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Linden GS, Lee S, Cook D, Birch CM, Hedequist DJ, Hresko MT, Hogue GD. Is the Child Opportunity Index a Factor in Surgical Outcomes for Adolescent Idiopathic Scoliosis? J Pediatr Orthop 2024; 44:e394-e399. [PMID: 38523414 DOI: 10.1097/bpo.0000000000002658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
Abstract
BACKGROUND Low socioeconomic status (SES) has been previously associated with delays in orthopaedic care. However, it is unclear how SES impacts patients with adolescent idiopathic scoliosis (AIS), particularly regarding preoperative major coronal curve angle or surgical outcomes. Utilizing the Child Opportunity Index (COI)-an address-driven measure of pediatric education, health/environment, and SES-we investigated whether COI is associated with differences in preoperative scoliosis magnitude, age at surgery, and AIS surgical outcomes. METHODS Consecutive patients with AIS surgically treated at a single center from 2011 to 2017 were reviewed. COI was calculated by inserting a patient's home address into the nationally available COI database to derive a COI value. COI is scored from 0.0 to 100.0 (0.0 is lowest, 100.0 is highest). Specifically, COI is categorized as very low (<20.0), low (20 to 39.9), moderate (40 to 59.9), high (60 to 79.9), and very high (≥80). Those without addresses were excluded. Patients without proper radiographs to assess curve correction were also excluded. A COI threshold of 60.0 was used to separate patients into a low (<60.0) or high COI ( ) group based on published COI guidelines. Outcomes, including preoperative curve magnitude, age at surgery, percentage curve correction, operative time (OT), intraoperative estimated blood loss per level fused, length of stay, and complications, were compared across groups. Pearson correlation analysis was used to assess correlations between COI and preoperative curve magnitude, as well as age. RESULTS Four hundred four patients were included in the study, and 263 had 2-year follow-up data. Patients were an average age of 14.9 years old (range: 11.2 to 19.8), had a median COI of 76 (range: 4 to 100), and had a mean preoperative major curve angle of 59 degrees (range: 36 to 93). COI was significantly higher for white patients compared with non-white (80.0 vs 40.0, P < 0.001), and higher for non-Hispanic individuals (79.0 vs 15.0, P < 0.001). Patients with Low COI were associated with a lower OT per level fused ( P = 0.003) and decreased postoperative complication risk ( P = 0.02). COI was not associated with preoperative major coronal curve angle, age at surgery, or any other surgical outcomes. CONCLUSION COI was significantly lower for non-white patients and those of Hispanic ethnicity. Patients from low COI backgrounds achieved similar surgical results as those from high COI addresses and had a decreased OT per level fused and complication incidence, though the clinical significance of these differences is unknown. Future prospective studies are needed to determine whether these findings are reproducible across other states and health systems. LEVEL OF EVIDENCE Level III-prognostic study.
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Affiliation(s)
- Gabriel S Linden
- Department of Orthopaedic Surgery, Boston Children's Hospital
- Tufts University School of Medicine
| | - Sydney Lee
- Department of Orthopaedic Surgery, Boston Children's Hospital
| | - Danielle Cook
- Department of Orthopaedic Surgery, Boston Children's Hospital
| | - Craig M Birch
- Department of Orthopaedic Surgery, Boston Children's Hospital
- Harvard Medical School, Boston, MA
| | - Daniel J Hedequist
- Department of Orthopaedic Surgery, Boston Children's Hospital
- Harvard Medical School, Boston, MA
| | - M Timothy Hresko
- Department of Orthopaedic Surgery, Boston Children's Hospital
- Harvard Medical School, Boston, MA
| | - Grant D Hogue
- Department of Orthopaedic Surgery, Boston Children's Hospital
- Harvard Medical School, Boston, MA
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Liu DS, Farid AR, Linden GS, Cook D, Birch CM, Hresko MT, Hedequist DJ, Hogue GD. Utility of postoperative laboratory testing after posterior spinal fusion for adolescent idiopathic scoliosis. Spine Deform 2024; 12:375-381. [PMID: 37884756 DOI: 10.1007/s43390-023-00771-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 09/23/2023] [Indexed: 10/28/2023]
Abstract
PURPOSE With advancements to blood management strategies, risk of perioperative transfusion following surgical treatment of adolescent idiopathic scoliosis (AIS) has diminished. We hypothesize that routine laboratory testing on postoperative-day 1 (POD1) and beyond is unnecessary. The purpose of this study is to determine necessity of POD1 labs, particularly hematocrit and hemoglobin levels, following surgical management of AIS. METHODS We performed a retrospective cohort study of consecutive AIS patients aged 11-19 who underwent posterior spinal fusion (PSF) at a single institution. Univariable logistic regression was utilized to determine factors associated with hematocrit ≤ 22% on POD1 or a postoperative transfusion. Firth's penalized logistic regression was used for any separation in data. Youden's index was utilized to determine the optimal point on the ROC curve that maximizes both sensitivity and specificity. RESULTS 527 patients qualified for this study. Among the eight total patients with POD1 hematocrit ≤ 22, none underwent transfusion. These patients had lower last intraoperative hematocrit levels compared to patients with POD1 hematocrit > 22% (24.1% vs 31.5%, p < 0.001), and these groups showed no difference in preoperative hematocrit levels (38.2% vs 39.8%, p = 0.11). Four patients underwent postoperative transfusion. Both preoperative hematocrit levels (34.0% vs 39.9%, p = 0.001) and last intraoperative hematocrit levels (25.1% vs 31.4%, p = 0.002) were lower compared to patients without transfusion. Intraoperative hematocrit < 26.2%, operative time of more than 35.8 min per level fused, or cell salvage > 241 cc were significant risk factors for postoperative transfusion. CONCLUSION Transfusion after PSF for AIS is exceedingly rare. POD1 labs should be considered when last intraoperative hematocrit < 26%, operative time per level fused > 35 min, or cell salvage amount > 241 cc. Otherwise, unless symptomatic, patients do not benefit from postoperative laboratory screening.
