Strategies to Minimize Blood Loss and Transfusion in Pediatric Spine Surgery

Umbilical cord mesenchymal stem cells combined with secretome for treating congenital pseudarthrosis of the Tibia: a case series

INTRODUCTION

Most patients with congenital pseudoarthrosis of tibia (CPT) do not have promising outcomes despite multiple attempts using conventional surgeries. The combination of umbilical cord-derived mesenchymal stem cells and conditioned medium (secretome) contains major components pivotal for the enhancement of fracture healing. The purpose of this study was to address fracture healing in CPT cases that were treated using the combined implantation of umbilical-cord mesenchymal stem cells (UC-MSCs) and secretome.

MATERIALS AND METHODS

From 2016 to 2017, six patients with CPT who were treated by one senior pediatric orthopedic consultant at a single center (3 girls and 3 boys; mean age of 5.8 years) were included in this case series. A combined procedure including resection of hamartomatous fibrotic tissue, implantation of MSCs and secretome, and fixation using a locking plate and screws was performed. Patients were followed up for a mean of 29 months. Leg-length discrepancy, refracture rate, functional outcome, and radiological outcomes were assessed preoperatively, immediately postoperatively and at the final follow-up.

RESULT

Five out of 6 (83%) of the patients experienced primary union. One patient experienced refracture; however, 8 months later, after another implantation and reconstruction were performed, union eventually occurred. Significant functional improvement was achieved after at least 1 year of follow-up.

CONCLUSION

This case series suggests that the combination of secretome and UC-MSCs is a potential treatment for CPT, it highlights the efficacy of the combined procedure in treating CPT and in achieving satisfying results. A larger number of subjects and longer follow-up are required for further study.

Blood loss in hip reconstructive surgery in children with cerebral palsy: when do I need to be prepared for blood transfusion?

The hip is the second most common joint involved in pediatric patients with cerebral palsy (CP). Hip reconstructive procedures are performed to improve function and comfort level. Blood loss can occur leading to blood transfusion in close to 1/3 of children with CP undergoing hip reconstruction. The purpose of this study was to report the rate and risk factors for blood transfusion after hip reconstruction in a large cohort of children with CP. We conducted a retrospective chart review of pediatric patients at our tertiary referral children's hospital who underwent reconstructive hip osteotomy over an 8-year period. Binary logistic regression was employed to compare and model differences in transfusion between age greater than 4 or 6 years and the number of osteotomies. A total of 180 patients met our inclusion criteria. Thirty-seven patients (20.6%) received blood transfusion. Incidence of transfusion increased as number of osteotomies increased from 1 to 4 (3.7%, 7.3%, 34.0%, 58.3%, respectively). We did not find a significant effect of age greater than 4 or 6 years on the rate of blood transfusion (P = 0.676 and P = 0.323, respectively). The number of osteotomies was a significant factor in the rate of blood transfusion in both models (P < 0.001). Number of osteotomies and not age was a significant risk factor in the rate of blood transfusion. This data can help the orthopedic surgeons in preoperative planning for the possibility of blood transfusion in these patients.

Complications, Results, and Risk Factors of Spinal Fusion in Patients With Myelomeningocele

STUDY DESIGN

Retrospective prognostic study.

OBJECTIVE

The purpose of this study assess was to assess the results of spinal fusion and identify factors associated with the development of post-spinal fusion infections in patients with myelomeningocele.

BACKGROUND

Surgical correction of neuromuscular scoliosis secondary to myelomeningocele is known to be associated with a high complication rate.

METHODS

A retrospective cohort study design was used to collect data on patients with myelomeningocele who underwent spinal fusion between the years of 1997-2013. Only subjects with a minimum of two years of continuous follow-up were included in the study. Demographic, surgical, clinical, and radiographic variables of interest were collected. Univariate and multivariable logistic regression analyses were used to identify factors predictive of an infection. Linear mixed model regression analyses were used to analyze postsurgical changes in radiographic parameters.

RESULTS

Of the 33 subjects included in the study, 33.3% developed a postoperative infection. Overall, 69.0% of patients achieved a >50% correction of primary curvature at the one-month time point. Of the measured variables, lumbar and thoracolumbar kyphosis (odds ratio: 10.9, 95% confidence interval [CI]: 1.2-158.3, p = .0465) and a low preoperative hematocrit odds ratio per 1% increase, 0.7 (95% CI: 0.5-0.9, p = .0145) were associated with developing a postoperative infection. There was a significant improvement in the proportion of subjects with a pelvic obliquity measurement <5° one month postsurgery (p = .0339), kyphosis (p = .0401), and Cobb angle of the primary curvature across all time points (p <.0001).

CONCLUSION

Type of procedure, neurosegmental level, transfusion rates, age at surgery, gender, length of operation, preoperative urinary tract infection, estimated blood loss, and the number of levels fused were not modifiable risk factors for future complications for patients with scoliosis secondary to myelomeningocele, whereas lumbar and thoracolumbar kyphosis or low hematocrit levels may lead to an increased risk for developing a postspinal fusion infection.

LEVEL OF EVIDENCE

Level II.