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BACKGROUND: Disseminated intravascular coagulation (DIC) is a rare but serious complication of pediatric scoliosis surgery; sparse current evidence warrants more information on causality and prevention. This systematic review sought to identify incidence of DIC in pediatric patients during or shortly after corrective scoliosis surgery and identify any predictive factors for DIC. METHODS: Medline/PubMed, EMBASE, and Ovid databases were systematically reviewed through July 2017 to identify pediatric patients with DIC in the setting of scoliosis surgery. Patient demographics, medical history, surgery performed, clinical course, suspected causes of DIC, and outcomes were collected. RESULTS: Eleven studies met inclusion criteria. Thirteen cases from 1974 to 2012 (mean age: 15.3 ± 4.3 years, 72% women) were identified, with neuromuscular (n = 7; 54%) scoliosis as the most common indication. There were no prior bleeding disorder histories; all preoperative labs were within normal limits. Procedures included 8 posterior segmental fusions (54%), 3 Harrington rods (31%), 1 Cotrel-Dubousset, and 1 unit rod. Eight patients experienced DIC intraoperatively and 5 patients experienced DIC postoperatively. Probable DIC causes included coagulopathy following intraoperatively retrieved blood reinfusion, infection from transfusion, rhabdomyolysis, hemostatic matrix application, heparin use, and hypovolemic shock. Most common complications included increased intraoperative blood loss (n = 8) and hypotension (n = 7). The mortality rate was 7.69%; one fatality occurred in the acute postoperative period. CONCLUSIONS: Prior bleeding disorder status notwithstanding, this review identified preliminary associations between variables during corrective scoliosis surgery and DIC incidence among pediatric patients, suggesting multiple etiologies for DIC in the setting of scoliosis surgery. Further investigation is warranted to quantify associated risk. CLINICAL RELEVANCE: This study brings awareness to a previously rarely discussed complication of pediatric scoliosis surgery. Further cognizance of DIC by scoliosis surgeons may help identify and prevent causes thereof.
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BACKGROUND: Children with congenital heart disease (CHD) have been reported to be at increased risk of developing scoliosis following cardiac surgery. Previous sample studies have reported that these patients may safely undergo posterior spinal fusion (PSF) with low complication rates. The goal of this study is to provide an updated analysis of the perioperative complication profile for posterior spinal fusion in a large cohort of pediatric patients with CHD, using a nationwide database. METHODS: A retrospective cohort study was conducted using 30-day perioperative outcomes data from the NSQIP-P database. Our inclusion criteria were all pediatric patients who underwent posterior spinal fusion by CPT code. Patients were subdivided into two groups: those with a history of cardiac surgery for CHD and those without. Postoperative complications were classified according to the Clavien-Dindo system. Risk factors were assessed in univariate and multivariate logistic regression analyses, with significance set at p < .05. RESULTS: Our results included 3,426 pediatric patients (68.2% female, 31.8% male) with a median age at spinal fusion of 13.7 ± 2.87 years. A CHD diagnosis was present in 312 patients, with 128 having had prior cardiac surgery. The overall complication rate was 6.68%, with a 10.9% rate in the prior cardiac surgery cohort (p = .068). The most common overall perioperative complications were unplanned readmission (3.5%), reoperation (2.6%), and superficial wound dehiscence (2.5%). Patients with a history of cardiac surgery were not at increased risk for postoperative complications; however, blood transfusion (p < .001), bronchopulmonary dysplasia (p < .001), combined bronchopulmonary dysplasia and previous cardiac surgery (p = .004), and a neuromuscular diagnosis (p < .001) were all risk factors for major postoperative complications in this cohort. CONCLUSIONS: Children with scoliosis who have undergone cardiac surgery to address CHD are not at an increased risk of perioperative complications within 30 days of undergoing a posterior spinal fusion. However, patients who underwent cardiac surgery for CHD who also had bronchopulmonary dysplasia or an associated neuromuscular diagnosis are at increased risk for perioperative complications. It is important for pediatric orthopedic spine surgeons to be familiar with an updated profile of potential perioperative obstacles they may face when treating these patients, as seen in a large and representative cohort. LEVEL OF EVIDENCE: Level III.
