Knee dislocations and associated fractures: risk factors for surgical reduction.

INTRODUCTION: Dissociation of the knee joint, or knee dislocations (KD), can lead to severe complications, often resulting in multiligament injuries. A subset of these injuries are irreducible by closed reduction and require open reduction. Identifying KDs that necessitate surgical intervention is crucial for optimal outcomes. While previous studies have explored various risk factors, the influence of associated fractures is less understood. MATERIALS AND METHODS: We queried the Trauma Quality Improvement Program (TQIP) database from 2017 to 2021, for non-congenital closed knee dislocations requiring surgery. Demographic variables were collected, and ICD-10 codes were used to identify associated tibia, femur, acetabular, and fibula fractures. ICD-10 codes were also used to identify nerve injuries and vascular injuries. Multivariate logistic regression was used to assess factors influencing the need for surgical reduction (SR). RESULTS: A total of 1,467 patients with KDs were included in the study, of which 411 (28.0%) underwent open surgical reduction (SR) while 1,056 (72.0%) were treated with nonsurgical closed reduction (nSR). Factors associated with SR included concomitant tibia fracture (OR = 1.683, C.I: 1.255-2.256, p < 0.001) and fibula fracture (OR = 1.457, C.I: 1.056-2.011, p = 0.022). Vascular injury had lower odds of SR (OR = 0.455, C.I: 0.292-0.708, p < 0.001). CONCLUSION: Our study demonstrated that KDs presenting with concomitant tibia and/or fibula fractures are more likely to require SR. The difficulty posed to closed reduction may be due to the influence of these fracture patterns on surrounding soft tissue as well as the lack of a stable bone structure necessary for achieving proper reduction. Physicians should be aware of the potential risk of this fracture pattern when caring for patients with KDs.

Frailty is a predictor of immediate postoperative complications following surgical management of knee dislocations.

PURPOSE: To assess the utility of frailty in predicting outcomes following surgical intervention for KDs. METHODS: The NIS database was queried for non-congenital knee dislocations from 2015 to 2019 that underwent ligament repair or surgical reduction. Patients were assigned frailty scores using the mFI-11, and outcomes were compared. Multivariate regression and ROC curve analysis were used to assess the independent association of obesity, frailty, VI, and age with adverse outcomes. RESULTS: A total of 3797 patients who underwent surgical management were included. Frailty was associated with extended LOS (OR 1.353, 95% CI 1.212-1.510, p < 0.001), adverse discharge (OR 1.716, 95% CI 1.515-1.946, p < 0.001), and complications (OR 1.449, 95% CI 1.352-1.553, p < 0.001). Severely frailty was associated with extended LOS (OR 1.838, 95% CI 1.611-2.097, p < 0.001), adverse discharge (OR 2.756, 95% CI 2.394-3.171, p < 0.001), and complications (OR 1.603, 95% CI 1.453-1.768, p < 0.001). Additionally, VI was a risk factor for extended LOS (OR 7.647 (6.442-9.076) p < 0.001), complications (OR 2.065 (1.810-2.341) p < 0.001), and adverse discharge (OR 1.825 (1.606-2.075), p < 0.001). Obesity was a risk factor for extended LOS (OR 1.599 (1.470-1.739), p < 0.001) and complications (OR 1.235 (1.108-1.377), p < 0.001). AUC analysis showed that frailty was the most accurate predictor of all outcomes when compared to VI, obesity, and age. CONCLUSIONS: Frailty is superior to age and obesity, and comparable to VI, at predicting adverse outcomes following surgical management of KDs. These findings suggest that frailty assessment might play a role in risk stratification and preoperative planning for KD patients that require surgical intervention.

Pediatric obesity and adverse outcomes following deformity correction surgery for adolescent idiopathic scoliosis: A cross-sectional analysis using 2015-2019 NIS data.