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Affiliation(s)
- David S Liu
- Harvard Combined Orthopaedic Residency Program, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | | | - Gabriel S Linden
- Department of Orthopaedic Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Danielle Cook
- Department of Orthopaedic Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Craig M Birch
- Harvard Medical School, Boston, MA, USA
- Department of Orthopaedic Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - M Timothy Hresko
- Harvard Medical School, Boston, MA, USA
- Department of Orthopaedic Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Daniel J Hedequist
- Harvard Medical School, Boston, MA, USA
- Department of Orthopaedic Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Grant D Hogue
- Harvard Medical School, Boston, MA, USA.
- Department of Orthopaedic Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA.
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Lins LAB, Birch CM, Berde C, Emans J, Hedequist D, Hresko MT, Karlin L, Glotzbecker MP. Late-presenting dural leak following spine fusion in the pediatric population. Spine Deform 2023; 11:1371-1380. [PMID: 37488330 DOI: 10.1007/s43390-023-00720-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 01/30/2022] [Accepted: 06/10/2023] [Indexed: 07/26/2023]
Abstract
PURPOSE The purpose is to describe how patients with a late-presenting dural leak (LPDL) after posterior spinal fusion (PSF) was diagnosed and treated at a single institution. METHODS Of the 1991 patients who underwent a PSF between 2010 and 2018, 6 patients were identified with a clinical course consistent with a potential LPDL. RESULTS Six patients with median age 16.9 years had onset of headache ranging 1-12 weeks postoperatively (median 6.5 weeks). All six patients presented with positional headache, and half (3/6) presented with emesis. 5/6 patients underwent contrast brain MRI, which demonstrated pachymeningeal enhancement. 4/5 patients with dural enhancement went on to have CT myelogram. Five patients had a CT myelogram, which identified a dural leak in all patients and localized the leak in four of five patients. All patients underwent an epidural blood patch, which resolved the pain in five patients. One patient without relief underwent revision surgery with removal of a medially placed screw and fibrin glue placement resolving symptoms. CONCLUSIONS Postoperative dural leaks associated with PSF may present in a delayed fashion. The majority of leaks were not associated with screw malposition. In diagnosing patients with suspected LPDL, we suggest brain MRI with contrast as a first step. Most patients with pachymeningeal enhancement shown on contrast brain MRI had dural leaks that were identified through CT myelograms. For patients with a dural leak, if there is no disruption from screws, a blood patch appears to be an effective treatment. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Laura A B Lins
- Department of Orthopedics and Rehabilitation, University of Wisconsin Hospitals and Clinics, Madison, WI, USA.