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Procedimentos Cirúrgicos Cardiovasculares/efeitos adversos , Cardiopatias Congênitas/cirurgia , Complicações Pós-Operatórias/etiologia , Escoliose/cirurgia , Fusão Vertebral/efeitos adversos , Adolescente , Transfusão de Sangue/estatística & dados numéricos , Displasia Broncopulmonar/etiologia , Criança , Bases de Dados Factuais , Feminino , Cardiopatias Congênitas/complicações , Humanos , Modelos Logísticos , Masculino , Análise Multivariada , Doenças Neuromusculares/etiologia , Estudos Retrospectivos , Fatores de Risco , Escoliose/congênito , Resultado do TratamentoRESUMO
A 53 year old-female patient with lupus had undergone a cephalo-medullary nailing for a femur shaft fracture 30 years ago. This was complicated by osteomyelitis, requiring multiple debridement procedures and hardware removal. Recently, she developed a painful soft tissue mass in the same region, which was ultimately diagnosed as pyomyositis. Because of chronic bone changes due to her past history, traditional imaging could not differentiate between osteomyelitis infarction and pseudotumor. A combined indium-labeled leukocyte scan with a technetium-99 sulfur colloid marrow scan ruled out osteomyelitis and guided proper treatment without osseous debridement and thus prevented unnecessary cross-contamination of the bone.
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Medula Óssea/diagnóstico por imagem , Fêmur/irrigação sanguínea , Infarto/diagnóstico por imagem , Osteomielite/diagnóstico por imagem , Piomiosite/diagnóstico por imagem , Diagnóstico Diferencial , Feminino , Humanos , Radioisótopos de Índio , Leucócitos , Pessoa de Meia-Idade , Cintilografia , Compostos Radiofarmacêuticos , Coloide de Enxofre Marcado com Tecnécio Tc 99mRESUMO
STUDY DESIGN: Retrospective review of the Nationwide Inpatient Sample from 2001 to 2010, a prospectively collected national database. OBJECTIVE: Structure an index to quantify adult spinal deformity (ASD) surgical risk based on risk factors for medical complications, surgical complications, revisions (R), mortality (M) rates, and length of hospital stay. SUMMARY OF BACKGROUND DATA: Evidence supporting ASD surgery cost-effectiveness and anticipating surgical risk is critical to evaluate the risk/benefit balance of such treatment for patients. MATERIALS AND METHODS: Discharges ages 25+, 4+ levels fused, diagnoses specific for scoliosis, and refusions. Five multivariate models determined independent risk factors that increased the risk of ≥1 for medical complications, surgical complications, R, M, and length of hospital stay. Models controlled for age, sex, race, revision status, surgical approach, levels fused, and osteotomy utilization. Odds ratios (ORs) were weighted using Nationwide Inpatient Sample weight files and based on their predictive category: 2 times for revision predictors and 4 times for mortality predictors. Predictors with OR≥1.5 were considered clinically relevant. Fifty points were distributed among the predictors based on their accumulative OR to establish a risk index. RESULTS: A total of 10,912 ASD discharges were identified (mean age: 62 y; 73% females; 14% revision cases). The structured risk index incorporated the following factors based on accumulative ORs: pulmonary circulation disorder (42.05), drug abuse (21.86), congestive heart failure (15.25), neurological disorder (17.31), alcohol abuse (13.24), renal failure (11.64), age>65 (12.28), coagulopathy (11.65), level +9 (6.7), revision (3.35), and osteotomy (3). These risk factors were scored: 14, 7, 5, 5, 4, 4, 4, 4, 2, 1, 1, respectively. Three risk thresholds were proposed: mild (0-10), moderate (10-20), severe >20/50 points. CONCLUSIONS: This study proposes an index to quantify the possible risk of morbidity before ASD surgery that will help patients, health insurance companies, and socioeconomic studies in assessing surgical risk/benefits. LEVEL OF EVIDENCE: Level III.
