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Folson AA, Agyapong KO, Dey D, Eghan P, Quaye B. Marfan syndrome in a Ghanaian male: The diagnostic challenges. Clin Case Rep 2024; 12:e8494. [PMID: 38380377 PMCID: PMC10876919 DOI: 10.1002/ccr3.8494] [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: 10/28/2023] [Revised: 01/15/2024] [Accepted: 01/19/2024] [Indexed: 02/22/2024] Open
Abstract
Marfan syndrome (MFS) is an autosomal dominantly inherited condition that has varying phenotypic expressions. This case report describes one such African patient, from Ghana, who had typical clinical and imaging traits of MFS but was first diagnosed incidentally at the age of 23 years. In this report, we explore the challenges of early diagnosis in this population.
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Affiliation(s)
- Aba A. Folson
- Department of Internal Medicine and Therapeutics, School of MedicineUniversity of Health and Allied SciencesHoGhana
| | | | - Dzifa Dey
- Department of Medicine and TherapeuticsUniversity of Ghana Medical School, College of Health Sciences, University of GhanaAccraGhana
| | - Philip Eghan
- Department of RadiologyUniversity of Ghana Medical CentreAccraGhana
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Kumarasamy S, Sawarkar DP, Singh PK, Kumar R, Chandra PS, Kale SS. Cervical kyphosis correction in Marfan syndrome: our experience and literature review. Childs Nerv Syst 2024; 40:495-502. [PMID: 37391518 DOI: 10.1007/s00381-023-06046-4] [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: 06/02/2023] [Accepted: 06/19/2023] [Indexed: 07/02/2023]
Abstract
BACKGROUND Spinal deformities are common in Marfan syndrome (MFS). They usually involve the thoraco-lumbar spine but rarely involves the cervical spine. Kyphosis is the common spine deformity of the cervical spine and mandates surgical correction as they are at risk of neurological deterioration since they are refractory to conservative management. Few studies of surgical correction of spine deformity included cervical deformity. OBJECTIVES To analyze the challenges faced during surgery, clinical and radiological outcome, and complications following surgical correction for cervical kyphosis in Marfan syndrome. METHODS We identified that 5 patients with a diagnosis of MFS with cervical kyphosis who underwent fusion surgery between the years 2010 and 2022 were reviewed, retrospectively. We analyzed the demographic details, radiological parameters, operative variables (blood loss and nuances), perioperative complications, length of stay, clinical and radiological outcome, and complications following fusion surgery for cervical kyphosis in MFS. RESULTS The mean age of patients was 16.6 ± 4.72 years (range, 12-23 years). The average kyphotic vertebra involved is 3 ± 0.7 bodies (range 2-4) with 2 patients with thoracic deformity. All patients underwent surgical deformity correction. All patients improved clinically with Nurick grade (pre vs. post: 3.4 vs. 2.2) and mJOA (pre vs. post: 8.2 vs. 12.6). There was significant deformity correction from 37.48° to 9.1°. Mean blood loss encountered was 900 ± 173.2 ml. Perioperative complications: wound complication with CSF leak (1). Late complications: ventilator dependence (1) and junctional kyphosis (1). Mean length of hospital stay was 103 ± 178.9 days. All patients were doing symptomatically better after mean follow-up of 58 ± 28.32 months. One patient is bedridden and hospitalized. CONCLUSION Cervical kyphosis is a rare spine deformity in patients with MFS, and they usually present with neurological deterioration mandating surgical correction. Multidisciplinary approach (pediatrics, genetics and cardiology) is required for systematic evaluation of these patients. They should be evaluated with necessary imaging to rule out associated spinal deformity (atlanto-axial subluxation, scoliosis, and intraspinal pathology like ductal ectasia). Our results suggest better surgical outcome in terms of low operative complications with neurologic improvement in MFS patients. These patients require regular follow-up to identify late complications (instrument failure, non-union, and pseudarthrosis).
