Orthopedic guidelines for the care of people with spina bifida

Application of multi-disciplinary team nursing model enhances recovery after surgery for total hip arthroplasty and total knee arthroplasty

AIM

To explore the effect of a multidisciplinary team (MDT) nursing model based on enhanced recovery after surgery (ERAS) in total hip arthroplasty (THA)/total knee arthroplasty (TKA) and evaluate its application in the perioperative period of patients.

METHODS

A retrospective analysis was conducted on 100 patients with THA/TKA treated at Shaoxing Second Hospital Medical Community General Hospital from January 2021 to December 2023. The patients were divided into an observation group (n = 50) and a control group (n = 50) based on the nursing method employed. The control group received traditional perioperative nursing, while the observation group received an MDT nursing model intervention based on the ERAS concept. Visual analogue scale (VAS) scores were recorded at 6, 24, and 72 hours post-surgery. Additionally, postoperative activities, hospitalization duration, and postoperative complications were documented. Differences in knee joint range of motion (ROM), hip Harris score, psychological stress response score, and quality of life score between the two groups before and one month after surgery were analyzed.

RESULTS

At 6, 24, and 72 hours post-surgery, patients in the observation group had significantly lower VAS scores compared to those in the control group (all P < 0.05). The observation group had an earlier first-time mobilization (P < 0.05). The length of hospitalization and hospitalization cost were significantly lower in the observation group than in the control group (both P < 0.05). The incidence rates of postoperative adverse reactions were 22.00% in the control group and 6.00% in the observation group (P < 0.05). One month post-surgery, the observation group showed significantly greater ROM, lower psychological stress and reaction scores, and higher Harris score and quality of life score compared to the control group (all P < 0.05).

CONCLUSION

The MDT nursing model based on ERAS concept for THA/TKA perioperative patients effectively alleviates postoperative pain, promotes early activity, shortens hospital stay, reduces hospital cost, decreases the incidence of complications, restores joint function, enhances quality of life, and reduces psychological stress.

Foot deformity and quality of life among independently ambulating children with spina bifida in South Korea

BACKGROUND

Children with spina bifida (SB) may have congenital or acquired foot deformities due to neurological defects in the spinal cord. As the musculoskeletal system keeps growing, foot deformities can develop or become aggravated. Thus, healthcare providers should provide constant monitoring and proper orthopedic management. Since foot deformities can affect not only the gait but also the daily life of children with SB, it is necessary to investigate the impact of foot deformities on everyday life. The purpose of this study was to examine the relationship between foot deformity and health-related quality of life (HRQoL) among independently ambulating children with SB.

METHODS

This cross-sectional study examined the associations between foot deformity and HRQoL using two patient-reported outcome measures (Oxford Ankle Foot Questionnaire, Pediatric Outcomes Data Collection Instrument) in 93 children with SB aged 7-18 years between January 2020 and July 2021.

RESULTS

Children with foot deformity (n = 54) reported lower scores in all subscales (physical, school and play, emotional, and footwear) of the Oxford Ankle Foot Questionnaire for children than those without foot deformity (n = 39; p < 0.001). Additionally, in terms of the Pediatric Outcomes Data Collection Instrument, children with foot deformity also reported poorer scores in four subscales (transfer and basic mobility, sports and physical functioning, comfort and pain, happiness with physical functioning; p < 0.001) than those without foot deformity, whereas upper extremity functioning was not significantly affected. Children with foot deformities, particularly those with bilateral foot deformities, equinus deformities, or mixed deformities, which are different types of right and left foot deformities, have a lower perceived HRQoL (p < 0.05).

CONCLUSIONS

Among independently ambulating children with SB, those with foot deformities showed lower HRQoL. Moreover, children with foot deformities tend to have other clinical problems, including bladder and bowel dysfunction. Therefore, orthopedic management should consider the multifaceted factors that affect children's daily life and HRQoL.

Evidence-based position paper of the UEMS PRM on the role of Physical and Rehabilitation Medicine (PRM) physician in the management of children and adults with spinal dysraphism

Spinal dysraphism (SD) or spina bifida (SB) is a congenital deformity that results from embryonic neural tube closure failure during fetal development. This evidence-based position paper represents the official position of the European Union through the UEMS PRM Section. This paper aims to evaluate the role of the physical and rehabilitation medicine (PRM) physician and PRM practice for children and adults with spinal dysraphism. A systematic literature review and a consensus procedure involved all European countries delegates represented in the UEMS PRM section through a Delphi process. The systematic literature review is reported together with thirty-two recommendations resulting from the Delphi procedure. The professional role of the PRM physician requires specific expertise in the treatment of patients with SD to plan, lead and monitor the rehabilitation process in an interdisciplinary setting and to participate in the assessment of the needs of these patients in the transitional phase from childhood to adulthood, with particular attention to the activity limitation and participation restriction.

