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The advent of ultra-minimally invasive endoscopic spine surgery, characterized by significantly reduced surgery times, minimal blood loss, and minimal tissue trauma, has precipitated a paradigm shift in the preoperative management of patients with cardiac disease undergoing elective spine procedures. This perspective article explores how these advancements have influenced the requirements for preoperative cardiac workups and the protocols surrounding the cessation of anticoagulation and antiplatelet therapies. Traditionally, extensive cardiac evaluations and the need to stop anticoagulation and antiplatelet agents have posed challenges, increasing the risk of cardiac events and delaying surgical interventions. However, the reduced invasiveness of endoscopic spine surgery presents a safer profile for patients with cardiac comorbidities, potentially minimizing the necessity for rigorous cardiac clearance and allowing for more flexible anticoagulation management. This perspective article synthesizes current research and clinical practices to provide a comprehensive overview of these evolving protocols. It also discusses the implications of these changes for patient safety, surgical outcomes, and overall healthcare efficiency. Finally, the article suggests directions for future research, emphasizing the need for updated guidelines that reflect the reduced perioperative risk associated with these innovative surgical techniques. This discussion is pivotal for primary care physicians, surgeons, cardiologists, and the broader medical community in optimizing care for this high-risk patient population.
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BACKGROUND: There is an increasing acceptance of conducting minimally invasive transforaminal lumbar interbody fusion (TLIF) in ambulatory surgical centers (ASCs). The Centers for Medicare and Medicaid Services (CMS) introduced the Hospitals Without Walls (HWW) program in March 2020. This program granted hospitals regulatory flexibility to offer services and procedures in nontraditional locations, including ASCs. However, implementation hurdles persist. METHODS: A survey was sent to 235 surgeons regarding the use of ASCs for performing TLIF surgeries on elderly patients. Multiple-choice questions covering various aspects of TLIF practice preferences, including surgical indications, decision factors for choosing ASCs over hospitals, implementation hurdles, reimbursement concerns, staffing issues, and the impact of CMS rules and regulations on TLIF in ASCs, particularly concerning physician ownership and self-referral conflicts governed by the Stark law, were asked. RESULTS: The survey completion rate was 25.8% (Figure 1). The most common surgical indications for TLIF in ASCs were spondylolisthesis (80%), spinal stenosis (62.5%), and low back pain (47.5%). Most surgeons (78%) believed TLIF could be safely performed in ASCs. Streamlined workflow, lower infection rates, and cost-effectiveness were advantages listed by 58.5% of surgeons. Patient's medical history (75.8%), followed by ASC resources and capabilities (61%) and surgeon preference (61%), were relevant factors. Higher efficiencies at ASCs (14.6%), contractual issues (9.8%), and ownership issues (7.3%) were less relevant to surgeons. About 65.9% of surgeons reported lower reimbursement in ASCs, and 43.9% said it was an implementation hurdle. Lower direct costs were reported by 53.7% of surgeons. Other hurdles included a lack of trained staff (24.4%), inadequate staffing (22.0%), cost overruns (26.8%), high Joint Commission or the Accreditation Association for Ambulatory Health Care credentialing costs, and surgeons feeling uncomfortable performing TLIF in ASCs (22.0%). Only 17.1% listed medical problems as a reason their patient was considered unsuitable for the ASC environment. A majority (53.7%) stated that their ASCs complied with strict Stark requirements by disclosing physician ownership interests. However, 22% of surgeons reported self-referrals under the "In-Office Ancillary Services Exception" allowed by the Stark law. CONCLUSION: Our survey data show that surgeons' perceptions of current CMS rules and regulations may hinder the transition into the ASC setting because they think the reimbursement is too low and the regulatory burden is too high. ASCs have disproportionally higher initial acquisition and ongoing costs related to staff training and maintenance of the TLIF technology that CMS should consider when determining the appropriate financial remuneration for these complex procedures. CLINICAL RELEVANCE: ASC offers a viable and attractive option for their TLIF procedure with the advantage of same-day discharge and at-home recovery.