| | - Craig M Birch
- Department of Orthopedics, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Charles Berde
- Harvard Medical School, Boston, MA, USA
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - John Emans
- Department of Orthopedics, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Daniel Hedequist
- Department of Orthopedics, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - M Timothy Hresko
- Department of Orthopedics, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Lawrence Karlin
- Department of Orthopedics, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Michael P Glotzbecker
- Department of Orthopedics, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Orthopedics, Rainbow Babies and Children's Hospital, Cleveland, OH, USA
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Montgomery BK, Cidambi EO, Birch CM, Wang K, Miller PE, Kim DS, Shore BJ. Minimizing Surgeon Radiation Exposure During Operative Treatment of Pediatric Supracondylar Humerus Fractures. J Pediatr Orthop 2023:01241398-990000000-00272. [PMID: 37104779 DOI: 10.1097/bpo.0000000000002421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
BACKGROUND Orthopaedic surgeons are exposed to high levels of radiation, which may lead to higher rates of cancer among orthopaedic surgeons. There are a series of techniques currently practiced to pin supracondylar humerus fractures including pinning the arm on the C-arm itself, using a plexiglass rectangle or a graphite floating arm board; however, the variation in radiation exposure to the surgeon is unknown. We aimed to determine how the position of the C-arm affects radiation exposure to the surgeon during the treatment of a pediatric supracondylar humerus fracture. MATERIAL AND METHODS A simulated operating room was created to simulate a closed reduction and percutaneous pinning of a supracondylar humerus fracture. A phantom model was used to simulate the patient's arm. We assessed performing the procedure with the arm on plexiglass, graphite, or on top of the C-arm image receptor. The C-arm was positioned either with the source down and image receptor up (standard position) or with the source up and image receptor down (inverted position). Radiation exposure was recorded from levels corresponding to the surgeon's head, midline, and groin. The estimated effective dose equivalent was calculated to account for the varying radiation sensitivity of different organs. RESULTS We found the effective dose equivalent, or the overall body damage from radiation, was 5.4 to 7.8% higher than the surgeon when the C-arm was in the inverted position (source up, image receptor down). We did not find any differences in radiation exposure to the surgeon when the arm was supported on plexiglass versus graphite. CONCLUSION The C-arm positioned in the standard fashion exposes the surgeon to less damaging radiation. Therefore, when the surgeon is standing, we recommend using the C-arm in the standard position. CLINICAL RELEVANCE Orthopaedic surgeons who stand should use the C-arm in the standard position to pin supracondylar humerus fractures to lower the risk of ionizing radiation exposure.
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Affiliation(s)
| | - Emily O Cidambi
- Department of Orthopaedic Surgery, Rady Children's Hospital, San Diego, CA
| | - Craig M Birch
- Department of Orthopaedic Surgery
- Harvard Medical School, Boston, MA
| | - Kemble Wang
- Melbourne Orthopaedic Surgeon, East Melbourne, Australia
| | | | - Don-Soo Kim
- Department of Radiology, Boston Children's Hospital
| | - Benjamin J Shore
- Department of Orthopaedic Surgery
- Harvard Medical School, Boston, MA
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Montgomery BK, Nandyala SV, Birch CM, Hogue G. Double Sublaminal Band Passage Technique for Spinal Deformity Correction. Cureus 2022; 14:e22719. [PMID: 35371806 PMCID: PMC8971098 DOI: 10.7759/cureus.22719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2022] [Indexed: 11/05/2022] Open
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Linden GS, Birch CM, Hresko MT, Cook D, Hedequist DJ. Intraoperative Use of Robotics With Navigation for Pedicle Screw Placement in Treatment of Pediatric High-grade Spondylolisthesis: A Preliminary Report. J Pediatr Orthop 2021; 41:591-596. [PMID: 34516471 DOI: 10.1097/bpo.0000000000001947] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Accurate pedicle screw placement is critical to surgically correct pediatric high-grade spondylolisthesis (HGS). The recent advent of robotics coupled with computer-assisted navigation (RAN) may represent a novel option to improve surgical outcomes of HGS, secondary to enhanced pedicle screw placement safety. This series presents the HGS-RAN technique adopted by our site, describing its surgical outcomes and feasibility. METHODS Consecutive patients with a diagnosis of HGS (Meyerding grade III to V), operated on using RAN from 2019 to 2020 at a single-center were reviewed. Demographics, screw accuracy, sagittal L5-S1 parameters, complications, and perioperative outcomes were described. All patients were treated with instrumentation, decompression, posterior lumbar interbody fusion, and reduction. Robotic time included anatomic registration to end of screw placement. Screw accuracy-defined as a screw placed safely within the planned intrapedicular trajectory-was characterized by the Gertzbein-Robbins system for patients with additional 3-dimensional imaging. RESULTS Ten HGS patients, with an average age of 13.7 years old, were included in the series. All 62 screws were placed without neurological deficit or complication. Seven patients had additional 3-dimensional imaging to assess screw accuracy (42 of 62 screws). One hundred percent of screws were placed safely with no pedicle breaches (Gertzbein-Robbins-grade A). Thirty screws (48%) were placed through separate incisions that were percutaneous/transmuscular and 32 screws (52%) were inserted through the main incision. There were statistically significant improvements in L5 slippage (P=0.002) and lumbosacral angle (P=0.002), reflecting successful HGS correction. The total median operative time was 324 minutes with the robotic usage time consuming a median of 72 minutes. Median estimated blood loss was 150 mL, and length-of-stay was a median 3 days. CONCLUSIONS This case-series demonstrates that RAN represents a viable option for HGS repair, indicated by high screw placement accuracy, safety, and L5-S1 slippage correction. Surgeons looking to adopt an emerging technique to enhance safety and correction of pediatric HGS should consider the RAN platform. LEVEL OF EVIDENCE Level IV-therapeutic study.
