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Tenan MS, Galvin JW, Mauntel TC, Tokish JM, Bailey JR, Barlow BT, Bevevino AJ, Bradley MW, Cameron KL, Burns TC, Eckel TT, Garcia EJ, Giuliani JR, Haley CA, Hurvitz AP, Janney CF, Kilcoyne KG, Lanzi JT, LeClere LE, McDonald LS, Min KS, Nesti LJ, Pallis M, Patzkowski JC, Posner MA, Potter BK, Provencher MA, Rhon DI, Roach CJ, Robins RJ, Ryan PM, Schmitz MR, Schuett DJ, Sheean AJ, Slabaugh MA, Smith JL, Volk WR, Waltz RA, Dickens JF. Generating the American Shoulder and Elbow Surgeons Score Using Multivariable Predictive Models and Computer Adaptive Testing to Reduce Survey Burden. Am J Sports Med 2021; 49:764-772. [PMID: 33523718 DOI: 10.1177/0363546520987240] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The preferred patient-reported outcome measure for the assessment of shoulder conditions continues to evolve. Previous studies correlating the Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive tests (CATs) to the American Shoulder and Elbow Surgeons (ASES) score have focused on a singular domain (pain or physical function) but have not evaluated the combined domains of pain and physical function that compose the ASES score. Additionally, previous studies have not provided a multivariable prediction tool to convert PROMIS scores to more familiar legacy scores. PURPOSE To establish a valid predictive model of ASES scores using a nonlinear combination of PROMIS domains for physical function and pain. STUDY DESIGN Cohort study (Diagnosis); Level of evidence, 3. METHODS The Military Orthopaedics Tracking Injuries and Outcomes Network (MOTION) database is a prospectively collected repository of patient-reported outcomes and intraoperative variables. Patients in MOTION research who underwent shoulder surgery and completed the ASES, PROMIS Physical Function, and PROMIS Pain Interference at varying time points were included in the present analysis. Nonlinear multivariable predictive models were created to establish an ASES index score and then validated using "leave 1 out" techniques and minimal clinically important difference /substantial clinical benefit (MCID/SCB) analysis. RESULTS A total of 909 patients completed the ASES, PROMIS Physical Function, and PROMIS Pain Interference at presurgery, 6 weeks, 6 months, and 1 year after surgery, providing 1502 complete observations. The PROMIS CAT predictive model was strongly validated to predict the ASES (Pearson coefficient = 0.76-0.78; R2 = 0.57-0.62; root mean square error = 13.3-14.1). The MCID/SCB for the ASES was 21.7, and the best ASES index MCID/SCB was 19.4, suggesting that the derived ASES index is effective and can reliably re-create ASES scores. CONCLUSION The PROMIS CAT predictive models are able to approximate the ASES score within 13 to 14 points, which is 7 points more accurate than the ASES MCID/SCB derived from the sample. Our ASES index algorithm, which is freely available online (https://osf.io/ctmnd/), has a lower MCID/SCB than the ASES itself. This algorithm can be used to decrease patient survey burden by 11 questions and provide a reliable ASES analog to clinicians.