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BACKGROUND: With the growing prevalence of lumbar spinal stenosis, endoscopic surgery, which incorporates techniques such as transforaminal, interlaminar, and unilateral biportal (UBE) endoscopy, is increasingly considered. However, the patient selection criteria are debated among spine surgeons. OBJECTIVE: This study used a polytomous Rasch analysis to evaluate the factors influencing surgeon decision-making in selecting patients for endoscopic surgical treatment of lumbar spinal stenosis. METHODS: A comprehensive survey was distributed to a representative sample of 296 spine surgeons. Questions encompassed various patient-related and clinical factors, and responses were captured on a logit scale graphically displaying person-item maps and category probability curves for each test item. Using a Rasch analysis, the data were subsequently analyzed to determine the latent traits influencing decision-making. RESULTS: The Rasch analysis revealed that surgeons' preferences for transforaminal, interlaminar, and UBE techniques were easily influenced by comfort level and experience with the endoscopic procedure and patient-related factors. Harder-to-agree items included technological aspects, favorable clinical outcomes, and postoperative functional recovery and rehabilitation. Descriptive statistics suggested interlaminar as the best endoscopic spinal stenosis decompression technique. However, logit person-item analysis integral to the Rasch methodology showed highest intensity for transforaminal followed by interlaminar endoscopic lumbar stenosis decompression. The UBE technique was the hardest to agree on with a disordered person-item analysis and thresholds in category probability curve plots. CONCLUSION: Surgeon decision-making in selecting patients for endoscopic surgery for lumbar spinal stenosis is multifaceted. While the framework of clinical guidelines remains paramount, on-the-ground experience-based factors significantly influence surgeons' selection of patients for endoscopic lumbar spinal stenosis surgeries. The Rasch methodology allows for a more granular psychometric evaluation of surgeon decision-making and accounts better for years-long experience that may be lost in standardized clinical guideline development. This new approach to assessing spine surgeons' thought processes may improve the implementation of evidence-based protocol change dictated by technological advances was endorsed by the Interamerican Society for Minimally Invasive Spine Surgery (SICCMI), the International Society for Minimal Intervention in Spinal Surgery (ISMISS), the Mexican Spine Society (AMCICO), the Brazilian Spine Society (SBC), the Society for Minimally Invasive Spine Surgery (SMISS), the Korean Minimally Invasive Spine Society (KOMISS), and the International Society for the Advancement of Spine Surgery (ISASS).
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PURPOSE: Bone and joint infections, complicated by the burgeoning challenge of antimicrobial resistance (AMR), pose significant public health threats by amplifying the disease burden globally. We leveraged results from the 2019 Global Burden of Disease Study (GBD) to explore the impact of AMR attributed to bone and joint infections in terms of disability-adjusted life years (DALYs), elucidating the contemporary status and temporal trends. METHODS: Utilizing GBD 2019 data, we summarized the burden of bone and joint infections attributed to AMR across 195 countries and territories in the 30 years from 1990 to 2019. We review the epidemiology of AMR in terms of age-standardized rates, the estimated DALYs, comprising years of life lost (YLLs) and years lived with disability (YLDs), as well as associations between DALYs and socio-demographic indices. RESULTS: The GBD revealed that DALYs attributed to bone and joint infections associated with AMR have risen discernibly between 1990 and 2019 globally. Significant geographical disparities and a positive correlation with socio-demographic indicators were observed. Staphylococcus aureus infections, Group A Streptococcus, Group B Streptococcus, Escherichia coli, Pseudomonas aeruginosa, Klebsiella pneumoniae, and Enterobacter-related bone and joint infections were associated with the highest DALYs because of a high proportion of antimicrobial resistance. Countries with limited access to healthcare, suboptimal sanitary conditions, and inconsistent antibiotic stewardship were markedly impacted. CONCLUSIONS: The GBD underscores the escalating burden of bone and joint infections exacerbated by AMR, necessitating urgent, multi-faceted interventions. Strategies to mitigate the progression and impact of AMR should emphasize prudent antimicrobial usage and robust infection prevention and control measures, coupled with advancements in diagnostic and therapeutic modalities.
