Atypical Mycobacterial Infections of the Spine: Evaluation and Management.

BACKGROUND: Atypical mycobacterial infections of the spine can be difficult to treat and represent a subset of the vertebral osteomyelitis and diskitis spectrum often requiring early and aggressive surgical intervention. The purpose of this review is to improve the understanding of and approach to disease management from the perspective of the spine surgeon. MATERIALS AND METHODS: Debridement or excision of the affected levels may be necessary to decrease mycobacterial loads and restore biomechanics. A close relationship with the patient's internal medicine and infectious disease specialists should be maintained to ensure disease eradication or remission. Long-term suppressive antibiotic therapy may be required for infection control. RESULTS AND CONCLUSION: Atypical mycobacterial spine infections are rare, complex, and difficult to eradicate. Our institution proposes a collaborative effort among the spine surgeon, infectious disease specialists, and internal medicine specialists to best approach the work-up, diagnosis, and treatment of these infections. [Orthopedics. 2024;47(2):e61-e66.].

Alternative Uses of O-Arm and Stealth Navigation Technology Over 10 Years: The University of Colorado Experience.

Intraoperative computed tomography scanning with O-arm and use of Stealth navigation can improve surgical outcomes in a variety of orthopedic subspecialties. In spine surgery, the accuracy, precision, and safety of pedicle screw and interbody implant placement has improved. This technology is now routinely used in percutaneous pedicle screw placement and minimally invasive sacroiliac joint fusion. Other applications include, but are not limited to, isthmic pars defect repair, lumbosacral pseudoarticulation resection in Bertolotti's syndrome, radiofrequency ablation, and en bloc tumor resection. Intraoperative navigation has numerous applications, and use of this technology should continue to evolve as the technology advances. [Orthopedics. 2023;46(2):e89-e97.].

Opioid Prescription Monitoring in Preoperative and Postoperative Sacroiliac Joint Fusion Patients.

INTRODUCTION: An estimated 15%-25% of patients with chronic low back pain may in fact suffer from sacroiliac (SI) joint dysfunction. SI joint fusion has become a common treatment option for the management of SI joint dysfunction. However, little is known about opioid use prior to and after surgical treatment in this patient population. METHODS: The medical records of 62 patients treated with SI joint fusion at our institution were reviewed in this retrospective study. The Colorado Prescription Drug Monitoring Program (CPDMP) was accessed to gather opioid prescription information for these patients. Only those patients who had received an opioid prescription within 3 months prior to their surgery were included in the study. Patients who had SI joint fusion but underwent another surgical procedure during the 12-month follow-up period were excluded from analysis. Preoperative (6 and 3 months) and postoperative (3, 6, 9, and 12 months) mean morphine milligram equivalents (MME) were collected from the CPDMP database for each patient. Patient demographic and medical comorbidity data were also documented to identify any correlations or potential risk factors for chronic opioid prescribing. Visual analog scale (VAS), Oswestry Disability Index (ODI), and Denver SI Joint Questionnaire (DSIJQ) scores were recorded for each patient to assess clinical outcomes. RESULTS: At 3 months prior to surgery, patients were prescribed an average of 47.2 mean MME/d. At no point postoperatively did the quantity of opioids, measured in MME/d, change significantly from the 3-month preoperative prescription quantities. There was no significant difference in the quantity of opioids received by men vs women, in patients with vs without anxiety and/or depression, or in younger vs older patients. Low body mass index was correlated with decreased opioid prescriptions at 6 months postoperative but became statistically insignificant again by 9 months postoperative.Significant improvements in VAS scores were recorded for all postoperative clinical evaluation timepoints (at 6 weeks and 3, 6, and 12 months) and compared to preoperative scores. By 12 months, VAS scores had decreased from 6.2 to 3.9 (P < 0.001). This change is not only statistically significant but also meets the criteria for minimum clinically important difference in scores. Both the ODI and DSIJQ patient-reported outcomes scores also showed significant improvements at 12 months after surgery (ODI: 48.9 preoperative vs 24.6 postoperative, P = 0.02; DSIJQ: 53.2 preoperative vs 17.4 postoperative, P = 0.014). The ODI improvement also met the minimum clinically important difference criteria. By 6 months postoperatively, there was no significant correlation in VAS or ODI and opioid use. There was no significant correlation between the DSIJQ scores and the daily dose of opioids at any point postoperatively. CONCLUSION: Quantity of opioid prescriptions received by patients with SI joint pain did not change significantly from 3 months preoperatively to any point postoperatively despite significant improvements in all patient-reported outcome measures. This discordance between long-term opioid requirements and positive clinical outcomes is concerning and warrants further investigation.