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Affiliation(s)
- Matthew S Tenan
- Investigation performed at the Defense Health Agency, Military Health System for the US Military, Rosslyn, Virginia, USA
| | - Joseph W Galvin
- Investigation performed at the Defense Health Agency, Military Health System for the US Military, Rosslyn, Virginia, USA
| | - Timothy C Mauntel
- Investigation performed at the Defense Health Agency, Military Health System for the US Military, Rosslyn, Virginia, USA
| | - John M Tokish
- Investigation performed at the Defense Health Agency, Military Health System for the US Military, Rosslyn, Virginia, USA
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- Investigation performed at the Defense Health Agency, Military Health System for the US Military, Rosslyn, Virginia, USA
| | - James R Bailey
- Investigation performed at the Defense Health Agency, Military Health System for the US Military, Rosslyn, Virginia, USA
| | - Brian T Barlow
- Investigation performed at the Defense Health Agency, Military Health System for the US Military, Rosslyn, Virginia, USA
| | - Adam J Bevevino
- Investigation performed at the Defense Health Agency, Military Health System for the US Military, Rosslyn, Virginia, USA
| | - Matthew W Bradley
- Investigation performed at the Defense Health Agency, Military Health System for the US Military, Rosslyn, Virginia, USA
| | - Kenneth L Cameron
- Investigation performed at the Defense Health Agency, Military Health System for the US Military, Rosslyn, Virginia, USA
| | - Travis C Burns
- Investigation performed at the Defense Health Agency, Military Health System for the US Military, Rosslyn, Virginia, USA
| | - Tobin T Eckel
- Investigation performed at the Defense Health Agency, Military Health System for the US Military, Rosslyn, Virginia, USA
| | - Estephan J Garcia
- Investigation performed at the Defense Health Agency, Military Health System for the US Military, Rosslyn, Virginia, USA
| | - Jeffrey R Giuliani
- Investigation performed at the Defense Health Agency, Military Health System for the US Military, Rosslyn, Virginia, USA
| | - Chad A Haley
- Investigation performed at the Defense Health Agency, Military Health System for the US Military, Rosslyn, Virginia, USA
| | - Andrew P Hurvitz
- Investigation performed at the Defense Health Agency, Military Health System for the US Military, Rosslyn, Virginia, USA
| | - Cory F Janney
- Investigation performed at the Defense Health Agency, Military Health System for the US Military, Rosslyn, Virginia, USA
| | - Kelly G Kilcoyne
- Investigation performed at the Defense Health Agency, Military Health System for the US Military, Rosslyn, Virginia, USA
| | - Joseph T Lanzi
- Investigation performed at the Defense Health Agency, Military Health System for the US Military, Rosslyn, Virginia, USA
| | - Lance E LeClere
- Investigation performed at the Defense Health Agency, Military Health System for the US Military, Rosslyn, Virginia, USA
| | - Lucas S McDonald
- Investigation performed at the Defense Health Agency, Military Health System for the US Military, Rosslyn, Virginia, USA
| | - Kyong S Min
- Investigation performed at the Defense Health Agency, Military Health System for the US Military, Rosslyn, Virginia, USA
| | - Leon J Nesti
- Investigation performed at the Defense Health Agency, Military Health System for the US Military, Rosslyn, Virginia, USA
| | - Mark Pallis
- Investigation performed at the Defense Health Agency, Military Health System for the US Military, Rosslyn, Virginia, USA
| | - Jeanne C Patzkowski
- Investigation performed at the Defense Health Agency, Military Health System for the US Military, Rosslyn, Virginia, USA
| | - Matthew A Posner
- Investigation performed at the Defense Health Agency, Military Health System for the US Military, Rosslyn, Virginia, USA
| | - Benjamin K Potter
- Investigation performed at the Defense Health Agency, Military Health System for the US Military, Rosslyn, Virginia, USA
| | - Matthew A Provencher
- Investigation performed at the Defense Health Agency, Military Health System for the US Military, Rosslyn, Virginia, USA
| | - Daniel I Rhon
- Investigation performed at the Defense Health Agency, Military Health System for the US Military, Rosslyn, Virginia, USA
| | - Christopher J Roach
- Investigation performed at the Defense Health Agency, Military Health System for the US Military, Rosslyn, Virginia, USA
| | - Richard J Robins
- Investigation performed at the Defense Health Agency, Military Health System for the US Military, Rosslyn, Virginia, USA
| | - Paul M Ryan
- Investigation performed at the Defense Health Agency, Military Health System for the US Military, Rosslyn, Virginia, USA
| | - Matthew R Schmitz
- Investigation performed at the Defense Health Agency, Military Health System for the US Military, Rosslyn, Virginia, USA
| | - Dustin J Schuett
- Investigation performed at the Defense Health Agency, Military Health System for the US Military, Rosslyn, Virginia, USA
| | - Andrew J Sheean
- Investigation performed at the Defense Health Agency, Military Health System for the US Military, Rosslyn, Virginia, USA
| | - Mark A Slabaugh
- Investigation performed at the Defense Health Agency, Military Health System for the US Military, Rosslyn, Virginia, USA
| | - Jennifer L Smith
- Investigation performed at the Defense Health Agency, Military Health System for the US Military, Rosslyn, Virginia, USA
| | - William R Volk