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Affiliation(s)
| | - Craig M Birch
- Department of Orthopaedic Surgery, Boston Children's Hospital
- Harvard Medical School, Boston, MA
| | - M Timothy Hresko
- Department of Orthopaedic Surgery, Boston Children's Hospital
- Harvard Medical School, Boston, MA
| | - Danielle Cook
- Department of Orthopaedic Surgery, Boston Children's Hospital
| | - Daniel J Hedequist
- Department of Orthopaedic Surgery, Boston Children's Hospital
- Harvard Medical School, Boston, MA
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Verhofste BP, Hedequist DJ, Birch CM, Rademacher ES, Glotzbecker MP, Proctor MR, Yen YM. Operative Treatment of Cervical Spine Injuries Sustained in Youth Sports. J Pediatr Orthop 2021; 41:617-624. [PMID: 34469395 DOI: 10.1097/bpo.0000000000001950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Little data exists on surgical outcomes of sports-related cervical spine injuries (CSI) sustained in children and adolescent athletes. This study reviewed demographics, injury characteristics, management, and operative outcomes of severe CSI encountered in youth sports. METHODS Children below 18 years with operative sports-related CSI at a Level 1 pediatric trauma center were reviewed (2004 to 2019). All patients underwent morden cervical spine instrumentation and fusion. Clinical, radiographic, and surgical characteristics were analyzed. RESULTS A total of 3231 patients (mean, 11.3±4.6 y) with neck pain were evaluated for CSI. Sports/recreational activities were the most common etiology in 1358 cases (42.0%). Twenty-nine patients (2.1%) with sports-related CSI (mean age, 14.5 y; range, 6.4 to 17.8 y) required surgical intervention. Twenty-five were males (86%). Operative CSI occurred in football (n=8), wrestling (n=7), gymnastics (n=5), diving (n=4), trampoline (n=2), hockey (n=1), snowboarding (n=1), and biking (n=1). Mechanisms were 27 hyperflexion/axial loading (93%) and 2 hyperextension injuries (7%). Most were cervical fractures (79%) and subaxial injuries (79%). Seven patients (24%) sustained spinal cord injury (SCI) and 3 patients (10%) cord contusion or myelomalacia without neurological deficits. The risk of SCI increased with age (P=0.03). Postoperatively, 2 SCI patients (29%) improved 1 American Spinal Injury Association Impairment Scale Grade and 1 (14%) improved 2 American Spinal Injury Association Impairment Scale Grades. Increased complications developed in SCI than non-SCI cases (mean, 2.0 vs. 0.1 complications; P=0.02). Bony fusion occurred in 26/28 patients (93%) after a median of 7.2 months (interquartile range, 6 to 15 mo). Ten patients (34%) returned to their baseline sport and 9 (31%) to lower-level activities. CONCLUSIONS The incidence of sports-related CSI requiring surgery is low with differences in age/sex, sport, and injury patterns. Older males with hyperflexion/axial loading injuries in contact sports were at greatest risk of SCI, complications, and permanent disability. Prevention campaigns, education on proper tackling techniques, and neck strength training are required in sports at high risk of hyperflexion/axial loading injury. LEVEL OF EVIDENCE Level III-retrospective cohort study.
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Affiliation(s)
| | | | | | | | - Michael P Glotzbecker
- Department of Orthopaedic Surgery, Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Mark R Proctor
- Neurosurgery, Boston Children's Hospital (Harvard Teaching Hospital), Boston, MA
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Sawires AN, Birch CM, Hedequist D. The Use of Robotics Coupled With Navigation for Pediatric Congenital Spine Deformity. HSS J 2021; 17:289-293. [PMID: 34539269 PMCID: PMC8436341 DOI: 10.1177/15563316211027166] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 06/01/2021] [Accepted: 06/04/2021] [Indexed: 11/16/2022]
Abstract
Background: Spinal instrumentation in children with congenital spine deformity poses challenges to the surgeon, given the small patient size and the anomalous anatomy often encountered. Purpose: We aimed to investigate the accuracy of screw placement when robotics coupled with real-time navigation was used for surgical treatment of pediatric congenital spine deformity at 1 institution. Methods: We conducted a retrospective search of our institution's database for all patients younger than 18 years of age with congenital spine deformity who were treated with the robotics surgical platform coupled with navigation between June 2019 and December 2020. We recorded data on demographics, location and type of anomaly, procedure performed, and intraoperative variables related to robotics and navigation. We reviewed the images of patients who had intraoperative 3-dimensional imaging or postoperative computed tomographic scans to determine the accuracy of screw placement using the Gertzbein-Robbins scale. Results: In 14 patients identified, a total of 95 screws were attempted, with 94 successfully placed using robotics coupled with navigation. There were no noted screw-related complications (neurologic or visceral) and no return to the operating room for screw malposition. Conclusion: Patients with congenital spine deformity present potentially unique challenges due to variant anatomy. This retrospective series suggests that robotics coupled with navigation for congenital spine deformity correction in the pediatric population may aid in accurate screw placement and reduce complication rates. More rigorous study is warranted.