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Affiliation(s)
- Sivaraman Kumarasamy
- Department of Neurosurgery, Neurosciences Center, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Dattaraj P Sawarkar
- Department of Neurosurgery, Neurosciences Center, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Pankaj Kumar Singh
- Department of Neurosurgery, Neurosciences Center, All India Institute of Medical Sciences, New Delhi, 110029, India.
| | - Rajinder Kumar
- Department of Neurosurgery, Neurosciences Center, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Poodipedi Sarat Chandra
- Department of Neurosurgery, Neurosciences Center, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Shashank Sharad Kale
- Department of Neurosurgery, Neurosciences Center, All India Institute of Medical Sciences, New Delhi, 110029, India
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He XY, Chen HX, Zhao ZR. Efficacy and safety of different anti-osteoporotic drugs for the spinal fusion surgery: A network meta-analysis. World J Clin Cases 2023; 11:7350-7362. [PMID: 37969460 PMCID: PMC10643061 DOI: 10.12998/wjcc.v11.i30.7350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 09/10/2023] [Accepted: 09/28/2023] [Indexed: 10/25/2023] Open
Abstract
BACKGROUND Administering anti-osteoporotic agents to patients perioperatively is a widely accepted approach for improving bone fusion rates and reducing the risk of complications. The best anti-osteoporotic agents for spinal fusion surgery remain unclear. AIM To investigate the efficacy and safety of different anti-osteoporotic agents in spinal fusion surgery via network meta-analysis. METHODS Searches were conducted in four electronic databases (PubMed, EMBASE, Web of Science, the Cochrane Library and China National Knowledge Infrastructure (CNKI) from inception to November 2022. Any studies that compared anti-osteoporotic agents vs placebo for spinal fusion surgery were included in this network meta-analysis. Outcomes included fusion rate, Oswestry disability index (ODI), and adverse events. Network meta-analysis was performed by R software with the gemtc package. RESULTS In total, 13 randomized controlled trials were included in this network meta-analysis. Only teriparatide (OR 3.2, 95%CI: 1.4 to 7.8) was more effective than placebo in increasing the fusion rate. The surface under the cumulative ranking curve (SUCRA) of teriparatide combined with denosumab was the highest (SUCRA, 90.9%), followed by teriparatide (SUCRA, 74.0%), zoledronic acid (SUCRA, 43.7%), alendronate (SUCRA, 41.1%) and risedronate (SUCRA, 35.0%). Teriparatide (MD -15, 95%CI: -28 to -2.7) and teriparatide combined with denosumab (MD -20, 95%CI: -40 to -0.43) were more effective than placebo in decreasing the ODI. The SUCRA of teriparatide combined with denosumab was highest (SUCRA, 90.8%), followed by teriparatide (SUCRA, 74.5%), alendronate (SURCA, 52.7), risedronate (SURCA, 52.1%), zoledronic acid (SURCA, 24.2%) and placebo (SURCA, 5.6%) for ODI. The adverse events were not different between groups. CONCLUSION This network meta-analysis suggests that teriparatide combined with denosumab and teriparatide alone significantly increase the fusion rate and decrease the ODI without increasing adverse events. Based on current evidence, teriparatide combined with denosumab or teriparatide alone is recommended to increase the fusion rate and to reduce ODI in spinal fusion patients.
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Affiliation(s)
- Xiao-Yuan He
- Spinal Surgery, Hainan Province Clinical Medical Center, Haikou 570100, Hainan Province, China
| | - Huan-Xiong Chen
- Spinal Surgery, Hainan Province Clinical Medical Center, Haikou 570100, Hainan Province, China
| | - Zhi-Rong Zhao
- Spinal Surgery, Hainan Province Clinical Medical Center, Haikou 570100, Hainan Province, China
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Fraser HG, Krakow A, Lin A, Harris H, Andras LA, Skaggs DL, Flynn JM, Fletcher ND. Outcomes of Posterior Spinal Fusion in Pediatric Patients with Down Syndrome. J Bone Joint Surg Am 2022; 104:2068-2073. [PMID: 36166508 DOI: 10.2106/jbjs.22.00588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Trisomy 21 or Down syndrome is associated with multiple orthopaedic manifestations. Although cervical instability is the most common spinal condition associated with Down syndrome, the prevalence of scoliosis has been estimated at 4.8% to 8.7%. Very few prior studies have documented the role of spinal fusion in this population, and all have included ≤10 patients. METHODS An institutional review board-approved multicenter retrospective analysis of patients with Down syndrome treated with spinal fusion between January 2009 and December 2019 was performed by cross-referencing Current Procedural Terminology (CPT) and International Classification of Diseases, Ninth and Tenth Revisions (ICD-9 and ICD-10) codes. Patients were followed for ≥2 years, with a mean follow-up of 3.77 years. Clinical and radiographic outcomes were collected, and complications were documented using the Clavien-Dindo-Sink (CDS) classification. RESULTS A total of 23 patients were included: 