- Investigation performed at the Defense Health Agency, Military Health System for the US Military, Rosslyn, Virginia, USA
| | - Robert A Waltz
- Investigation performed at the Defense Health Agency, Military Health System for the US Military, Rosslyn, Virginia, USA
| | - Jonathan F Dickens
- Investigation performed at the Defense Health Agency, Military Health System for the US Military, Rosslyn, Virginia, USA
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Abstract
OBJECTIVES To determine whether there is a patient-reported functional difference between combat-related knee disarticulations (KDs) and transfemoral amputations (TFAs). SETTING Role 3 Military Trauma Centers. PATIENTS We identified and contacted all KDs and TFAs performed at the Walter Reed National Military Medical Center, Walter Reed Army Medical Center, and National Naval Medical Center from January 2003 until July 2012 to participate in a retrospective functional cohort analysis. Ten KD patients were available for study completion and were matched against 18 patients in the TFA group. INTERVENTION Knee disarticulation versus transfemoral amputation. MAIN OUTCOME MEASUREMENTS The following surveys were obtained from the participants-AAOS Lower Limb Outcome Questionnaire (LLQ), Tegner Activity Scale, SF-36, and Prosthetic Evaluation Questionnaires (PEQs). RESULTS Ten KD patients agreed to participate in the study, and 18 TFA matched controls were interviewed. Patients were followed up at an average of 66 months (interquartile range 50-79 months) after injury. There were no significant differences with regard to the SF-36, PEQ, LLQ, and Tegner Activity Scale scores. CONCLUSIONS We detected no functional differences measured on the PEQ, LLQ, SF-36, and Tegner Activity Scale scores between KDs and TFAs. In the absence of a proven functional difference, we advocate performing trauma-related amputations at the most distal level the osseous and soft tissue injuries permit. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Elizabeth M Polfer
- Department of Orthopaedics, William Beaumont Army Medical Center, El Paso, TX
- Department of Surgery, Uniformed Services University, Bethesda, MD
| | - Benjamin W Hoyt
- Department of Surgery, Uniformed Services University, Bethesda, MD
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD
| | - Adam J Bevevino
- Department of Orthopaedics, William Beaumont Army Medical Center, El Paso, TX
- Department of Surgery, Uniformed Services University, Bethesda, MD
| | - Jonathan A Forsberg
- Department of Surgery, Uniformed Services University, Bethesda, MD
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD
| | - Benjamin K Potter
- Department of Surgery, Uniformed Services University, Bethesda, MD
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD
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Lehman RA, Kang DG, Lenke LG, Sucato DJ, Bevevino AJ. Return to sports after surgery to correct adolescent idiopathic scoliosis: a survey of the Spinal Deformity Study Group. Spine J 2015; 15:951-8. [PMID: 24099682 DOI: 10.1016/j.spinee.2013.06.035] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Revised: 03/29/2013] [Accepted: 06/14/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT There are no guidelines for when surgeons should allow patients to return to sports and athletic activities after spinal fusion for adolescent idiopathic scoliosis (AIS). Current recommendations are based on anecdotal reports and a survey performed more than a decade ago in the era of first/second-generation posterior implants. PURPOSE To identify current recommendations for return to sports and athletic activities after surgery for AIS. STUDY DESIGN/SETTING Questionnaire-based survey. PATIENT SAMPLE Adolescent idiopathic scoliosis after corrective surgery. OUTCOME MEASURES Type and time to return to sports. METHODS A survey was administered to members of the Spinal Deformity Study Group. The survey consisted of surgeon demographic information, six clinical case scenarios, three different construct types (hooks, pedicle screws, hybrid), and questions regarding the influence of lowest instrumented vertebra (LIV) and postoperative physical therapy. RESULTS Twenty-three surgeons completed the survey, and respondents were all experienced expert deformity surgeons. Pedicle screw instrumentation allows earlier return to noncontact and contact sports, with most patients allowed to return to running by 3 months, both noncontact and contact sports by 6 months, and collision sports by 12 months postoperatively. For all construct types, approximately 20% never allow return to collision sports, whereas all surgeons allow eventual return to contact and noncontact sports regardless of construct type. In addition to construct type, we found progressively distal LIV resulted in more surgeons never allowing return to collision sports, with 12% for selective thoracic fusion to T12/L1 versus 33% for posterior spinal fusion to L4. Most respondents also did not recommend formal postoperative physical therapy (78%). Of all surgeons surveyed, there was only one reported instrumentation failure/pullout without neurologic deficit after a patient went snowboarding 2 weeks postoperatively. CONCLUSIONS Modern posterior instrumentation allows surgeons to recommend earlier return to sports after fusion for AIS, with the majority allowing running by 3 months, noncontact and contact sports by 6 months, and collision sports by 12 months.