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Affiliation(s)
- Andrew N. Sawires
- Department of Orthopedic Surgery, Lenox Hill Hospital, New York, NY, USA
| | - Craig M. Birch
- Department of Orthopedic Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel Hedequist
- Department of Orthopedic Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
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Cohen LL, Birch CM, Cook DL, Hedequist DJ, Karlin LI, Emans JB, Hresko MT, Snyder BD, Glotzbecker MP. Variability in Antibiotic Treatment of Pediatric Surgical Site Infection After Spinal Fusion at A Single Institution. J Pediatr Orthop 2021; 41:e380-e385. [PMID: 33782367 DOI: 10.1097/bpo.0000000000001811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Recent focus on surgical site infections (SSIs) after posterior spine fusion (PSF) has lowered infection rates by standardizing perioperative antibiotic prophylaxis. However, efforts have neglected to detail antibiotic treatment of SSIs. Our aim was to document variability in antibiotic regimens prescribed for acute and latent SSIs following PSF in children with idiopathic, neuromuscular, and syndromic scoliosis. METHODS This study included patients who developed a SSI after PSF for scoliosis at a pediatric tertiary care hospital between 2004 and 2019. Patients had to be 21 years or younger at surgery. Exclusion criteria included growing rods, staged surgery, and revision or removal before SSI diagnosis. Infection was classified as acute (within 90 d) or latent. Clinical resolution of SSI was measured by return to normal lab values. Each antibiotic was categorized as empiric or tailored. RESULTS Eighty subjects were identified. The average age at fusion was 14.7 years and 40% of the cohort was male. Most diagnoses were neuromuscular (53%) or idiopathic (41%).Sixty-three percent of patients had an acute infection and 88% had a deep infection. The majority (54%) of subjects began on tailored antibiotic therapy versus empiric (46%). Patients with a neuromuscular diagnosis had 4.0 times the odds of receiving initial empiric treatment compared with patients with an idiopathic diagnosis, controlling for infection type and time (P=0.01). Ninety-two percent of patients with acute SSI retained implants at the time of infection and 76% retained them as of August 2020. In the latent cohort, 27% retained implants at infection and 17% retained them as of August 2020. CONCLUSIONS Patients with acute infections were on antibiotics longer than patients with latent infections. Those with retained implants were on antibiotics longer than those who underwent removal. By providing averages of antibiotic duration and lab normalization, we hope to standardize regimens moving forward and develop SSI-reducing pathways encompassing low-risk patients. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Lara L Cohen
- University of Miami Miller School of Medicine, Miami, FL
| | - Craig M Birch
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA
| | - Danielle L Cook
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA
| | - Daniel J Hedequist
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA
| | - Lawrence I Karlin
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA
| | - John B Emans
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA
| | - Michael T Hresko
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA
| | - Brian D Snyder
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA
| | - Michael P Glotzbecker
- Department of Orthopaedic Surgery, Rainbow Babies and Children's Hospital, Cleveland, OH
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Verhofste BP, Emans JB, Miller PE, Birch CM, Thompson GH, Samdani AF, Sanchez Perez-Grueso FJ, McClung AM, Glotzbecker MP. Growth-Friendly Spine Surgery in Arthrogryposis Multiplex Congenita. J Bone Joint Surg Am 2021; 103:715-726. [PMID: 33475309 DOI: 10.2106/jbjs.20.00600] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Arthrogryposis multiplex congenita (AMC) is a condition that describes neonates born with ≥2 distinct congenital contractures. Despite spinal deformity in 3% to 69% of patients, inadequate data exist on growth-friendly instrumentation (GFI) in AMC. Our study objectives were to describe current GFI trends in children with AMC and early-onset scoliosis (EOS) and to compare long-term outcomes with a matched idiopathic EOS (IEOS) cohort to determine whether spinal rigidity or extremity contractures influenced outcomes. METHODS Children with AMC and spinal deformity of ≥30° who were treated with GFI for ≥24 months were identified from a multicenter EOS database (1993 to 2017). Propensity scoring matched 35 patients with AMC to 112 patients with IEOS with regard to age, sex, construct, and curve. Multivariable linear mixed modeling compared changes in spinal deformity and the 24-item Early Onset Scoliosis Questionnaire (EOSQ-24) across cohorts. Cohort complications and reoperations were analyzed using multivariable Poisson regression. RESULTS Preoperatively, groups