96% had ≥1 medical comorbidities, including 16 (70%) with congenital heart disease, of whom 88% had previous cardiac surgery, and 10 (44%) with thyroid disorders. All 23 patients underwent posterior spinal fusion. The mean estimated blood loss was 617 ± 459 mL, the mean length of the surgical procedure was 290 ± 92.7 minutes, and the mean length of hospital stay was 6.03 ± 2.91 days. The major Cobb angle measured 61.7° ± 17.6°, which corrected to 19.4° ± 14.8° (68.6% correction; p < 0.001), with well-maintained correction at 2 years of 22.0° ± 10.3° (64.3% correction; p = 0.158). Thirteen (57%) of 23 patients had a change in curve of >5°. There were no intraoperative complications; however, 12 patients (52%) sustained postoperative complications (e.g., need for reoperation, implant failure, and pulmonary complications), including 6 patients with CDS type 3 or 4 (e.g., wound dehiscence, late superficial abscess, pleural effusion, pseudarthrosis, and readmission for hypoxia). Four patients (17%) required a revision surgical procedure. One patient (4%) required an unplanned intensive care unit admission. CONCLUSIONS Although instrumented spinal fusion can effectively correct spinal deformity in these patients, complications are more frequent than in children with adolescent idiopathic scoliosis, with over half of patients sustaining a complication. LEVEL OF EVIDENCE Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Helyn G Fraser
- Department of Orthopaedic Surgery, Emory University, Atlanta, Georgia
| | - Arielle Krakow
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Adrian Lin
- Children's Hospital of Los Angeles, Los Angeles, California
| | - Hilary Harris
- Department of Orthopaedics, Children's Healthcare of Atlanta, Atlanta, Georgia
| | | | - David L Skaggs
- Children's Hospital of Los Angeles, Los Angeles, California
| | - John M Flynn
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Nicholas D Fletcher
- Department of Orthopaedics, Children's Healthcare of Atlanta, Atlanta, Georgia
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Chotigavanichaya C, Vatidvarodom P, Ariyawatkul T, Ruangchainikom M, Wilartratsami S, Chotivichit A, Thanapipatsiri S, Santipas B, Adulkasem N, Luksanapruksa P. Surgical outcome of scoliosis in patients with Marfan syndrome. Spine Deform 2022; 10:1453-1460. [PMID: 35908146 DOI: 10.1007/s43390-022-00547-z] [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: 01/21/2022] [Accepted: 06/18/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE To evaluate clinical and radiographic outcomes after surgical scoliosis correction and posterior instrumented fusion in SMF patients. METHODS A single-center medical database was reviewed to identify MF patients who presented with scoliosis from 2000 to 2015. Patients who underwent spinal fusion surgery were included. Demographic, operative and clinical data were reviewed, and the preoperative, postoperative, and latest follow-up radiographic parameters were compared. RESULTS Twelve patients were identified (2 males, 10 females) with an average age at surgery of 14.4 ± 2.6 years. Comorbidities were found in 84.6%. Most patients (90.9%) presented with a right thoracic curve. The average preoperative Cobb angle was 75.6 ± 15.5 degrees. Posterior instrumented spinal fusion was performed in all patients (1 hook/pedicular screw and 11 pedicle screws only). The average follow-up period was 6.8 ± 3.1 years. The mean postoperative Cobb angle after surgery and at the final follow-up was 33.4 ± 18.0 degrees and 35.5 ± 18.4 degrees, respectively. There was a statistically significant difference among the preoperative and postoperative Cobb angles (p < 0.001), but no significant difference among the sagittal angles. Two perioperative complications including superficial wound infection and broken rods were observed. CONCLUSIONS Posterior scoliosis correction and instrumented spinal fusion resulted in a satisfactory outcome in MF patients. Perioperative complications are not uncommon; however, no neurological complication or spinal decompensation was observed in this study. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Chatupon Chotigavanichaya
- Division of Spine Surgery, Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Panjapol Vatidvarodom
- Division of Spine Surgery, Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Thanase Ariyawatkul
- Division of Spine Surgery, Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Monchai Ruangchainikom
- Division of Spine Surgery, Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Sirichai Wilartratsami
- Division of Spine Surgery, Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Areesak Chotivichit
- Division of Spine Surgery, Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Surin Thanapipatsiri
- Division of Spine Surgery, Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Borriwat Santipas
- Division of Spine Surgery, Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Nath Adulkasem
- Division of Spine Surgery, Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Panya Luksanapruksa
- Division of Spine Surgery, Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand.