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Anos de Vida Ajustados por Deficiência , Carga Global da Doença , Humanos , Farmacorresistência Bacteriana , Antibacterianos/uso terapêutico , Masculino , Saúde Global , Artrite Infecciosa/epidemiologia , Artrite Infecciosa/microbiologia , Artrite Infecciosa/tratamento farmacológico , Feminino , Doenças Ósseas Infecciosas/microbiologia , Doenças Ósseas Infecciosas/epidemiologia , Doenças Ósseas Infecciosas/tratamento farmacológico , Anos de Vida Ajustados por Qualidade de VidaRESUMO
STUDY DESIGN: Systematic Review and Meta-Analysis. OBJECTIVES: This study aimed to evaluate the clinical and radiological outcomes of surgically treated adjacent segment disease (ASDis) following ACDF with either anterior plate construct (APC) or stand-alone anchored spacers (SAAS). METHOD: Multiple databases were searched until December 2022 for pertinent studies. The primary outcome was health-related quality of life outcomes [JOA, NDI, and VAS], whereas, the secondary outcomes included operative characteristics [estimated blood loss (EBL) and operative time (OT)], radiological outcomes [C2-C7 Cobb angle, disc height index (DHI) changes, fusion rate], and complications. RESULTS: A total of 5 studies were included, comprising 210 patients who had been surgically treated for cervical ASDis. Among them, 113 received APC, and 97 received SAAS. Postoperative dysphagia was significantly higher in the APC group [47% vs 11%, OR = 7.7, 95% CI = 3.1-18.9, P < .05]. Similarly, operative time and blood loss were higher in the APC group compared to the SAAS group; [MD = 16.96, 95% CI = 7.87-26.06, P < .05] and [MD = 5.22, 95% CI = .35 - 10.09, P < .05], respectively. However, there was no difference in the rate of prolonged dysphagia and clinical outcomes in terms of JOA, NDI, and VAS. Furthermore, there was no difference in the radiological parameters including the C2-7 Cobb angle and DHI as well as the fusion rate. CONCLUSION: Our meta-analysis demonstrated that both surgical techniques (APC and SAAS) are effective in treating ASDis. However, with low certainty of the evidence, considering patients are at high risk of dysphagia following revision cervical spine surgery SAAS may be the preferred choice.
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INTRODUCTION: Anterior cervical decompression and fusion (ACDF) is the standard surgical procedure for cervical radiculopathy and myelopathy, although ACDF includes risks of adjacent segment disease (ASD) and subsequent revision procedures. Various interbody cage, plate, and screw options can be utilized. Stand-alone devices were designed to overcome undesired complications ofâ¯hardware prominence and associated dysphagia, soft tissue violation, and adjacent level encroachment. Implants include biomechanical structural support (cage) composed of various materials (polyetheretherketone (PEEK)/titanium) and integral fixation (screws/blades). The purpose was to compare intraoperative, short- and long-term outcomes ofâ¯revision ACDF using a stand-alone implant (ACDF-ZP group) versus traditional interbody PEEK cage, titanium plate, and screw instrumentation (ACDF-CP group). METHODS: This was a retrospective, cohort study reviewing charts of patients who underwent revision ACDF. The primary outcome measure was the incidence of postoperative dysphagia. Secondary outcomes included intraoperative, short-term, and long-term outcomes and complications. RESULTS: Sixty-one patients were included (ACDF-ZP group = 50; ACDF-CP group = 11). In-hospital incidence of dysphagia was significantly less in the ACDF-CP group (P = 0.041). Thrity-one (62.0%) of the ACDF-ZP group reported dysphagia postoperatively, half resolved by 6 weeks, and two persisted for more than 6 months. Five (45.5%) of the ACDF-CP group reported dysphagia with most resolving within 6 weeks. There were no statistically significant differences between groups in short- or long-term complications, dysphonia, or reoperation rates. No statistical significance was seen in blood loss, operative time, hospital stay, local and global alignment, or cage subsidence. CONCLUSION: Rates of dysphagia were comparable between groups at short and long-term follow-up, despite a greater incidence of postoperative dysphagia in the ACDF-ZP group. All complications and occurrences of cage subsidence were observed in the ACDF-ZP group, which may be attributed to the larger sample size. Given these findings, zero-profile stand-alone implants and traditional interbody PEEK cage, titanium plate, and screw instrumentation appear to be both safe and effective options for revision ACDF.