BACKGROUND: Obesity in the pediatric population has been a growing medical concern over the last few decades with a prevalence of 19.7% as of 2017-2020. Obesity is a risk factor for greater scoliotic curves and failure of conservative therapy for adolescent idiopathic scoliosis (AIS). Establishing a correlation between obesity and a wide variety of adverse outcomes following scoliosis surgery can assist in the preoperative consultation with the family and proper optimization of the patient for scoliosis fusion surgery. METHODS: The National Inpatient Sample (NIS) was used to access inpatient data from 2015 to 2019. Pediatric patients with idiopathic scoliosis admitted for spinal deformity correction via posterior spinal fusion of over 8 levels were identified. Patients were stratified based on the comorbid diagnosis of obesity. Variables that were significantly associated with outcomes (p < 0.05) were used in a multivariable logistic regression to control for confounders. Backwards stepwise p-value removal was used to build the final model and model fit was assessed using the area under the curve. RESULTS: A total of 855 obese and 17,285 non-obese pediatric patients undergoing posterior instrumented fusion for scoliotic deformity correction were identified. The obese group was associated with a higher rate of SSI (0.6% vs 0.1%, p < 0.001), UTI (1.2% vs. 0.3%, p < 0.001), and AKI (0.6% vs 0.1%, p = 0.12) compared to the normal BMI group. Obese patients were also more likely to have a non-routine discharge when compared to non-obese (4.7% vs. 2.3%, p < 0.001). The rate of having more than one complication occurring postoperatively was higher in the obese group, however, this finding was not significant (0.6%, vs 0.4%, p = 0.385). On multivariate regression analysis, obesity was positively associated with SSI (OR = 2.758, CI = 0.999-7.614, p = 0.050), UTI (OR = 2.221, CI = 1.082-4.560, p = 0.030), non-routine discharge (OR = 1.515, CI = 1.070-2.147, p = 0.019), and an extended LOS (OR = 1.869, CI = 1.607-2.174, p < 0.001). CONCLUSION: Obesity was associated with postoperative blood transfusion, SSI, UTI, increased length of stay, and non-routine discharge after pediatric AIS deformity surgery. In addition to the increased morbidity seen in obese patients, we also identified the significantly increased cost of care for this group when compared to non-obese patients. These data should be used for a robust preoperative risk assessment and evidence for BMI optimization prior to deformity correction for AIS.

Management of spinal trauma in pregnant patients: A systematic review of the literature.

BACKGROUND: Despite the high incidence of spine trauma globally, traumatic spinal cord injury (tSCI) during pregnancy is considered a rare medical emergency. The literature on acute management of these patients is sparse compared with that of mothers with preexisting tSCI. This systematic review aims to evaluate management strategies for tSCI during pregnancy in improving neurologic, obstetric, and neonatal outcomes. METHODS: A systematic review of PubMed/MEDLINE was performed without language restriction from inception until November 2, 2023 for patients who acquired tSCI during pregnancy. Excluded articles described postpartum trauma, trauma before pregnancy, or SCI of nontraumatic etiology such as neoplastic, vascular, hemorrhagic, or ischemic origin. Primary outcomes investigated were maternal American Spinal Injury Association (ASIA) grade, pregnancy termination, cesarean delivery, prematurity, and neonatal adverse events. RESULTS: Data from 73 patients were extracted from 43 articles from 1955 to 2023. The mothers' median age was 24 years (interquartile range, 23-30 years), and the average gestational age at the time of injury was 21.1 ± 7.7 weeks. The thoracic spine was the most common segment affected (41.1%) and had the greatest proportion of complete tSCI (46.6%). Furthermore, ASIA score improvement was observed in 17 patients with 3 patients experiencing a 2-score improvement and 1 patient experiencing a 3-score improvement. Among these patients, 86% of ASIA B and 100% of ASIA C patients showed neurologic improvement, compared to only 17% of ASIA A patients. Surgically managed patients had a lower rate of neonatal adverse events than conservatively managed patients (11% vs. 34%). CONCLUSION: Acute tSCI requires a coordinated effort between a multidisciplinary team with careful consideration. While maternal neurologic improvement was observed more often following a better ASIA grade on presentation, the presence of neonatal adverse events was less common in patients treated with surgery than in patients who were managed conservatively. LEVEL OF EVIDENCE: Systematic Review; Level IV.

Atlantoaxial subluxation and Down syndrome: A cross-sectional analysis.