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Affiliation(s)
- Ronald A Lehman
- Department of Orthopaedic Surgery and Rehabilitation, Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bethesda, MD 20889, USA; Division of Orthopaedics, Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA.
| | - Daniel G Kang
- Department of Orthopaedic Surgery and Rehabilitation, Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bethesda, MD 20889, USA
| | - Lawrence G Lenke
- Department of Orthopaedic Surgery, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8233, St. Louis, MO 63110, USA
| | - Daniel J Sucato
- Department of Orthopaedic Surgery, Texas Scottish Rite Hospital for Children, 2222 Welborn Street, Dallas, TX 75219, USA
| | - Adam J Bevevino
- Department of Orthopaedic Surgery and Rehabilitation, Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bethesda, MD 20889, USA
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Kang DG, Lehman RA, Wagner SC, Bevevino AJ, Tracey RW, Gaume RE, Dmitriev AE. Effects of rod reduction on pedicle screw fixation strength in the setting of Ponte osteotomies. Spine J 2015; 15:146-52. [PMID: 25088957 DOI: 10.1016/j.spinee.2014.07.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Revised: 06/10/2014] [Accepted: 07/29/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The use of a rod reduction device can have deleterious consequences on pedicle screw pullout strength (POS) in the thoracic spine. However, posterior-only osteotomies in the thoracic spine are often performed to improve flexibility of the spine and offset forces of deformity correction maneuvers. PURPOSE To investigate the effect on pedicle screw POS caused by the rod reduction technique in the presence of facet osteotomies in the thoracic spine. STUDY DESIGN/SETTING The study is a biomechanical study using human cadaveric spine specimens. METHODS Thoracic Ponte osteotomies were performed on 3 thoracic levels in 15 cadaveric specimens. The right rod was contoured with a 5-mm residual gap at the middle level and was reduced using a rod reduction device. On the left side (paired control), a rod with no mismatch was placed. Biomechanical testing was performed with tensile load to failure "in line" with the screw axis and POS measured in Newtons (N). RESULTS After rod reduction, thoracic pedicle screw POS was significantly decreased (40%) compared with the control (419±426 N vs. 708±462 N, p=.002) and remained statistically significant after adjusting for bone mineral density (BMD) (p=.05). Eleven (73%) of the pedicle screws had visible pullout/failure during the reduction attempt and occurred irrespective of BMD. CONCLUSIONS Despite thoracic Ponte osteotomies and increased flexibility of the spinal segments, the rod reduction device still significantly decreased pedicle screw POS, typically resulting in outright failure of the screw-bone interface. Therefore, rod reduction technique of any kind should be performed with caution as it frequently results in suboptimal pedicle screw fixation.
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Affiliation(s)
- Daniel G Kang
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bldg 19, Rm #2101, Bethesda, MD 20889, USA
| | - Ronald A Lehman
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bldg 19, Rm #2101, Bethesda, MD 20889, USA; Division of Orthopaedics, Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA.