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Li J, Zhao M, Yao Z, Zhang X, Guo D, Zhao X, Zhang W. Intraoperative hypotension during surgical treatment for Marfan syndrome scoliosis in children. J Child Orthop 2022; 16:416-423. [PMID: 36238138 PMCID: PMC9550993 DOI: 10.1177/18632521221126923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 09/01/2022] [Indexed: 11/17/2022] Open
Abstract
PURPOSE To explore the occurrence and risk factors of intraoperative hypotension during children's Marfan syndrome scoliosis surgery and summarize the associated hemodynamic features and handle measures. METHODS Twenty-two Marfan syndrome scoliosis patients who underwent spinal surgery at Beijing Children's Hospital were retrospectively reviewed between January 2001 and January 2020. Intraoperative hypotension is defined as the minimum mean arterial pressure ≤ 60 mm Hg. The patients were divided into the hypotension group and the control group. Clinical, radiographic, and operative data were compared between the two groups. The risk factors, hemodynamic features, and handle measures for intraoperative hypotension in Marfan syndrome scoliosis surgery were analyzed and summarized. RESULTS Twenty-two patients were included in the study, with a mean age of 11.4 years at initial surgery. The follow-up period ranged from 24 to 152 months. Intraoperative hypotension occurred in 14 cases, with an incidence of 63.6%. The proportion of pulmonary dysfunction in the hypotension group was higher than in the control group (100.0% vs 50.0%, p < 0.05). The spinal flexibility was significantly lower in the hypotension group (28.3% ± 14.2% vs 46.5% ± 11.5%, p < 0.05). Fourteen patients with intraoperative hypotension had decreased intraoperative systolic blood pressure 21.0%-50.0% compared with baseline. One patient had a transient decrease in the muscle strength of the lower limbs. No complications were observed during the follow-up. CONCLUSION The incidence of intraoperative hypotension in Marfan syndrome scoliosis children who underwent surgery was 63.6%. The risk factors included preoperative pulmonary dysfunction and poor spinal flexibility. Comprehensive preoperative evaluation and effective hemodynamic handling measures should be undertaken to prevent further complications in children with Marfan syndrome scoliosis.
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Affiliation(s)
- Jiayi Li
- Beijing Children’s Hospital, Capital
Medical University, National Center for Children’s Health, Beijing, China
| | - Mengqi Zhao
- Beijing Children’s Hospital, Capital
Medical University, National Center for Children’s Health, Beijing, China
| | - Ziming Yao
- Department of Orthopedics, Beijing
Children’s Hospital, Capital Medical University, National Center for Children’s
Health, Beijing, China,Ziming Yao, Department of Orthopedics,
Beijing Children’s Hospital, Capital Medical University, National Center for
Children’s Health, Beijing 100045, China.
| | - Xuejun Zhang
- Department of Orthopedics, Beijing
Children’s Hospital, Capital Medical University, National Center for Children’s
Health, Beijing, China,Xuejun Zhang, Department of Orthopedics,
Beijing Children’s Hospital, Capital Medical University, National Center for
Children’s Health, Beijing 100045, China.