Background: Atlantoaxial subluxation (AAS) is a diagnosis describing misalignment of the C1 vertebra relative to C2. Excessive translation of this joint, located adjacent to the medullary brain stem, can lead to devastating neurological consequences. A higher prevalence of AAS within the Down syndrome (DS) population has been well-established. This study aims to establish a prevalence rate of DS in patients hospitalized for AAS and compare outcomes between AAS patients with and without DS. Methods: This study utilized the National Inpatient Sample (NIS) provided by the Healthcare Cost and Utilization Project (HCUP). In accordance with HCUP 2023 Clinical Classifications Software Refined files, data were queried using the International Classification of Diseases 10th Edition codes for DS and AAS. Demographics, comorbidities, hospital course, and outcomes were examined and compared using binary and linear multivariate regression. IBM SPSS software was used for data analysis. Results: Of the 213,095 patients in the NIS database admitted between 2016 and 2020 with AAS as their primary diagnosis, 7.2% were DS patients. DS patients were significantly younger (26.56 ± 20.81 vs. 49.39 ± 27.63, P < 0.01), less likely to be female (33.30% vs. 52.10%), and had fewer comorbidities (diabetes mellitus, hypertension, and hyperlipidemia) than non-DS patients. There was no significant difference in likelihood to undergo surgical fusion between DS patients and non-DS patients with AAS. Conclusion: This large-scale study using NIS data determined that 7.2% of all patients admitted to hospitals for AAS are DS patients. The analysis of demographics, hospital course, and outcomes can influence the development of treatment protocols for AAS in the DS population.

Conservative management of spinal pathology with autologous conditioned serum: A systematic review of the literature.

BACKGROUND: Chronic inflammatory pain is associated with increased expression of interleukin (IL)-1, an inflammatory cytokine, and activity on its receptor (IL-1R). In response, the body produces IL-1R antagonist (IL-1Ra) to reduce this signaling. Autologous conditioned serum (ACS) is the only biologic therapy for spinal pathologies that enhances the action of endogenous IL-1Ra reserves to improve symptoms. This systematic review investigates the effectiveness of ACS in treating pain and disability caused by spinal pathologies. AIM: To evaluate the use of ACS as a conservative management option for spinal pathology. METHODS: A systematic review of PubMed/Medline was performed to identify studies investigating administration of ACS for treatment of any spinal pathology. RESULTS: Six articles were included, comprising 684 patients treated with epidural (n = 133) or transforaminal (n = 551) ACS injections. Patients had an average age of 54.0 years with slight female predominance (53.2%). The lumbar spine was most commonly treated, with 567 patients (82.9%) receiving injections for lumbar radiculopathy (n = 67), degenerative disc disease (DDD) (n = 372), or spinal stenosis (n = 128); cervical injections were performed in 109 patients (15.9%). Mean (SD) follow-up was 21.7 (4.8) weeks from first ACS injection. All studies investigating mechanical lumbar and lumbar or cervical radicular pain reported significant pain reduction at final follow-up compared to baseline. ACS achieved comparable or superior results to lumbar epidural steroid injections. Adverse events were reported in 21 patients (3.1%), with no serious adverse events. CONCLUSION: ACS injection is a safe and effective intervention for pain reduction in many spinal pathologies, including cervical and lumbar radiculopathies.

Frailty as a Predictor of Outcomes in Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis.

Frailty is an emerging concept in clinical practice used to predict outcomes and dictate treatment algorithms. Frail patients, especially older adults, are at higher risk for adverse outcomes. Aneurysmal subarachnoid hemorrhage (aSAH) is a neurosurgical emergency associated with high morbidity and mortality rates that have previously been shown to correlate with frailty. However, the relationship between treatment selection and post-treatment outcomes in frail aSAH patients is not established. We conducted a meta-analysis of the relevant literature in accordance with PRISMA guidelines. We searched PubMed, Embase, Web of Science, and Google Scholar using "Subarachnoid hemorrhage AND frailty" and "subarachnoid hemorrhage AND frail" as search terms. Data on cohort age, frailty measurements, clinical grading systems, and post-treatment outcomes were extracted. Of 74 studies identified, four studies were included, with a total of 64,668 patients. Percent frailty was 30.4% under a random-effects model in all aSAH patients (p < 0.001). Overall mortality rate of aSAH patients was 11.7% when using a random-effects model (p < 0.001). There was no significant difference in mortality rate between frail and non-frail aSAH patients, but this analysis only included two studies and should be interpreted cautiously. Age and clinical grading, rather than frailty, independently predicted outcomes and mortality in aSAH patients.