The University of Colorado Virtual Physical Examination for Spine Surgeons: A Preliminary Study.

As coronavirus disease 2019 (COVID-19) reached pandemic status, in-person orthopedic clinics across the United States were forced to close as many states adopted stay-at-home orders. Previously, the use of telemedicine in orthopedic practices was minimal for a variety of reasons, one being the inability to perform a physical examination in a specialty reliant on direct patient contact for diagnosis and treatment. A prospective cohort of 52 patients consented to participate in a novel virtual physical examination protocol during routine telemedicine visits at a large, tertiary orthopedic spine practice. Participants were asked to perform a series of carefully designed physical maneuvers using readily available household objects to allow their provider to better assess sensory and motor function in the tele-medicine setting. Patients were then asked to complete a short satisfaction survey. In total, 52 patients completed the physical examination and survey. Males and females were distributed evenly among the cohort at 50%. The mean age was 52.1±15.5 years. The average score for ease of understanding the examination (1=easiest, 5=hardest) was 1.1, while the average score for ease of performance was 1.5. Most participants (97.56%) felt their provider was better able to understand their condition using the virtual examination findings. This study highlights the utility of a virtual physical examination for assessment of spine patients in the telemedicine setting. Furthermore, this study illustrates the ease with which such an examination can be implemented and performed to improve patient evaluation and satisfaction. [Orthopedics. 2022;45(1):e7-e10.].

What's New in Pediatric Spine Growth Modulation and Implant Technology for Early-Onset Scoliosis?

BACKGROUND: Early-onset scoliosis (EOS) affects roughly 1 to 2 out of 10,000 live births per year. Because this subset of patients has a yet to achieve a majority of their skeletal growth, a number of treatment challenges need to be addressed before surgical intervention. If left untreated, EOS can cause a number of problems throughout the patient's lifespan, particularly in regards to the growth of the thorax and pulmonary development. A wide variety of surgical systems and techniques are available to the treating surgeon. METHODS: A review of the orthopaedic literature from 2010 to 2015 relating to pediatric spine growth modulation was performed. Ninety-eight papers were identified and, following exclusion criteria, a total of 31 papers were selected for further review. RESULTS: This paper summarizes the recently published literature regarding growth-friendly spinal implants, the status of their Food and Drug Administration approval labeling as well as the indications, applications, and complications associated with their implementation. CONCLUSIONS: There are a growing number of options at the surgeon's disposal when treating patients with EOS. As surgeons, we must continue to be vigilant in our demand for sound clinical evidence as we strive to provide optimal care for our patients. The rapidly advancing field of spinal growth modulation is exciting. More work must be done to further enhance our ability to predictably modulate growth in the pediatric spine.

Ultrasound findings in asymptomatic patients with modular metal on metal total hip arthroplasty.

OBJECTIVE: The use of metal-on-metal and modular total hip arthroplasty is associated with potentially serious local and systemic complications. The primary aim of this study was to identify the prevalence of a pseudotumor in asymptomatic patients with a particular metal-on-metal hip prosthesis after a minimum follow-up of 5 years using ultrasound evaluation. A secondary purpose was to identify associations between the presence of pseudotumor and serum metal ion levels following implantation. METHODS: We prospectively evaluated data collected from 36 asymptomatic patients who underwent implantation of a Profemur Z metal-on-metal total hip arthroplasty from January 2004 to January 2010. Serum metal ion levels were collected in 2012 and 2015. Hip ultrasounds were performed in 2015. RESULTS: Pseudotumors were found in 7/36 patients (19.4%). The average pseudotumor size measured 38.2 cm3 (range 7.35 cm3-130.81 cm3). Elevated metal ion levels were found in all patients at all time points. No statistical correlation was found between the presence of pseudotumor and patient age, age of the implant, component design, and any of the serum metal ion levels or ratios. CONCLUSIONS: One in every five asymptomatic patients with metal-on-metal implants was found to have a periarticular pseudotumor. There was no dose-dependent relationship found between elevated serum metal ion levels and the development of a pseudotumor. Our findings suggest that in patients with known elevated metal ion levels, continued monitoring of ion levels may not be a reliable predictor of pseudotumor formation, and ultrasound surveillance can and should be routinely used to document the presence and progression of pseudotumor.