| | - Scott C Wagner
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bldg 19, Rm #2101, Bethesda, MD 20889, USA
| | - Adam J Bevevino
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bldg 19, Rm #2101, Bethesda, MD 20889, USA
| | - Robert W Tracey
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bldg 19, Rm #2101, Bethesda, MD 20889, USA
| | - Rachel E Gaume
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bldg 19, Rm #2101, Bethesda, MD 20889, USA
| | - Anton E Dmitriev
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bldg 19, Rm #2101, Bethesda, MD 20889, USA; Division of Orthopaedics, Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
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Abstract
BACKGROUND Open calcaneus fractures can be limb threatening and almost universally result in some measure of long-term disability. A major goal of initial management in patients with these injuries is setting appropriate expectations and discussing the likelihood of limb salvage, yet there are few tools that assist in predicting the outcome of this difficult fracture pattern. QUESTIONS/PURPOSES We developed two decision support tools, an artificial neural network and a logistic regression model, based on presenting data from severe combat-related open calcaneus fractures. We then determined which model more accurately estimated the likelihood of amputation and which was better suited for clinical use. METHODS Injury-specific data were collected from wounded active-duty service members who sustained combat-related open calcaneus fractures between 2003 and 2012. One-hundred fifty-five open calcaneus fractures met inclusion criteria. Median followup was 3.5 years (interquartile range: 1.5, 5.1 years), and amputation rate was 44%. We developed an artificial neural network designed to estimate the likelihood of amputation, using information available on presentation. For comparison, a conventional logistic regression model was developed with variables identified on univariate analysis. We determined which model more accurately estimated the likelihood of amputation using receiver operating characteristic analysis. Decision curve analysis was then performed to determine each model's clinical utility. RESULTS An artificial neural network that contained eight presenting features resulted in smaller error. The eight features that contributed to the most predictive model were American Society of Anesthesiologist grade, plantar sensation, fracture treatment before arrival, Gustilo-Anderson fracture type, Sanders fracture classification, vascular injury, male sex, and dismounted blast mechanism. The artificial neural network was 30% more accurate, with an area under the curve of 0.8 (compared to 0.65 for logistic regression). Decision curve analysis indicated the artificial neural network resulted in higher benefit across the broadest range of threshold probabilities compared to the logistic regression model and is perhaps better suited for clinical use. CONCLUSIONS This report demonstrates an artificial neural network was capable of accurately estimating the likelihood of amputation. Furthermore, decision curve analysis suggested the artificial neural network is better suited for clinical use than logistic regression. Once properly validated, this may provide a tool for surgeons and patients faced with combat-related open calcaneus fractures in which decisions between limb salvage and amputation remain difficult.
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Affiliation(s)
- Adam J. Bevevino
- />Regenerative Medicine Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910 USA
- />Department of Orthopaedics, National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889 USA
- />Department of Surgery, Uniformed Services University of Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814 USA
| | - Jonathan F. Dickens
- />Department of Orthopaedics, National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889 USA
- />Department of Surgery, Uniformed Services University of Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814 USA
| | - Benjamin K. Potter
- />Regenerative Medicine Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910 USA
- />Department of Orthopaedics, National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889 USA
- />Department of Surgery, Uniformed Services University of Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814 USA
| | - Theodora Dworak
- />Department of Orthopaedics, National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889 USA
| | - Wade Gordon
- />Department of Orthopaedics, National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889 USA
- />Department of Surgery, Uniformed Services University of Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814 USA
| | - Jonathan A. Forsberg
- />Regenerative Medicine Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910 USA
- />Department of Orthopaedics, National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889 USA
- />Department of Surgery, Uniformed Services University of Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814 USA
- />Section of Orthopaedics and Sports Medicine, Department of Molecular Medicine and Surgery, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
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Bevevino AJ, Kang DG, Lehman RA, Van Blarcum GS, Wagner SC, Gwinn DE. Systematic review and meta-analysis of minimally invasive transforaminal lumbar interbody fusion rates performed without posterolateral fusion. J Clin Neurosci 2014; 21:1686-90. [PMID: 24913928 DOI: 10.1016/j.jocn.2014.02.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Revised: 02/14/2014] [Accepted: 02/22/2014] [Indexed: 10/25/2022]
Abstract
The need for posterolateral fusion (PLF) in addition to interbody fusion during minimally invasive (MIS) transforaminal lumbar interbody fusion (TLIF) has yet to be established. Omitting a PLF significantly reduces overall surface area available for achieving a solid arthrodesis, however it decreases the soft tissue dissection and costs of additional bone graft. The authors sought to perform a meta-analysis to establish the fusion rate of MIS TLIF performed without attempting a PLF. We performed an extensive Medline and Ovid database search through December 2010 revealing 39 articles. Inclusion criteria necessitated that a one or two level TLIF procedure was performed through a paramedian MIS approach with bilateral posterior pedicle screw instrumentation and without posterolateral bone grafting. CT scan verified fusion rates were mandatory for inclusion. Seven studies (case series and case-controls) met inclusion criteria with a total of 408 patients who underwent MIS TLIF as described above. The mean age was 50.7 years and 56.6% of patients were female. A total of 78.9% of patients underwent single level TLIF. Average radiographic follow-up was 15.6 months. All patients had local autologous interbody bone grafting harvested from the pars interarticularis and facet joint of the approach side. Either polyetheretherketone (PEEK) or allograft interbody cages were used in all patients. Overall fusion rate, confirmed by bridging trabecular interbody bone on CT scan, was 94.7%. This meta-analysis suggests that MIS TLIF performed with interbody bone grafting alone has similar fusion rates to MIS or open TLIF performed with interbody supplemented with posterolateral bone grafting and fusion.