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Pacientes Internados , Coluna Vertebral/anormalidades , Coluna Vertebral/cirurgia , Adulto , Demografia , Humanos , Tempo de Internação , Análise Multivariada , Razão de Chances , Fatores de RiscoRESUMO
INTRODUCTION: Elderly patients are at risk of fracture nonunion, given the potential setting of osteopenia, poorer fracture biology, and comorbid medical conditions. Risk factors predicting fracture nonunion may compromise the success of fracture nonunion surgery. The purpose of this study was to investigate the effect of patient age on clinical and functional outcome following long bone fracture nonunion surgery. MATERIALS AND METHODS: A retrospective analysis of prospectively collected data identified 288 patients (aged 18-91) who were indicated for long bone nonunion surgery. Two-hundred and seventy-two patients satisfied study inclusion criteria and analyses were performed comparing elderly patients aged ≥65 years (n = 48) with patients <65 years (n = 224) for postoperative wound complications, Short Musculoskeletal Functional Assessment (SMFA) functional status, healing, and surgical revision. Regression analyses were performed to look for associations between age, smoking status, and history of previous nonunion surgery with healing and functional outcome. Twelve-month follow-up was obtained on 91.5% (249 of 272) of patients. RESULTS: Despite demographic differences in the aged population, including a predominance of medical comorbidities (P < .01) and osteopenia (P = .02), there was no statistical differences in the healing rate of elderly patients (95.8% vs 95.1%, P = .6) or time to union (6.2 ± 4.1 months vs. 7.2 ± 6.6, P = .3). Rates of postoperative wound complications and surgical revision did not statistically differ. Elderly patients reported similar levels of function up to 12 months after surgery. Regression analyses failed to show any significant association between age and final union or time to union. There was a strong positive association between smoking and history of previous nonunion surgery with time to union. Age was associated (positively) with 12-month SMFA activity score. CONCLUSIONS: Smoking and failure of previous surgical intervention were associated with nonunion surgery outcomes. Patient's age at the time of surgery was not associated with achieving union. Advanced age was generally not associated with poorer nonunion surgery outcomes.
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PURPOSE: Nonunions of the upper and lower extremity have been associated with pain and functional deficits. Recent studies have demonstrated that healing of these nonunions is associated with pain relief and both subjective and objective functional improvement. The purpose of this study was to determine which patient and surgical factors correlated with successful healing of a nonunion following surgical intervention. METHODS: Between September 2004 and February 2008, all patients with a "long bone nonunion" presenting to our academic trauma service were enrolled in a prospective data base. Baseline functional, demographic and pain status was obtained. Follow-up was obtained at 3, 6, and 12 months following surgical intervention, with longer follow-up as possible. One hundred and thirty-four patients with a variety of fracture nonunions were operated on by four different fellowship trained trauma surgeons with experience ranging from 2 to 15 years and variable nonunion surgery loads. Patients were stratified into one of three groups: 1. Patients who healed following one surgical intervention, 2. those who healed following multiple surgical intervention, and 3. those who failed to heal (remain ununited or underwent amputation). Healing was determined radiographically and clinically. Complications were recorded. Logistic regression analysis was performed to assess the cor-relation between specific baseline and surgical characteristics and healing. RESULTS: A minimum of 1 year follow-up was available for all 134 patients. One hundred and one patients (76%) with a mean age of 50 years healed at a mean of 6 months (range, 3 to 16) after one surgery. Twenty-two patients (16%) with a mean age of 47 years, who required more than one intervention, healed their nonunions at a mean of 11 months (range, 4 to 23). Eleven patients (8%) with a mean age of 50 years failed to heal at an average of 12 months follow-up. Complication rates were 11%, 68%, and 100% respectively for those who healed following one procedure, multiple procedures, and those who never healed. Higher surgeon volume (greater than 10 cases per year) was associated with 85% increased healing rates (OR = 0.15, 0.05-0.47 CI). The presence of a postoperative complication was associated with a 9 times lower likelihood of successful union as well (OR = 9.0, 2.6-31.7 CI). Patient age, sex, BMI, initial injury mechanism, tobacco use, and initial injury characteristics did not correlate with failure to heal. CONCLUSION: Our data is similar to other studies assessing outcomes following other complex reconstructive procedures. It appears that more experienced (higher volume) reconstructive surgeons and the development of fewer postoperative complications is associated with greater success following repair of a long bone nonunion. Infection at any point during treatment is associated with failure to achieve successful union.