Effect of Body Mass Index on Blood Transfusion in Total Hip and Knee Arthroplasty.

Perioperative blood management remains a challenge during total hip arthroplasty (THA) and total knee arthroplasty (TKA). The purpose of this study was to systematically examine the relationship between body mass index (BMI) and perioperative blood transfusion during THA and TKA while attempting to resolve conflicting results in previously published studies. The authors retrospectively evaluated 2399 patients, 896 of whom underwent THA and 1503 of whom underwent TKA. Various outcome variables were assessed for their relationship to BMI, which was stratified using the World Health Organization classification scheme (normal, <25 kg/m(2); overweight, 25-30 kg/m(2); obese, >30 kg/m(2)). Among patients undergoing THA, transfusion rates were 34.8%, 27.6%, and 21.9% for normal, overweight, and obese patients, respectively (P=.002). Among patients undergoing TKA, transfusion rates were 17.3%, 11.4%, and 8.3% for normal, overweight, and obese patients, respectively (P=.002). Patients with an elevated BMI have decreased rates of blood transfusion following both THA and TKA. This same cohort also loses a significantly decreased percentage of estimated blood volume. No trends were identified for a relationship between BMI and deep venous thrombosis, pulmonary embolism, myocardial infarction, discharge location, length of stay, 30-day readmission rate, and preoperative hemoglobin level. Elevated BMI was significantly associated with increased estimated blood loss in patients undergoing THA and those undergoing TKA. There was a statistically significant trend toward increased deep surgical-site infection in patients undergoing THA (P=.043). Patients with increased BMI have lower rates of blood transfusion and lose a significantly smaller percentage of estimated blood volume following THA and TKA. [Orthopedics.2016; 39(5):e844-e849.].

Rivaroxaban Versus Enoxaparin for Venous Thromboembolism Prophylaxis after Hip and Knee Arthroplasty.

The oral Factor Xa inhibitor rivaroxaban (Xarelto) has been the pharmacologic agent used for venous thromboembolism (VTE) prophylaxis after primary hip and knee arthroplasty (THA/TKA) at our institution since February 2012. The purpose of our study was to compare rates of VTE and major bleeding between rivaroxaban and our previous protocol of enoxaparin after THA/TKA. A retrospective cohort study was performed including 2406 consecutive patients at our institution between 1/1/11 and 9/30/13. Patients who did not have unilateral primary THA/TKA or who received other anticoagulants were excluded. Of the 1762 patients included, 1113 patients (63.2%) received enoxaparin and 649 patients (36.8%) received rivaroxaban. This study found no demonstrable differences between these two anticoagulants in rates of VTE, infection, reoperation, transfusion, or major bleeding. Therapeutic, Retrospective comparative study, Level III.

Predictors and complications of blood transfusion in total hip and knee arthroplasty.

Perioperative patient optimization can minimize the need for blood transfusions in patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA). The purpose of this study was to determine predictors and complications of transfusions. This retrospective review analyzed 1795 patients who underwent primary THA and TKA at our institution between January 2011 and December 2012. Of the 1573 patients ultimately included the rates of transfusion were 9.27% in TKA and 26.6% in THA. Significant predictors for transfusion include: preoperative hemoglobin, age, female gender, body mass index, creatinine, TKA, operating room time, operative blood loss, and intra-operative fluids. The DVT rate was comparable, but deep surgical site infection rate among transfused patients was 2.4% compared to 0.5% in non-transfused patients (P = 0.0065).