What is the Role of Scoliosis Surgery in Adolescents and Adults with Myelomeningocele? A Systematic Review

BACKGROUND

Life expectancy of individuals with spina bifida has continued to improve over the past several decades. However, little is known about the longitudinal course of scoliosis in individuals with myelomeningocele (MMC), a spina bifida subtype, across their lifespan. Specifically, it is not known whether management during or after the transition years from adolescence to adulthood is associated with comorbidities in adulthood nor if these individuals benefit from scoliosis treatment later in life.

QUESTIONS/PURPOSES

In this systematic review, we asked: (1) Is the risk of secondary impairments (such as bladder or bowel incontinence, decreased ambulation, and skin pressure injuries) higher among adolescents and adults with MMC and scoliosis than among those with MMC without scoliosis? (2) Is there evidence that surgical management of scoliosis is associated with improved functional outcomes in adolescents and adults with MMC? (3) Is surgical management of scoliosis associated with improved quality of life in adolescents and adults with MMC?

METHODS

We performed a systematic review of articles in Medline and Embase from 2000 until February 5, 2021. Search terms such as "spinal dysraphism," "spina bifida," "meningomyelocele," and "scoliosis" were applied in diverse combinations. A total of 1429 publications were identified, and 13 were eligible for inclusion. We included original studies reporting on scoliosis among individuals older than 15 years with MMC. When available, we extracted the prevalence of MMC and scoliosis, studied population age, percentage of patients experiencing complications, functional outcomes, and overall physical function. We excluded non-English articles and those with fewer than 10 individuals with scoliosis and MMC. We used the Preferred Reporting Items for Systematic Reviews and Meta-analyses, and registered the review before data collection (PROSPERO: CRD42021236357). We conducted a quality assessment using the Methodologic Index for Nonrandomized Studies (MINORS) tool. In 13 included studies, there were 556 individuals with MMC and scoliosis. Most were retrospective case series, although a minority were retrospective/comparative studies. The mean MINORS score was 12.3 ± 1.65 (a MINORS score over 12 generally is considered good reporting quality, scores below 12 are considered at high risk of bias).

RESULTS

In general, studies found that individuals with MMC and scoliosis were more likely to have secondary impairments such as bladder/bowel incontinence, decreased ambulation, and pressure injuries than were patients with MMC without scoliosis. These secondary impairments were associated with hydrocephalus and high-level MMC lesions. However, when one study evaluated mortality, the results showed that although most deceased individuals who had spina bifida had scoliosis, no association was found between the age of death and scoliosis. Among the studies evaluating functional outcomes, none supported strong functional improvement in individuals with MMC after surgery for scoliosis. No correlation between the Cobb angle and sitting balance was noted; however, the degree of pelvic obliquity and the level of motor dysfunction showed a strong correlation with scoliosis severity. There was no change in sitting pressure distributions after spinal surgery. The lesion level and scoliosis degree independently contributed to the degree of lung function impairment. Although studies reported success in correcting coronal deformity and stopping curve progression, they found no clear benefit of surgery on health-related quality of life and long-term outcomes. These studies demonstrated that the level of neurologic function, severity of hydrocephalus, and brainstem dysfunction are greater determinants of quality of life than spinal deformity.

CONCLUSION

This systematic review found that adolescents and adults with MMC and scoliosis are more likely to have secondary impairments than their peers with MMC only. The best-available evidence does not support strong functional improvement or health-related quality of life enhancement after scoliosis surgery in adolescents and adults with MMC. The level of neurologic dysfunction, hydrocephalus, and brainstem dysfunction are greater determinants of quality of life. Future prospective studies should be designed to answer which individuals with MMC and scoliosis would benefit from spinal surgery. Our findings suggest that the very modest apparent benefits of surgery should cause surgeons to approach surgical recommendations in this patient population with great caution, and surgeons should counsel patients and their families that the risk of complications is high and the benefits may be small.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Team Approach: The Management of Adolescents and Adults with Scoliosis and Spina Bifida

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Globally, the prevalence of myelomeningocele, the most common subtype of spina bifida, is 0.2 to 6.5 per 1,000 live births. In the U.S., adults account for >67% of the overall population with spina bifida.

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With an estimated prevalence of up to 50%, scoliosis is one of the most common and severe orthopaedic conditions in patients with myelomeningocele.

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The variable effects that scoliosis can have on an individual, the comorbidities associated with progressive scoliosis, and the risks associated with spine surgery call for a strong partnership and care coordination between medical and surgical teams to deliver a patient-centered approach.

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A coordinated, structured, planned, and incremental team approach can help individuals achieve the overall goals of functionality and independence, as well as successful transition to adulthood.

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Teams should consider a patient's social determinants of health (e.g., poverty or language barriers) and the effect of scoliosis on quality of life before proceeding with spinal deformity correction.

Development of a core outcome set for the orthopaedic management of spinal dysraphism

Aims

The aim of this study is to define a core outcome set (COS) to allow consistency in outcome reporting amongst studies investigating the management of orthopaedic treatment in children with spinal dysraphism (SD).