did not differ with regard to age (p = 0.87), sex (p = 0.96), construct (p = 0.62), rate of nonoperative treatment (p = 0.54), and major coronal curve magnitude (p = 0.96). After the index GFI, patients with AMC had reduced percentage of coronal correction (35% compared with 44%; p = 0.01), larger residual coronal curves (49° compared with 42°; p = 0.03), and comparable percentage of kyphosis correction (17% compared with 21%; p = 0.52). In GFI graduates (n = 81), final coronal curve magnitude (55° compared with 43°; p = 0.22) and final sagittal curve magnitude (47° compared with 47°; p = 0.45) were not significantly different at the latest follow-up after definitive surgery. The patients with AMC had reduced T1-S1 length (p < 0.001), comparable T1-S1 growth velocity (0.66 compared with 0.85 mm/month; p = 0.05), and poorer EOSQ-24 scores at the time of the latest follow-up (64 compared with 83 points; p < 0.001). After adjusting for ambulatory status and GFI duration, patients with AMC developed 51% more complications (incidence rate ratio, 1.51 [95% confidence interval (CI), 1.11 to 2.04]; p = 0.009) and 0.2 more complications/year (95% CI, 0.02 to 0.33 more; p = 0.03) compared with patients with IEOS. CONCLUSIONS Patients with AMC and EOS experienced less initial deformity correction after the index surgical procedure, but final GFI curve magnitudes and total T1-S1 growth during active treatment were statistically and clinically comparable with IEOS. Nonambulatory patients with AMC with longer GFI treatment durations developed the most complications. Multidisciplinary perioperative management is necessary to optimize GFI and to improve quality of life in this complex population. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Bram P Verhofste
- Department of Orthopaedic Surgery, Boston Children's Hospital (Harvard Teaching Hospital), Boston, Massachusetts
| | - John B Emans
- Department of Orthopaedic Surgery, Boston Children's Hospital (Harvard Teaching Hospital), Boston, Massachusetts
| | - Patricia E Miller
- Department of Orthopaedic Surgery, Boston Children's Hospital (Harvard Teaching Hospital), Boston, Massachusetts
| | - Craig M Birch
- Department of Orthopaedic Surgery, Boston Children's Hospital (Harvard Teaching Hospital), Boston, Massachusetts
| | - George H Thompson
- Department of Orthopaedic Surgery, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Amer F Samdani
- Shriners Hospital for Children, Philadelphia, Pennsylvania
| | | | | | - Michael P Glotzbecker
- Department of Orthopaedic Surgery, Rainbow Babies and Children's Hospital, Cleveland, Ohio
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Verhofste BP, Glotzbecker MP, Birch CM, O'Neill NP, Hedequist DJ. Halo-gravity traction for the treatment of pediatric cervical spine disorders. J Neurosurg Pediatr 2019; 25:1-10. [PMID: 31881541 DOI: 10.3171/2019.10.peds19513] [Citation(s) in RCA: 4] [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: 09/04/2019] [Accepted: 10/28/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Halo-gravity traction (HGT) is an effective and safe method for gradual correction of severe cervical deformities in adults. However, the literature is limited on the use of HGT for cervical spine deformities that develop in children. The objective of the present study was to evaluate the safety and efficacy of HGT for pediatric cervical spine deformities. METHODS Twenty-eight patients (18 females) whose mean age was 11.3 ± 5.58 years (range 2-24.9 years) underwent HGT. Common indications included kyphosis (n = 12), rotatory subluxation (n = 7), and basilar invagination (n = 6). Three children (11%) received traction to treat severe occipitocervical instability. For these 3 patients, traction combined with a halo vest, with bars attached rigidly to the vest, but with the ability to slide through the connections to the halo crown, was used to guide the corrective forces and moments in a specific and controlled manner. Patients ambulated with a wheelchair or halo walker under constant traction. Imaging was done before and during traction to evaluate traction efficacy. The modified Clavien-Dindo-Sink classification was used to categorize complications. RESULTS The mean duration of HGT was 25 days (IQR 13-29 days), and the mean traction was 29% ± 13.0% of body weight (IQR 19%-40% of body weight). The mean kyphosis improved from 91° ± 20.7° (range 64°-122°) to 56° ± 17.6° (range 32°-96°) during traction and corresponded to a mean percentage kyphosis correction of 38% ± 13.8% (range 21%-57%). Twenty-five patients (89%) underwent surgical stabilization, and 3 patients (11%) had rotatory subluxation that was adequately reduced by traction and were treated with a halo vest as their definitive treatment. The mean hospital stay was 35 days (IQR 17-43 days).Nine complications (32%) occurred: 8 grade I complications (28%), including 4 cases of superficial pin-site infection (14%) and 4 cases of transient paresthesia (14%). One grade II complication (4%) was seen in