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Introduction: Closed reduction and intramedullary nailing is the preferred surgical intervention for femoral shaft fractures. Open reduction involves opening the fracture site and is performed in various circumstances. Comparative studies of the approaches have conflicting results. We sought to compare the outcomes and complications of open and closed reduction for intramedullary nailing of femoral shaft fractures. Materials and methods: Following the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines, a systematic review of comparative studies included the databases and registers PubMed (Medline), Embase, Scopus, and Cochrane Central (PROSPERO registration ID: CRD42022325382). Additional studies were identified through hand and citation searching. Two reviewers independently extracted data. The standardized mean difference and 95% confidence intervals were determined for continuous variables, whereas odds ratios and 95% confidence intervals were assessed for dichotomous variables. Results: Closed reduction had a higher pooled union rate (93.93%, 92.02%), an increased odds ratio for union (OR = 1.624 [95% CI: 1.004, 2.624]; p = .048), and a faster time to union (SMD = -0.292 [95% CI: -0.549, -0.0.035]; p = .026). There were no differences in operative time (SMD = 0.128 [95% CI: -0.700, 0.956] p = .762) or overall complication rate (OR = 1.314 [95% CI: 0.966, 1.787] p = .082). Conclusions: Closed reduction has the advantage of higher union rates, quicker time to union, and lower overall infection compared to open reduction for intramedullary nailing of femoral shaft fractures. Open reduction remains a reasonable alternative with acceptable union rates when closed reduction is not feasible.
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OBJECTIVES: To assess the reliability of the postoperative radiographic Matta grading for quality of reduction of acetabular fractures. DESIGN: An inter-reliability and intrareliability study. SETTING: Level I trauma center. PARTICIPANTS: 15 independent observers of different levels of experience who evaluated 115 sets of postoperative acetabulum radiographs in 35 consecutive patients with displaced acetabular fractures between January 2017 and January 2019. MAIN OUTCOME MEASUREMENTS: To assess the interobserver and intraobserver reliability of Matta radiographic grading for postoperative quality of reduction of acetabular fractures. RESULTS: The overall interobserver agreement was excellent among all groups with an average absolute intraclass correlation coefficient (ICC) of 0.91 (95% CI 0.93-0.97). When stratifying the agreement based on experience, the orthopaedic trauma fellow subgroup had the highest rate with an ICC of 0.92. The overall intraobserver agreement was good with an ICC of 0.81 (95% CI 0.74-0.85). CONCLUSION: The Matta radiographic grading was a reliable tool for the evaluation of quality of reduction after surgical fixation of acetabular fractures with excellent interobserver and good intraobserver reliabilities among different levels of observers.
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Fraturas do Quadril , Fraturas da Coluna Vertebral , Acetábulo/diagnóstico por imagem , Acetábulo/lesões , Acetábulo/cirurgia , Humanos , Variações Dependentes do Observador , Reprodutibilidade dos TestesRESUMO
STUDY DESIGN: Systematic review and meta-analysis. OBJECTIVE: To compare outcomes and complication rates in patients undergoing bariatric surgery (BS) prior to spine surgery. METHODS: A systematic review and meta-analysis were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines comparing the outcomes of spine surgery between subjects with prior bariatric surgery to those who were considered obese with no prior bariatric surgery. RESULTS: A total of 183, 570 patients were included in the 4 studies meeting inclusion criteria. The mean patient age was 52.9 years, and the majority were female (68%). The two groups consisted of a total of 36, 876 patients with prior BS and 146, 694 obese patients without prior BS. The overall rate of complications in the prior BS group was 6.4% (4.5%-38.7%) compared to 11.9% (11.2%-55.4%) in the non-prior BS obese group with a statistically significant difference between the two groups. The prior BS group had lower rates of renal, neurological, and thromboembolic complications, with a lower mortality and readmission rate. In a subgroup undergoing cervical spine surgery, patients with prior BS had fewer cardiac, GI, and total complications. For patients undergoing thoracolumbar spine surgery, patients with prior BS had fewer thromboembolic and total complications. CONCLUSION: Patients undergoing bariatric surgery prior to spine surgery had fewer renal, neurological, and thromboembolic complications as well as a decreased mortality and readmission rate.