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Ossos do Braço/cirurgia , Fixação Interna de Fraturas , Consolidação da Fratura , Fraturas não Consolidadas/cirurgia , Ossos da Perna/cirurgia , Adolescente , Adulto , Amputação Cirúrgica , Ossos do Braço/diagnóstico por imagem , Ossos do Braço/lesões , Ossos do Braço/fisiopatologia , Criança , Pré-Escolar , Feminino , Fixação Interna de Fraturas/efeitos adversos , Fraturas não Consolidadas/diagnóstico por imagem , Fraturas não Consolidadas/fisiopatologia , Humanos , Ossos da Perna/diagnóstico por imagem , Ossos da Perna/lesões , Ossos da Perna/fisiopatologia , Modelos Lineares , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Dor Pós-Operatória/etiologia , Radiografia , Recuperação de Função Fisiológica , Reoperação , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: Defining bone quality remains elusive. From a patient perspective bone quality can best be defined as an individual's likelihood of sustaining a fracture. Fracture risk indicators and performance measures can help clinicians better understand individual fracture risk. Educational resources such as the Web can help clinicians and patients better understand fracture risk, communicate effectively, and make decisions concerning diagnosis and treatment. QUESTIONS/PURPOSES: We examined four questions: What tools can be used to identify individuals at high risk for fracture? What clinical performance measures are available? What strategies can help ensure that patients at risk for fracture are identified? What are some authoritative Web sites for educating providers and patients about bone quality? METHODS: Using Google, PUBMED, and trademark names, we reviewed the literature using the terms "bone quality" and "osteoporosis education." Web site legitimacy was evaluated using specific criteria. Educational Web sites were limited to English-language sites sponsored by nonprofit organizations RESULTS: The Fracture Risk Assessment Tool® (FRAX®) and the Fracture Risk Calculator (FRC) are reliable means of assessing fracture risk. Performance measures relating to bone health were developed by the AMA convened Physician Consortium for Performance Improvement® and are included in the Physician Quality Reporting Initiative. In addition, quality measures have been developed by the Joint Commission. Strategies for identifying individuals at risk include designating responsibility for case finding and intervention, evaluating secondary causes of osteoporosis, educating patients and providers, performing cost-effectiveness evaluation, and using information technology. An abundance of authoritative educational Web sites exists for providers and patients. CONCLUSIONS: Effective clinical indicators, performance measures, and educational tools to better understand and identify fracture risk are now available. The next challenge is to encourage broader use of these resources so that individuals at high risk for fracture will not just be identified but will also adhere to therapy.
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Fraturas Ósseas/epidemiologia , Medição de Risco/métodos , Absorciometria de Fóton , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Internet , Osteoporose , Fraturas por Osteoporose/epidemiologia , Educação de Pacientes como Assunto , Inquéritos e QuestionáriosRESUMO
BACKGROUND: The goal of this review was to compare the functional outcomes of patients less than 60 and greater than or equal to 60 years old following operative stabilization of unstable ankle fractures. The review was conducted as a retrospective analysis of prospectively collected data at two level one trauma centers and a tertiary referral academic center. MATERIALS AND METHODS: All patients operatively treated for an unstable ankle fracture were entered into a database and prospectively followed. The postoperative protocol was standardized for all patients. Baseline characteristics, complications, additional surgery, functional status and the American Orthopaedic Foot and Ankle Society score (AOFAS) were assessed. The intervention chosen was open reduction and internal fixation of unstable ankle fractures. AOFAS hindfoot score and Short Musculoskeletal Functional Assessment (SMFA) questionnaire were used as the main outcome measures in the study. A p < 0.05 was considered significant. RESULTS: Three hundred sixty-nine (369) patients were entered into the database, 313 (84.8%) were less than 60 years old. At 3 months, 57% (32/56) of patients greater than or equal to 60 years old reported limitation of activities versus 33% (103/313) of patients less than 60 years old (p = 0.005). At 6 and 12 months, these percentages improved to 41% versus 10% (p = 0.001), and 29% versus 7.4% (p = 0.001) for older and younger individuals respectively. However, when compared to their baseline scores, both groups achieved a return to pre-injury status. Total AOFAS scores were not significantly different at 3, 6, or 12 months (p = 0.431). CONCLUSION: Operative fixation of unstable ankle fractures in patients greater than or equal to 60 years old can provide a reasonable functional result at the 1-year followup with a return to preoperative baseline even though they report more limitation of activities than younger patients.