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Affiliation(s)
- Adam J Bevevino
- Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Building #19, Bethesda, MD 20889, USA
| | - Daniel G Kang
- Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Building #19, Bethesda, MD 20889, USA.
| | - Ronald A Lehman
- Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Building #19, Bethesda, MD 20889, USA
| | - Gregory S Van Blarcum
- Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Building #19, Bethesda, MD 20889, USA
| | - Scott C Wagner
- Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Building #19, Bethesda, MD 20889, USA
| | - David E Gwinn
- Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Building #19, Bethesda, MD 20889, USA
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Bevevino AJ, Lehman RA, Tintle SM, Kang DG, Dworak TC, Potter BK. Incidence and morbidity of concomitant spine fractures in combat-related amputees. Spine J 2014; 14:646-50. [PMID: 24071037 DOI: 10.1016/j.spinee.2013.06.098] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Revised: 05/28/2013] [Accepted: 06/24/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT High-energy blasts are the most frequent cause of combat-related amputations in Operations Iraqi and Enduring Freedom (OIF/OEF). The nondiscriminating effects of this mechanism often result in both appendicular and axial skeletal injuries. Despite this recognized coincident injury pattern, the incidence and consequence of spine fractures in trauma-related combat amputees are unknown. PURPOSE This study sought to determine the incidence and morbidity of the associated spine fractures on patients with traumatic lower extremity amputation sustained during OIF/OEF. STUDY DESIGN/SETTING Retrospective case control. PATIENT SAMPLE Two hundred twenty-six combat-related lower extremity amputees presenting to a single institution and injured between 2003 and 2008 were included for analysis. OUTCOME MEASURES Physiologic and functional outcome measures were used to determine the influence of spine fractures on combat amputees. Physiologic measures included intensive care unit (ICU) admission rates, injury severity score (ISS), rate of narcotic/neuropathic pain use, and heterotopic ossification (HO) rates. Functional outcome measures included return-to-duty rates and ambulatory status at final follow-up. METHODS Data from 300 consecutive combat-related lower extremity amputations were retrospectively reviewed and grouped. Group 1 consisted of amputees with associated spine fractures, and Group 2 consisted of amputees without spine fractures. The results of the two groups were compared with regard to initial presentation and final functional outcomes. RESULTS A total of 226 patients sustained 300 lower extremity amputations secondary to combat-related injuries, the most common mechanism being an improvised explosive device. Twenty-nine of these patients had a spine fracture (13%). Group 1 had a higher ISS than Group 2 (30 vs. 19, p<.001). Group 1 patients were also more likely to be admitted to the ICU (86% vs. 46%, p<.001). Furthermore, Group 1 patients had a significantly higher rate of HO in their residual limbs (82% vs. 55%, p<.005). CONCLUSIONS The incidence of spine fractures in combat-related amputees is 13%. The results suggest that combat-related amputees with spine fractures are more likely to sustain severe injuries to other body systems, as indicated by the significantly higher ISS and rates of ICU admission. This group also had a significantly higher rate of HO formation, which may be attributable to the greater local and/or systemic injuries sustained by these patients.
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Affiliation(s)
- Adam J Bevevino
- Department of Orthopedics, Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bethesda, MD 20889, USA.
| | - Ronald A Lehman
- Department of Orthopedics, Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bethesda, MD 20889, USA
| | - Scott M Tintle
- Department of Orthopedics, Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bethesda, MD 20889, USA
| | - Daniel G Kang
- Department of Orthopedics, Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bethesda, MD 20889, USA
| | - Theodora C Dworak
- Department of Orthopedics, Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bethesda, MD 20889, USA
| | - Benjamin K Potter
- Department of Orthopedics, Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bethesda, MD 20889, USA
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Kang DG, Lehman RA, Tracey RW, Cody JP, Rosner MK, Bevevino AJ. Outcomes following cervical disc arthroplasty in an active duty military population. J Surg Orthop Adv 2013; 22:10-5. [PMID: 23449049 DOI: 10.3113/jsoa.2013.0010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Symptomatic cervical radiculopathy is a common problem in the active duty military population and can cause significant disability leading to limited duty status and loss of operational readiness and strength. Based on their increasing experience with cervical disc arthroplasty (CDA) in this unique patient population, the authors set out to further evaluate the outcomes and complications of CDA in active duty military patients. A retrospective review of a single military tertiary medical center was performed between August 2008 and August 2012 and the clinical outcomes of patients who underwent cervical disc arthroplasty were evaluated. There were 37 active duty military patients, with a total of 41 CDA. The study found good relief of preoperative symptoms (92%) and the ability to maintain operational readiness with a high rate of return to full unrestricted duty (95%) with an average follow-up of 6 months. There was a low rate of complications related to the anterior cervical approach (5%-8%), with no device- or implant-related complications.