| | - Dong Guo
- Department of Orthopedics, Beijing
Children’s Hospital, Capital Medical University, National Center for Children’s
Health, Beijing, China
| | - Xin Zhao
- Department of Anesthesiology, Beijing
Children’s Hospital, Capital Medical University, National Center for Children’s
Health, Beijing, China
| | - Weiping Zhang
- Beijing Children’s Hospital, Capital
Medical University, National Center for Children’s Health, Beijing, China
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Joo PY, Caruana DL, Gouzoulis MJ, Moore HG, Zhu JR, Ameri B, Grauer JN. Marfan syndrome and adolescent idiopathic scoliosis patients have similar 90-day postoperative outcomes and 5-year reoperation rates after spinal deformity surgery. Spine Deform 2022; 10:1169-1174. [PMID: 35362940 DOI: 10.1007/s43390-022-00501-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 03/19/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE Outcomes after spinal deformity surgery in patients with Marfan syndrome (MFS) are poorly characterized given the rarity of the condition. Updated analyses from nationally representative samples, and comparison to outcomes after more commonly performed procedures for conditions such as adolescent idiopathic scoliosis (AIS) could help define the relative risks. METHODS Using the 2010-2020 PearlDiver administrative databases, patients who underwent posterior spinal fusion for > 7 segments were extracted. MFS patients were matched 1:4 to AIS patients based on age, sex, and Elixhauer comorbidity index (ECI). Ninety-day outcomes and 5-year reoperation rates were compared. Significance was set at p < 0.05. RESULTS In total, 206 MFS patients were matched to 825 AIS patients. After adjusting for age, sex, and ECI, multivariate odds ratios (OR) for 90-day any, serious, and minor adverse events, as well as readmissions, were not significantly different for those with MFS compared to those with AIS (p > 0.05 for each). Five-year reoperation rates were also not significantly different (13.1% for the MFS cohort and 13.0% for the AIS cohort (no difference by log-rank, p = 0.9). CONCLUSION While deformity surgery is much less commonly performed for MFS than AIS, it is not uncommonly considered for patients with this condition. Despite some known technical challenges for MFS deformity surgery, the current study leveraged a large, national database to find that 90-day adverse events and 5-year reoperations were not different for matched MFS and AIS patients undergoing deformity surgery. For select patients, these findings should be useful for surgical planning and patient counseling.
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Affiliation(s)
- Peter Y Joo
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT, 06510, USA
| | - Dennis L Caruana
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT, 06510, USA
| | - Michael J Gouzoulis
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT, 06510, USA
| | - Harold G Moore
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT, 06510, USA
| | - Justin R Zhu
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT, 06510, USA
| | - Bijan Ameri
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT, 06510, USA
| | - Jonathan N Grauer
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT, 06510, USA.
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Andersen NH, Hauge EM, Baad-Hansen T, Groth KA, Berglund A, Gravholt CH, Stochholm K. Musculoskeletal diseases in Marfan syndrome: a nationwide registry study. Orphanet J Rare Dis 2022; 17:118. [PMID: 35248143 PMCID: PMC8898450 DOI: 10.1186/s13023-022-02272-2] [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: 11/13/2021] [Accepted: 02/20/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Marfan syndrome is associated with abnormalities in the musculoskeletal system including scoliosis, pectus deformities, protrusio acetabuli, and foot deformities. Over a life span, many patients with Marfan syndrome will need treatment; however, the musculoskeletal morbidity over a life span is not well described. The aim of the present study was to assess the overall burden of musculoskeletal disease in patients with Marfan syndrome.
Materials and methods
A registry-based, nationwide epidemiological study of patients with a Ghent II verified Marfan syndrome diagnosis from 1977 to 2014. Each patient was matched on age, and sex with up to 100 controls from the background population.
Results
We identified 407 patients with Marfan syndrome and 40,700 controls and compared their musculoskeletal diagnoses and surgical treatments using Cox proportional hazards ratio (HR). The risk of a registration of a musculoskeletal diagnosis in patients with Marfan syndrome was significantly increased compared to controls (HR: 1.94 (1.69–2.24). One out of six with Marfan syndrome was registered with scoliosis (HR: 36.7 (27.5–48.9). Scoliosis was more common in women with Marfan syndrome compared to men (HR: 4.30 (1.73–1.08)). One out of 11 were registered with a pectus deformity HR: 40.8 (28.1–59.3), and one out of six with a deformity of the foot. Primarily pes planus (HR: 26.0 (15.2–44.3). The proportion of patients with Marfan syndrome (94/407) that underwent musculoskeletal surgery was also significantly higher (HR: 1.76 (1.43–2.16)). The major areas of surgery were the spine, pectups correction, and surgery of the foot/ankle. Ten patients with Marfan syndrome had elective orthopedic surgery without being recognized and diagnosed with Marfan syndrome until later in life. None of these had scoliosis, pectus deformity or a foot deformity. Among patients with an aortic dissection, the age at dissection was 34.3 years in those with at least one major musculoskeletal abnormality. In patients without a major abnormality the age at dissection was 45.1 years (p < 0.01).