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STUDY DESIGN: Meta-analysis. OBJECTIVE: To compare outcomes between minimally invasive scoliosis surgery (MISS) and traditional posterior instrumentation and fusion in the correction of adolescent idiopathic scoliosis (AIS). METHODS: A literature search was performed using MEDLINE, PubMed, EMBASE, Google scholar and Cochrane databases, including studies reporting outcomes for both MISS and open correction of AIS. Study details, demographics, and outcomes, including curve correction, estimated blood loss (EBL), operative time, postoperative pain, length of stay (LOS), and complications, were collected and analyzed. RESULTS: A total of 4 studies met the selection criteria and were included in the analysis, totaling 107 patients (42 MIS and 65 open) with a mean age of 16 years. Overall there was no difference in curve correction between MISS (73.2%) and open (76.7%) cohorts. EBL was significantly lower in the MISS (271 ml) compared to the open (527 ml) group, but operative time was significantly longer (380 min for MISS versus 302 min for open). There were no significant differences between the approaches in pain, LOS, complications, or reoperations. CONCLUSION: MISS was associated with less blood loss but longer operative times compared to traditional open fusion for AIS. There was no difference in curve correction, postoperative pain, LOS, or complications/reoperations. While MISS has emerged as a feasible option for the surgical management of AIS, further research is warranted to compare these 2 approaches.
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Decompression surgery is the most common surgical treatment for lumbar spinal stenosis (LSS). Relatively low satisfaction rate was reported. Patients often complaint of residual numbness despite significant pain relief. We hypothesized that numbness had a significant impact on patient satisfaction, but had not been evaluated, which is associated with low satisfaction rate. This study aimed to examine how much numbness is associated with patient satisfaction. We retrospectively reviewed prospectively collected data from consecutive patients who underwent decompression without fusion for LSS. We evaluated the Numeric Rating Scale (NRS) scores of low back pain (LBP), leg pain, and leg numbness preoperatively and at the final follow-up visit. Improvement was evaluated using minimum clinically important differences (MCIDs). Patient satisfaction was evaluated using the question, "How satisfied are you with the overall result of your back operation?". There are four possible answers consisting of "very satisfied (4-point)", "somewhat satisfied (3-point)", "somewhat dissatisfied (2-point)", or "very dissatisfied (1-point)". Spearman correlation was used to evaluate the association between patient satisfaction and reaching MCIDs. A total of 116 patients were included. All three components had correlation with patient satisfaction with the correlation efficient of 0.30 in LBP, 0.22 in leg pain, and 0.33 in numbness. Numbness had greatest correlation efficient value. We showed that numbness has a greater impact than leg/back pain on patient satisfaction in patients undergoing decompression for LSS. We suggest not only LBP and leg pain but also numbness should be evaluated pre- and postoperatively.