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Affiliation(s)
- Daniel G Kang
- Department of Orthopaedic Surgery and Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA.
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Bevevino AJ, Lehman RA. Commentary: Access to care affects the rate of spinal deformity surgery. Spine J 2013; 13:124-6. [PMID: 23452568 DOI: 10.1016/j.spinee.2012.11.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Accepted: 11/20/2012] [Indexed: 02/03/2023]
Affiliation(s)
- Adam J Bevevino
- Division of Orthopaedics, Department of Orthopaedic Surgery and Rehabilitation, Uniform Services University of Health Sciences, Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bethesda, MD 20889, USA
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Lehman R, Bevevino AJ, Brewer DD, Skelly AC, Anderson PA. A systematic review of cervical artificial disc replacement wear characteristics and durability. Evid Based Spine Care J 2012; 3:31-8. [PMID: 23236311 PMCID: PMC3519402 DOI: 10.1055/s-0031-1298606] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Study design: Systematic review. Clinical questions: (1) What evidence is available from studies of cervical total disc arthroplasty (C-ADR) failure and retrieval regarding durability, wear, and reasons for failure of C-ADR? (2) What evidence is available from experimental models regarding the durability of C-ADR beyond 5 years? Methods: We searched electronic databases to identify published reports of explanted cervical artificial discs and biomechanical simulations of disc wear. Results: Nine articles were identified describing 17 devices explanted from human patients and four articles describing 23 devices explanted from non-human subjects. Wear properties were not consistently reported across studies, so summaries for specific variables are based on few cases. No device had been implanted longer than 4 years. In both human and non-human subjects, devices showed evidence of metallic and polymeric (for discs with polymer components) debris. Inflammatory cells were frequently present in surrounding soft tissues. Signs of infection were uncommon. Four patients had reactions interpreted as hypersensitivity to metal. We identified three articles on biomechanical wear simulations. Devices were tested between 10 and 20 million cycles in axial loading, flexion/extension, and lateral bending. No device failures were reported. One study suggests such simulations may represent 50 or more years of wear in actual patients. Conclusion: Cervical disc implants consistently produced polymeric and metallic debris, which was typically accompanied by inflammation. Hypersensitivity to metal may increase risk for device failure. Biomechanical simulations indicate that cervical disc implants may be durable beyond the currently reported length of clinical follow-up.
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Affiliation(s)
- Ronald Lehman
- Walter Reed National Military Medical Center, Bethesda, MD, USA
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Affiliation(s)
- Daniel G Kang
- Department of Orthopaedic Surgery and Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
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Kang DG, Lehman RA, Laufer DM, Bevevino AJ. Development of Scoliosis Following Complex Combat-Related Lower-Extremity Amputations: Two Case Reports. JBJS Case Connect 2012; 2:e19. [PMID: 29252420 DOI: 10.2106/jbjs.cc.k.00146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Daniel G Kang
- Department of Orthopaedic Surgery and Rehabilitation, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889.
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Bevevino AJ, Lehman RA. Commentary: Electromyographic thresholds for stimulated thoracic pedicle screws are influenced by multiple factors. Spine J 2012; 12:133-5. [PMID: 22405615 DOI: 10.1016/j.spinee.2012.01.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2011] [Accepted: 01/05/2012] [Indexed: 02/03/2023]
Affiliation(s)
- Adam J Bevevino
- Integrated Department of Orthopaedic Surgery and Rehabilitation, Walter Reed National Military Medical Center, 8901 Wisconsin Ave. NW, Bethesda, MD 20889, USA
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