a child with Down syndrome and a preexisting neurological deficit; this patient developed flaccid paralysis that rapidly resolved with weight removal. Six cases (21%) of temporary neck discomfort occurred as a sequela of a preexisting condition and resolved without treatment within 24-48 hours. CONCLUSIONS HGT in children is safe and effective for the gradual correction of cervical kyphosis, atlantoaxial subluxation, basilar invagination, and os odontoideum. Cervical traction is an additional tool for the pediatric spine surgeon if uncertainties exist that the spinal alignment required for internal fixation and deformity correction can be safely achieved surgically. Common complications included grade I complications such as superficial pin-site infections and transient paresthesias. Halo vest gravity traction may be warranted in patients with baseline neurological deficits and severe occipitocervical instability to reduce the chance of catastrophic movement.
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Affiliation(s)
- Bram P Verhofste
- 1Department of Orthopaedic Surgery, Boston Children's Hospital
- 2Harvard Medical School, Boston, Massachusetts
| | - Michael P Glotzbecker
- 3Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center; and
- 4Department of Orthopaedic Surgery, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Craig M Birch
- 1Department of Orthopaedic Surgery, Boston Children's Hospital
- 2Harvard Medical School, Boston, Massachusetts
| | - Nora P O'Neill
- 1Department of Orthopaedic Surgery, Boston Children's Hospital
- 2Harvard Medical School, Boston, Massachusetts
| | - Daniel J Hedequist
- 1Department of Orthopaedic Surgery, Boston Children's Hospital
- 2Harvard Medical School, Boston, Massachusetts
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Verhofste BP, Glotzbecker MP, Hresko MT, Miller PE, Birch CM, Troy MJ, Karlin LI, Emans JB, Proctor MR, Hedequist DJ. Perioperative acute neurological deficits in instrumented pediatric cervical spine fusions. J Neurosurg Pediatr 2019; 24:1-11. [PMID: 31419801 DOI: 10.3171/2019.5.peds19200] [Citation(s) in RCA: 3] [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: 04/16/2019] [Accepted: 05/22/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Pediatric cervical deformity is a complex disorder often associated with neurological deterioration requiring cervical spine fusion. However, limited literature exists on new perioperative neurological deficits in children. This study describes new perioperative neurological deficits in pediatric cervical spine instrumentation and fusion. METHODS A single-center review of pediatric cervical spine instrumentation and fusion during 2002-2018 was performed. Demographics, surgical characteristics, and neurological complications were recorded. Perioperative neurological deficits were defined as the deterioration of preexisting neurological function or the appearance of new neurological symptoms. RESULTS A total of 184 cases (160 patients, 57% male) with an average age of 12.6 ± 5.30 years (range 0.2-24.9 years) were included. Deformity (n = 39) and instability (n = 36) were the most frequent indications. Syndromes were present in 39% (n = 71), with Down syndrome (n = 20) and neurofibromatosis (n = 12) the most prevalent. Eighty-seven (48%) children presented with preoperative neurological deficits (16 sensory, 16 motor, and 55 combined deficits).A total of 178 (96.7%) cases improved or remained neurologically stable. New neurological deficits occurred in 6 (3.3%) cases: 3 hemiparesis, 1 hemiplegia, 1 quadriplegia, and 1 quadriparesis. Preoperative neurological compromise was seen in 4 (67%) of these new deficits (3 myelopathy, 1 sensory deficit) and 5 had complex syndromes. Three new deficits were anticipated with intraoperative neuromonitoring changes (p = 0.025).Three (50.0%) patients with new neurological deficits recovered within 6 months and the child with quadriparesis was regaining neurological function at the latest follow-up. Hemiplegia persisted in 1 patient, and 1 child died due a complication related to the tracheostomy. No association was found between neurological deficits and indication (p = 0.96), etiology (p = 0.46), preoperative neurological symptoms (p = 0.65), age (p = 0.56), use of halo vest (p = 0.41), estimated blood loss (p = 0.09), levels fused (p = 0.09), approach (p = 0.07), or fusion location (p = 0.07). CONCLUSIONS An improvement of the preexisting neurological deficit or stabilization of neurological function was seen in 96.7% of children after cervical spine fusion. New or progressive neurological deficits occurred in 3.3% of the patients and occurred more frequently in children with preoperative neurological symptoms. Patients with syndromic diagnoses are at higher risk to develop a deficit, probably due to the severity of deformity and the degree of cervical instability. Long-term outcomes of new neurological deficits are favorable, and 50% of patients experienced complete neurological recovery within 6 months.