Conclusions
The extent of musculoskeletal disease is quite significant in Marfan syndrome, and many will need corrective surgery during their life span. Surgeons should be aware of undiagnosed patients with Marfan syndrome when treating patients with a Marfan syndrome like-phenotype.
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Ikwuezunma IA, Margalit A, Sponseller PD. Tranexamic acid use is associated with reduced intraoperative blood loss during spine surgery for Marfan syndrome. Spine Deform 2022; 10:419-423. [PMID: 34611839 DOI: 10.1007/s43390-021-00416-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 09/11/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE The utility of tranexamic acid (TXA) in patients with Marfan syndrome (MFS) is uncertain given associated aberrations within the vasculature and clotting cascade. Therefore, this study aimed to assess the association of TXA use with intraoperative blood loss and allogeneic blood transfusions in patients with MFS who underwent spinal arthrodesis. METHODS We queried our institutional database for MFS patients who underwent spinal arthrodesis for scoliosis between 2000 and 2020 by one surgeon. We excluded procedures spanning < 4 vertebral levels, those using anterior or combined anterior/posterior approaches, and those involving growing rods, postoperative infection, or spondylolisthesis. Fifty-two patients met our criteria, of whom 22 were treated with TXA and 30 were not. Mean differences in blood loss, transfusion volume, and proportions receiving transfusion were compared between TXA and the control groups using Student t, chi-squared, or Fisher exact tests. Alpha = 0.05. RESULTS MFS patients treated with TXA experienced less mean (± standard deviation) intraoperative blood loss (1023 ± 534 mL) compared to the control group (1436 ± 1022 mL) (p = 0.01). The TXA group had estimated blood volume loss of 27% ± 16% compared to 36% ± 21% for controls (p = 0.05). No differences were found in allogeneic transfusion rate (p = 0.66) or transfusion volume (p = 0.15). CONCLUSIONS We found an association between TXA use and reduced blood loss during surgical treatment of MFS-associated scoliosis, suggesting that the connective tissue deficiency in MFS does not interfere with TXA's mechanism of action. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Ijezie A Ikwuezunma
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N. Caroline Street, JHOC 5223, Baltimore, MD, 21287, USA
| | - Adam Margalit
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N. Caroline Street, JHOC 5223, Baltimore, MD, 21287, USA
| | - Paul D Sponseller
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N. Caroline Street, JHOC 5223, Baltimore, MD, 21287, USA.
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Pollock L, Ridout A, Teh J, Nnadi C, Stavroulias D, Pitcher A, Blair E, Wordsworth P, Vincent TL. The Musculoskeletal Manifestations of Marfan Syndrome: Diagnosis, Impact, and Management. Curr Rheumatol Rep 2021; 23:81. [PMID: 34825999 PMCID: PMC8626407 DOI: 10.1007/s11926-021-01045-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2021] [Indexed: 11/29/2022]
Abstract
Purpose of Review
Marfan syndrome (MFS) is an autosomal dominant heritable disorder of fibrillin-1 (FBN1) with predominantly ocular, cardiovascular, and musculoskeletal manifestations that has a population prevalence of approximately 1 in 5–10,000 (Chiu et al. Mayo Clin Proc. 89(1):34–42, 146, Dietz 3, Loeys et al. J Med Genet. 47(7):476–85, 4). Recent Findings The vascular complications of MFS still pose the greatest threat, but effective management options, such as regular cardiac monitoring and elective surgical intervention, have reduced the risk of life-threatening cardiovascular events, such as aortic dissection. Although cardiovascular morbidity and mortality remains high, these improvements in cardiovascular management have extended the life expectancy of those with MFS by perhaps 30–50 years from an estimated mean of 32 years in 1972 (Dietz 3, Gott et al. Eur J Cardio-thoracic Surg. 10(3):149–58, 147, Murdoch et al. N Engl J Med. 286(15):804–8, 148). The musculoskeletal manifestations of MFS, which to date have received less attention, can also have a significant impact on the quality of life and are likely to become more important as the age of the Marfan syndrome population increases (Hasan et al. Int J Clin Pract. 61(8):1308–1320, 127). In addition, musculoskeletal manifestations are often critically important in the diagnosis of MFS. Summary Here, we review the main clinically relevant and diagnostically useful musculoskeletal features of MFS, which together contribute to the “systemic features score” (referred to hereafter as systemic score), part of the revised Ghent nosology for MFS. We discuss current treatment strategies and highlight the need for a multidisciplinary approach to diagnosis and management. Finally, we review new pharmacological approaches that may be disease modifying and could help to improve the outcome for individuals with this syndrome.
