field of skeletal dysplasia participated in a Delphi process, which comprised analysis of a thorough literature review with subsequent generation of 26 diagnosis and care recommendations, followed by two rounds of anonymous voting with an intervening face-to-face meeting. Those recommendations with more than 80% agreement were considered as consensual. RESULTS After the first voting round, consensus was reached to support 12 of 26 (46%) statements. After the panel discussion, the group reached consensus on 22 of 24 revised statements (92%). CONCLUSIONS Consensus-based, expert best practice guidelines developed as a standard of care to assist accurate diagnosis, minimize associated health risks, and improve clinical outcomes for patients with type II collagen skeletal dysplasias.
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Affiliation(s)
- Ravi Savarirayan
- Victorian Clinical Genetics Services, Murdoch Children's Research Institute, University of Melbourne, VIC, Parkville, Australia.
| | - Viviana Bompadre
- Department of Orthopedics and Sports Medicine, Seattle Children's Hospital, Seattle, WA, USA
| | - Michael B Bober
- Division of Genetics, Nemours A.I. duPont Hospital for Children, Wilmington, DE, USA
| | - Tae-Joon Cho
- Division of Pediatric Orthopaedics, Seoul National University Children's Hospital, Seoul, South Korea
| | - Michael J Goldberg
- Department of Orthopedics and Sports Medicine, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Julie Hoover-Fong
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Melita Irving
- Department of Clinical Genetics, Guy's and St Thomas NHS, London, UK
| | - Shawn E Kamps
- Department of Radiology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - William G Mackenzie
- Department of Orthopedic Surgery, Nemours A.I. duPont Hospital for Children, Wilmington, DE, USA
| | - Cathleen Raggio
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Samantha S Spencer
- Department of Orthopedic Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Klane K White
- Department of Orthopedics and Sports Medicine, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
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27
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Savarirayan R, Rossiter JP, Hoover-Fong JE, Irving M, Bompadre V, Goldberg MJ, Bober MB, Cho TJ, Kamps SE, Mackenzie WG, Raggio C, Spencer SS, White KK. Best practice guidelines regarding prenatal evaluation and delivery of patients with skeletal dysplasia. Am J Obstet Gynecol 2018; 219:545-562. [PMID: 30048634 DOI: 10.1016/j.ajog.2018.07.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 07/15/2018] [Accepted: 07/17/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Skeletal dysplasia comprises a heterogeneous and collectively common group of inherited disorders of development, growth, and maintenance of the human skeleton. There is potential for increased perinatal morbidity and mortality in pregnant women who themselves have skeletal dysplasia, and for affected fetuses where skeletal dysplasia is suspected in utero. OBJECTIVE We sought to establish guidelines for perinatal health care professionals who should be aware of these risks, to optimize maternal and child health pregnancy outcomes through best prenatal and delivery management practices. STUDY DESIGN A panel of 13 multidisciplinary international experts participated in a Delphi process, which comprised consideration of thorough literature review and a list of 54 possible care recommendations subject to 2 rounds of anonymous voting and a face-to-face meeting. Those recommendations with >80% agreement were considered as consensual. RESULTS During the first round, consensus was reached to support 30 out of the 54 statements. After the panel discussion, the group reached consensus on 40 statements. These statements include guidelines for the evaluation and treatment of pregnant women with skeletal dysplasia and for the unborn child with or suspected to have skeletal dysplasia. CONCLUSION Consensus-based best practice guidelines are provided as a minimum of standard care to minimize associated health risks, and improve clinical outcomes for patients with skeletal dysplasia.
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