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Affiliation(s)
- Bram P Verhofste
- 1Department of Orthopaedic Surgery, Boston Children's Hospital; and
- 2Harvard Medical School, Boston, Massachusetts
| | - Michael P Glotzbecker
- 1Department of Orthopaedic Surgery, Boston Children's Hospital; and
- 2Harvard Medical School, Boston, Massachusetts
| | - Michael T Hresko
- 1Department of Orthopaedic Surgery, Boston Children's Hospital; and
- 2Harvard Medical School, Boston, Massachusetts
| | - Patricia E Miller
- 1Department of Orthopaedic Surgery, Boston Children's Hospital; and
- 2Harvard Medical School, Boston, Massachusetts
| | - Craig M Birch
- 1Department of Orthopaedic Surgery, Boston Children's Hospital; and
- 2Harvard Medical School, Boston, Massachusetts
| | - Michael J Troy
- 1Department of Orthopaedic Surgery, Boston Children's Hospital; and
- 2Harvard Medical School, Boston, Massachusetts
| | - Lawrence I Karlin
- 1Department of Orthopaedic Surgery, Boston Children's Hospital; and
- 2Harvard Medical School, Boston, Massachusetts
| | - John B Emans
- 1Department of Orthopaedic Surgery, Boston Children's Hospital; and
- 2Harvard Medical School, Boston, Massachusetts
| | - Mark R Proctor
- 1Department of Orthopaedic Surgery, Boston Children's Hospital; and
- 2Harvard Medical School, Boston, Massachusetts
| | - Daniel J Hedequist
- 1Department of Orthopaedic Surgery, Boston Children's Hospital; and
- 2Harvard Medical School, Boston, Massachusetts
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Birch JG, Lincoln TL, Mack PW, Birch CM. Congenital fibular deficiency: a review of thirty years' experience at one institution and a proposed classification system based on clinical deformity. J Bone Joint Surg Am 2011; 93:1144-51. [PMID: 21776551 DOI: 10.2106/jbjs.j.00683] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Congenital longitudinal deficiency of the fibula is the most common lower extremity congenital deficiency, with a broad spectrum of severity and subsequent reconstructive treatment. Published classification schemes do not accurately predict reconstructive treatment currently in practice. METHODS We reviewed all medical records of patients with a dominant deformity of congenital fibular deficiency who were managed at our institution between 1971 and 2005. We assessed the impact of limb-length inequality, foot deformity, bilateral extremity involvement, and extent of fibular preservation on the treatment of the limb deficiency. RESULTS One hundred and four patients (including twenty-two with bilateral congenital fibular deficiency) with 126 affected extremities had adequate radiographs to be included in the study. Femoral shortening was noted in seventy (85.4%) of eighty-two patients with unilateral limb involvement. Limb-length discrepancy prior to any treatment remained proportional in forty-seven (82.5%) of fifty-seven patients during an average duration of follow-up of ten years and ten months (range, two years to fifteen years and six months). Limb salvage with foot preservation was deemed feasible in thirty-eight (97.4%) of thirty-nine five-rayed feet, thirty (81.1%) of thirty-seven four-rayed feet, twenty (48.8%) of forty-one three-rayed feet, and one of nine feet having fewer than three rays. Twenty-two (41.5%) of fifty-three limbs with an absent or vestigial fibula were not treated with amputation. Of the twenty-two patients with bilateral fibular deficiency, twelve (54.5%) had preservation of both feet, three (13.6%) had unilateral amputation, and seven (31.8%) had bilateral amputation. CONCLUSIONS We propose a simplified classification for congenital fibular deficiency based on the clinical status of the foot and the magnitude of limb shortening as a percentage of the contralateral limb on radiographs. This classification may be effectively applied in infancy to allow the physician and family to anticipate the extent of deformity at maturity and to estimate the amount of treatment required to reconstruct this limb deformity. This system more accurately predicted the management of patients with fibular deficiency who were managed at our institution over the past three decades .
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Affiliation(s)
- John G Birch
- Texas Scottish Rite Hospital for Children, 2222 Welborn Street, Dallas, TX 75219, USA.
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