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Dor Lombar , Estenose Espinal , Descompressão Cirúrgica , Humanos , Hipestesia/etiologia , Perna (Membro) , Dor Lombar/cirurgia , Vértebras Lombares/cirurgia , Satisfação do Paciente , Estudos Retrospectivos , Estenose Espinal/complicações , Estenose Espinal/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND: Pediatric pelvic fractures (PPF) are uncommon among children requiring hospitalization after blunt trauma. The present study explored our experience for the prevalence, patients demographics, clinical characteristics, injury pattern and management of pediatric pelvic fractures in a level I trauma center. METHODS: This is a retrospective review of prospectively collected data obtained from trauma registry database for all pediatrics trauma patients of age ≤18 years. Data were analyzed according to different aspects relevant to the clinical applications such as Torode classification for pelvic ring fracture (Type I-IV), open versus closed triradiate cartilage, and surgical versus non-surgical management. RESULTS: During the study period (3 and half years), a total of 119 PPF cases were admitted at the trauma center (11% of total pediatric admissions); the majority had pelvic ring fractures (91.6%) and 8.4% had an acetabular fracture. The mean age of patients was 11.5 ± 5.7, and the majority were males (78.2%). One hundred and four fractures were classified as type I (5.8%), type II (13.5%), type III (68.3%) and type IV (12.5%). Patients in the surgical group were more likely to have higher pelvis AIS (p = 0.001), type IV fractures, acetabular fractures and closed triradiate cartilage as compared to the conservative group. Type III fractures and open triradiate cartilage were significantly higher in the conservative group (p < 0.05). Patients with closed triradiate cartilage frequently sustained spine, head injuries, acetabular fracture and had higher mean ISS and pelvis AIS (p < 0.01) than the open group. However, the rate of in-hospital complications and mortality were comparable among different groups. The overall mortality rate was 2.5%. CONCLUSION: PPF are uncommon and mainly caused by high-impact trauma associated with multisystem injuries. The majority of PPF are stable, despite the underlying high-energy mechanism. Management of PPF depends on the severity of fracture as patients with higher grade fractures require surgical intervention. Furthermore, larger prospective study is needed to understand the age-related pattern and management of PPF.
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Fraturas Ósseas , Pediatria , Ossos Pélvicos , Adolescente , Criança , Fraturas Ósseas/diagnóstico por imagem , Fraturas Ósseas/epidemiologia , Fraturas Ósseas/cirurgia , Humanos , Masculino , Ossos Pélvicos/diagnóstico por imagem , Ossos Pélvicos/cirurgia , Estudos Prospectivos , Estudos Retrospectivos , Centros de TraumatologiaRESUMO
BACKGROUND: Core decompression (CD) has been used in the treatment of pre-collapse stages avascular necrosis (AVN) with good results. Hyperbaric oygen therapy (HBO) was used as a non-invasive treatment for pre-collapse stages osteonecrosis with favorable results. This study aimed to compare the outcomes of HBO versus CD in stage II of non-traumatic AVN of the femoral head. METHODS: Data were collected retrospectively for patients with non-traumatic AVN of the femoral head that was confirmed by MRI and underwent HBO or CD between January 2010 and December 2018, with a minimum follow-up of 12 months. Oxford Hip Score (OHS), radiographic progression, and Short-Form 12(SF12) were used to assess the outcomes. RESULTS: Nineteen patients with 23 stage II AVN of the femoral head were included, 12 (52.2%) in CD, and 11 (47.8%) in the HBO group with an average follow-up of 34.2 ± 18.4 months.66.7% of patients in CD and 81.8% in the HBO group achieved satisfactory hip function outcome with statistically significant mean Oxford Hip Score (35.8 ± 6.7 and 35.5 ± 5.1) (P 0.009 & .003) respectively.No statistical difference of OHS and SF12 (PCS &MCS) was found between the two groups (P 0.202, 0.128 & .670 respectively).Eight (34.7%) cases progressed to a higher radiological stage at one year follow-up. The rate of progression was not statistically significant between both groups (P 0.469) with no statistical difference of OHS and SF12 (PCS & MCS) in the progressed group (P 0.747, 0.648 & 0.416) respectively. CONCLUSION: This study showed that the HBO is promising and as effective as CD in the treatment of non-traumatic pre-collapsed AVN of the femoral head. Hence, HBO could be used as an alternative non-invasive treatment option.