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Affiliation(s)
- Lily Pollock
- Kennedy Institute of Rheumatology, NDORMS, University of Oxford, Oxford, UK
| | - Ashley Ridout
- Department of Rheumatology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - James Teh
- Department of Radiology, Oxford University Hospitals NHS Foundation Trust, Oxford, England, UK
| | - Colin Nnadi
- Department of Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Alex Pitcher
- Department of Cardiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Edward Blair
- Department of Clinical Genetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Paul Wordsworth
- Department of Rheumatology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Tonia L Vincent
- Kennedy Institute of Rheumatology, NDORMS, University of Oxford, Oxford, UK. .,Department of Rheumatology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
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Zeigler SM, Sloan B, Jones JA. Pathophysiology and Pathogenesis of Marfan Syndrome. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1348:185-206. [PMID: 34807420 DOI: 10.1007/978-3-030-80614-9_8] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Marfan syndrome (MFS) is a systemic connective tissue disorder that is inherited in an autosomal dominant pattern with variable penetrance. While clinically this disease manifests in many different ways, the most life-threatening manifestations are related to cardiovascular complications including mitral valve prolapse, aortic insufficiency, dilatation of the aortic root, and aortic dissection. In the past 30 years, research efforts have not only identified the genetic locus responsible but have begun to elucidate the molecular pathogenesis underlying this disorder, allowing for the development of seemingly rational therapeutic strategies for treating affected individuals. In spite of these advancements, the cardiovascular complications still remain as the most life-threatening clinical manifestations. The present chapter will focus on the pathophysiology and clinical treatment of Marfan syndrome, providing an updated overview of the recent advancements in molecular genetics research and clinical trials, with an emphasis on how this information can focus future efforts toward finding betters ways to detect, diagnose, and treat this devastating condition.
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Affiliation(s)
- Sanford M Zeigler
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Brandon Sloan
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Jeffrey A Jones
- Division of Cardiothoracic Surgery, Medical University of South Carolina and Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA.
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Abstract
STUDY DESIGN A retrospective study of the prospective cohort. OBJECTIVE To demonstrate the accurate distribution of the severity of scoliosis in patients with Marfan syndrome, and to identify the predictive physical features for progression of scoliosis in Marfan syndrome. SUMMARY OF BACKGROUND DATA To date, no study has unveiled the risk factors for the progression of scoliosis in Marfan syndrome. METHODS We retrospectively obtained data from a prospective cohort of the Marfan syndrome clinic at our institute. We enrolled patients whose whole spine radiographs in the standing position were evaluated at the age of 15 or above, from January 2014 to March 2020. The collected variables were physical manifestations defined as in the systemic score of the revised Ghent nosology. We classified the degree of scoliosis into four categories: "not apparent," "mild" (10° ≤ Cobb < 25°), "moderate" (25° ≤ Cobb < 40°), and "severe" (40° ≤ Cobb or surgery conducted). To identify the risk factors for progression of scoliosis in Marfan syndrome, we conducted univariate and multivariate association analyses between severe scoliosis and each physical manifestation. RESULTS We identified 131 eligible patients (61 men and 70 women) with a mean age of 31.2 years. Scoliosis with a Cobb angle of ≥10° was identified in 116 patients (88.5%). Moderate scoliosis was identified in 33 patients (25.2%) and severe scoliosis in 53 patients (40.5%). The prevalence of each physical manifestation was equivalent to that reported in previous studies. Multivariate logistic regression analysis revealed that female sex (odds ratio, 3.27) and positive wrist sign (4.45) were predictive factors for progression of scoliosis into severe state in patients with Marfan syndrome. CONCLUSIONS The present study demonstrated the accurate distribution of the severity of scoliosis and identified the predictive factors for progression of scoliosis in patients with Marfan syndrome.Level of Evidence: 3.