Methods

Relevant outcomes will be identified in a four-stage process from both the literature and key stakeholders (patients, their families, and clinical professionals). Previous outcomes used in clinical studies will be identified through a systematic review of the literature, and each outcome will be assigned to one of the five core areas, defined by the Outcome Measures in Rheumatoid Arthritis Clinical Trials (OMERACT). Additional possible outcomes will be identified through consultation with patients affected by SD and their families.

Results

Outcomes identified in these stages will be included in a two-round Delphi process that will involve key stakeholders in the management of SD. A final list including the identified outcomes will then be summarized in a consensus meeting attended by representatives of the key stakeholders groups.

Conclusion

The best approach to provision of orthopaedic care in patients with SD is yet to be decided. The reporting of different outcomes to define success among studies, often based on personal preferences and local culture, has made it difficult to compare the effect of treatments for this condition. The development of a COS for orthopaedic management in SD will enable meaningful reporting and facilitate comparisons in future clinical trials, thereby assisting complex decision-making in the clinical management of these children.

Cite this article: Bone Jt Open 2022;3(1):54–60.

Follow-up of brace-treated scoliosis in children with cerebral palsy and spina bifida

PURPOSE

This study aimed to describe brace use, progression of scoliosis, and surgery in children with cerebral palsy (CP) and spina bifida (SB) who were initially treated with a brace.

METHODS

Medical records were retrospectively analysed for brace compliance, treatment complications, curve size measurements with and without the brace at both start and at follow-up, and number of patients undergoing spine surgery.

RESULTS

Sixty-eight children were included (CP 47, SB 21), 37 of whom were girls, with a mean age at start of treatment of 11.1 (CP) and 8.2 (SB) years. Most had severe motor problems; only four children with CP and five with SB were able to walk. Thirty-five in the group with CP and 11 in the group with SB had a curve size over 40°.Forty used the brace full-time, 19 half-time and nine for a varying proportion of time. Transient complications of brace treatment were seen in 28%. The yearly progression of curve-size was 4.2° in CP and 2.3° in SB.Twenty-eight patients underwent surgery and complications were present in 75% of these patients. Twenty-seven out of 46 patients with severe scoliosis did not undergo surgery.

CONCLUSION

Brace treatment was possible, even in patients with severe scoliosis. Bracing can delay the progression of scoliosis.

[Expert consensus on diagnosis and treatment of spina bifida]

Spina bifida and tethered spinal cord are congenital diseases that can lead to severe disability. At present, most doctors in relevant specialties in China still have insufficient understanding of spina bifida, resulting in high incidence and aggravation of its complications. To provide guidance for the diagnosis and treatment of spina bifida and tethered spinal cord in China, experts from neurosurgery, urology, orthopedics, spine surgery, and rehabilitation departments who have experiences in the diagnosis and treatment of spina bifida discussed and summarized their experiences, and referred to the relevant literature on the diagnosis and treatment of spina bifida at home and abroad. Expert consensus was formed in the following aspects: concept, classification, and pathological changes of spina bifida; diagnosis; treatment process and operation timing; principles and methods of treatment; rehabilitation; and follow up. This expert consensus can provide reference for relevant care providers of spina bifida in China.

[Preliminary analysis of the clinical characteristics of 1 012 patients with secondary lower limb deformity of spina bifida from QIN Sihe Orthopedic Surgery Case Data between October 12, 1986 and December 31, 2020]

OBJECTIVE

To analyze the characteristics of patients with secondary lower limb deformity of spina bifida based on the QIN Sihe Orthopedic Surgery Case Data, and provide the references for clinical research, diagnosis, and treatment.

METHODS

A clinical data of 1 012 patients with secondary lower limb deformity of spina bifida between October 12, 1986 and December 31, 2020 selected from QIN Sihe Orthopedic Surgery Case Data was retrospectively analyzed. Among them, 231 cases (22.83%) had undergone orthopedic surgery for lower extremity deformities in other hospitals. The gender, age at surgery, indicators related to spina bifida (deformity side, comorbidity, sensory disturbance level), and information related to surgery (operating time, surgical site, postoperative fixation method) were analyzed.

RESULTS

Of the 1012 patients, 457 were males and 555 were females. The age was 3-51 years at the time of surgery, with a median of 18.0 years; among them, the 15-30 years old group had the most patients, accounting for 53.16%. Most deformities involved both lower limbs (652 cases, 64.43%). There were 111 cases of ulcers in the weight-bearing area of the foot, 265 cases of gatism, 554 cases of sensory disturbance, and 85 cases of abnormal hair on the waist. From 2010 to 2019, there were significantly more patients undergoing surgery than before 2010, reaching 61.17%. Sensory disturbances mostly occurred in the ankle and foot. A total of 1 149 sites were treated with surgery, of which the most ankle joint deformities were corrected by surgery, accounting for 84.33%. The main fixation methods after orthopedic surgery were external fixation, including Ilizarov external fixation (442 cases), combined external fixation (315 cases), and plaster fixation (189 cases).

CONCLUSION

Spina bifida can be secondary to severe deformities of the lower limbs, mainly in the ankles. Common complications include ulcers in the weight-bearing area, dysfunction of urine and feces, and sensory disturbances; external fixation is the main method of fixation after surgery.