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Traumatismos do Tornozelo/fisiopatologia , Traumatismos do Tornozelo/cirurgia , Fíbula/lesões , Fraturas Ósseas/fisiopatologia , Fraturas Ósseas/cirurgia , Recuperação de Função Fisiológica/fisiologia , Adolescente , Adulto , Fatores Etários , Idoso , Traumatismos do Tornozelo/complicações , Estudos de Coortes , Feminino , Fraturas Ósseas/complicações , Humanos , Instabilidade Articular/etiologia , Instabilidade Articular/fisiopatologia , Instabilidade Articular/cirurgia , Masculino , Pessoa de Meia-Idade , Amplitude de Movimento Articular/fisiologia , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Adulto JovemRESUMO
UNLABELLED: There has been increased emphasis on validated, patient-reported functional outcomes after orthopaedic interventions for various conditions. The few reports on these types of outcomes after treatment of fracture nonunions are limited to specific anatomic sites, limited by small numbers, and retrospective. To determine whether successful healing of established long-bone nonunions resulted in improved functional outcomes and reduction in patient-reported pain scores, we prospectively followed 80 patients. These patients had a mean of 1.4 surgical procedures before enrollment and a mean of 18 months had elapsed from previous surgery until enrollment. Baseline data and functional scores were obtained before intervention. Seventeen of the 80 patients (21%) had positive intraoperative cultures. At a mean of 18.7 months (range, 12-36 months), 72 (90%) nonunions had healed. Patients with healed nonunions scored better on the Short Musculoskeletal Functional Assessment. Pain scores among all patients improved compared with baseline, but to a greater degree in patients who achieved healing by final followup. Our data suggest improvement in pain scores is seen in all patients after surgery, whereas successful internal fixation leads to improved function. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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Transplante Ósseo , Terapia por Estimulação Elétrica/instrumentação , Fixação Interna de Fraturas/métodos , Fraturas não Consolidadas/cirurgia , Satisfação do Paciente , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Traumatismos do Braço/diagnóstico por imagem , Traumatismos do Braço/cirurgia , Placas Ósseas , Parafusos Ósseos , Terapia Combinada , Terapia por Estimulação Elétrica/métodos , Feminino , Seguimentos , Fixação Interna de Fraturas/efeitos adversos , Fraturas não Consolidadas/diagnóstico por imagem , Humanos , Traumatismos da Perna/diagnóstico por imagem , Traumatismos da Perna/cirurgia , Masculino , Pessoa de Meia-Idade , Medição da Dor , Probabilidade , Estudos Prospectivos , Radiografia , Recuperação de Função Fisiológica , Análise de Regressão , Reoperação/métodos , Fatores de Tempo , Resultado do Tratamento , Adulto JovemRESUMO
PURPOSE: To review one surgeon's experience with a novel type of "hybrid" locking plate (which has both 3.5mm and 4.5mm locking holes) for difficult fractures of the meta-diaphyseal humeral shaft. METHODS: Over a 2-year period, 24 patients who presented with a metaphyseal humeral fracture or nonunion (proximal or distal) were treated surgically by a single surgeon. A "hybrid" locking plate containing 3.5mm locking holes on one end and 4.5mm locking holes on the other end (Metaphyseal plate, Synthes, Paoli, Pa) was used in all patients. The selection of this implant was based on fracture location and bone quality. Fractures were operated on through an anterolateral or direct posterior approach. All fractures were secured with a minimum of three 4.5mm screws on one side of the fracture and three 3.5mm screws on the other side. All patients were treated with a similar post-operative protocol for early range of shoulder and elbow motion. RESULTS: Three patients were lost to follow-up. The cohort consisted of 15 women and 6 men with a mean age of 49 years (range 18-78). There were 14 acute fractures and 7 nonunions. Twelve fractures involved the distal metaphyseal segment and 9 involved the proximal metaphyseal segment. Twenty-two patients completed a minimum 6-month clinical and radiographic follow-up and form the basis for this report. All 21 patients healed their fractures or nonunions at a mean of 4.5 months. There were no infections or hardware failures. In every case the "hybrid" nature of the plate design was felt to be advantageous. CONCLUSION: This "second generation" metaphyseal locking plate, which affords the surgeon the ability to place a greater number of smaller calibre screws within a short bone segment, while using traditional large fragment screw fixation in the longer segment, is clearly an improvement in plate design. Meta-diaphyseal upper extremity long bones may serve as the most ideal location for this implant.