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Feng G, Huang Y, Huang L, Wang Y, Wang J, Zhou C, Wang L, Zhou Z, Yang X, Liu L, Song Y. A novel posterior multiple screws distraction reducer system versus anterior release, posterior internal distraction, and subsequent spinal fusion for severe scoliosis. BMC Musculoskelet Disord 2021; 22:144. [PMID: 33546654 PMCID: PMC7866657 DOI: 10.1186/s12891-021-03963-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 01/08/2021] [Indexed: 02/08/2023] Open
Abstract
Purpose We previously reported anterior release, posterior internal distraction, and subsequent spinal fusion (ARPIDF) for the correction of severe scoliosis with a satisfactory correction rate. However, surgical procedures were completed in 2–3 stages. Here we compare Cobb angle of ≥90° in scoliosis correction between a novel posterior multiple screws distraction reducer (MSDR) system and ARPIDF. Methods Thirty-six patients with severe scoliosis treated by MSDR or ARPIDF (n = 18 in both groups). We retrospectively analyzed and compared outcome measures between the two groups over a minimum follow-up duration of 2 years. The following variables were compared between the two groups: age at surgery, sex, etiology, flexibility of the main thoracic curve, number of fused segments and screws, operation time, estimated blood loss, hospitalization time, follow-up duration, various radiological parameters, complication rate, and Scoliosis Research Society-30 score. Results There were no significant between-group differences with respect to age, sex, etiology, flexibility of the main thoracic curve, number of fused segments and screws, and follow-up duration. Further, there was no significant difference in terms of preoperative, postoperative, and final follow-up findings of the radiographic data. However, the ARPIDF group had longer operation and hospitalization times and greater blood loss. In the ARPIDF group, 4 patient developed complications (infection, intraoperative neuromonitoring changes, transient dyspnea); none of these events occurred in the MSDR group. Conclusion The use of MSDR helped achieve greater scoliosis correction with a shorter operation time, lower blood loss, and lower complication rate than the use of ARPIDF. MSDR facilitates safer and easier correction of severe scoliosis without increasing surgical risk.
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Affiliation(s)
- Ganjun Feng
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Yong Huang
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Leizhen Huang
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Yongliang Wang
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Juehan Wang
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Chunguang Zhou
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Lei Wang
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Zhongjie Zhou
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Xi Yang
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Limin Liu
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China.
| | - Yueming Song
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
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A 16-Year-Old Male with Thoracic Compression following Posterior Spinal Instrumentation and Fusion for Marfan-Associated Syndromic Scoliosis. Case Rep Orthop 2020; 2020:6617028. [PMID: 33381338 PMCID: PMC7748892 DOI: 10.1155/2020/6617028] [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: 10/13/2020] [Revised: 11/28/2020] [Accepted: 12/03/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction Marfan syndrome is an autosomal dominant disorder caused by a mutation in the FBN1 gene which affects connective tissue. The features of Marfan syndrome include many musculoskeletal abnormalities which require orthopaedic surgical intervention. Given the expansive phenotypic variations and comorbidities associated with Marfan syndrome, knowledge of perioperative risk factors and potential complications is essential. Case In this case report, the authors describe a patient with Marfan syndrome who underwent spinal instrumentation and fusion from T3 to L4 for correction of syndromic scoliosis. The patient had a complicated perioperative course requiring significant fluid resuscitation and vasoactive medications to support blood pressure. He required intensive care unit level care for continued hemodynamic instability despite resuscitation in the postoperative period. Common causes of postoperative hypotension such as hypovolemic shock, sepsis, ongoing hemorrhage, and prolonged effects of anesthesia were diagnostically ruled out. Ultimately, the patient's refractory hypotension was determined to be from mechanical compression, both from prolonged intraoperative prone positioning exacerbated by pectus excavatum and from the surgically corrected spine decreasing the diameter of his thoracic cavity (as referenced by his postoperative Haller index). Conclusion Mechanical compression of thoracic contents as a result of a worsening chest wall deformity can be a complication of spinal deformity correction.
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