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BACKGROUND: Although studies are available on high-energy Lisfranc injuries, the evidence for increasingly reported low-energy Lisfranc injuries in active individuals, including athletes and military personnel, remains scarce and mostly retrospective. PURPOSE: This meta-analysis aimed to review the return-to-play (RTP) and return-to-duty (RTD) rates with regard to the anatomic type and the management of low-energy Lisfranc injuries in a high-demand, active population. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we searched the MEDLINE (PubMed), EMBASE, Google Scholar, and Cochrane databases through June 2019 to identify studies on low-energy Lisfranc injuries in athletes and military personnel. The primary outcomes were RTP/RTD rates and time to RTP/RTD, and the secondary outcomes were time missed from practice, games missed, time to full recovery, midfoot arthritis rate, and reoperation rate. RESULTS: Overall, 15 studies (N = 441 patients) were included in the meta-analysis. Of these, 6 studies were of level 3 evidence, 8 studies were level 4 (case series), and 1 study was level 5. Of the 441 subjects, 380 (86.17%) were able to RTP and RTD. There was no statistically significant difference in RTP rates for operative versus nonoperative treatment, ORIF versus PA, or bony versus ligamentous injuries. The mean time missed from practice/duty for operative versus nonoperative treatment was 58.02 days (95% CI, 13.6-102.4 days; I 2 = 98.03%) and 116.4 days (95% CI, 62.4-170.4 days; I 2 = 99.45%), respectively. The mean time missed from practice/duty for bony versus ligamentous injury was 98.9 days (95% CI, 6.1-191.7 days; I 2 = 99.82%) and 76.5 days (95% CI, 37.9-115.02 days; I 2 = 99.83%), respectively, with no statistically significant differences (standardized mean difference = 3.62 days [95% CI: -5.7 to 13 days]; I 2 = 83.17%). CONCLUSION: This review indicated an overall excellent RTP/RTD rate for low-energy Lisfranc injuries in high-demand individuals. The time missed from athletic participation/military duty was not affected by injury treatment type, the bony versus ligamentous nature of the injury, or athlete player position. However, the low evidence levels and significant heterogeneity of the included studies precludes making conclusions regarding length of time missed or optimal management. Higher-quality studies on low-energy Lisfranc injuries are needed.
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BACKGROUND: Proximal fifth metatarsal fractures are among the most common forefoot injuries in athletes. The management of this injury can be challenging because of delayed union and refractures. Intramedullary (IM) screw fixation rather than nonoperative management has been recommended in the athletic population. PURPOSE: To provide an updated summary of the return-to-play (RTP) rate and time to RTP after Jones fractures in athletes with regard to their management, whether operative or nonoperative, and to explore the union rate and time to union as well as the rate of complications such as refractures. STUDY DESIGN: Meta-analysis. METHODS: Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, 2 independent team members searched several databases including PubMed, MEDLINE, Embase, Google Scholar, Web of Science, Cochrane Library, and ClinicalTrials.gov through November 2019 to identify studies reporting on Jones fractures of the fifth metatarsal exclusively in athletes. The primary outcomes were the RTP rate and time to RTP, whereas the secondary outcomes were the number of games missed, time to union, and union rate as well as the rates of nonunion, delayed union, and refractures. RESULTS: Of 168 studies identified, 22 studies were eligible for meta-analysis with a total of 646 Jones fractures. The overall RTP rate was 98.4% (95% CI, 97.3%-99.4%) in 626 of 646 Jones fractures. The RTP rate with IM screw fixation only was 98.8% (95% CI, 97.8%-99.7%), with other surgical fixation methods (plate, Minifix) was 98.4% (95% CI, 95.8%-100.0%), and with nonoperative management was 71.6% (95% CI, 45.6%-97.6%). There were 3 studies directly comparing RTP rates with surgical versus nonoperative management, which showed significant superiority in favor of surgery (odds ratio, 0.033 [95% CI, 0.005-0.215]; P < .001). The RTP rate according to type of sport was 99.0% (95% CI, 97.5%-100.0%) in football, 91.1% (95% CI, 82.2%-99.4%) in basketball, and 96.6% (95% CI, 92.6%-100.0%) in soccer. The overall time to RTP was 9.6 weeks (95% CI, 8.5-10.7 weeks). The time to RTP in the surgical group (IM screw fixation) was 9.6 weeks (95% CI, 8.3-10.9 weeks), which was significantly less than that in the nonoperative group of 13.1 weeks (95% CI, 8.2-18.0 weeks). The pooled union rate in the operative group (excluding refractures) was 97.3% (95% CI, 95.1%-99.4%), whereas the pooled union rate in the nonoperative group was 71.4% (95% CI, 49.1%-93.7%). The overall time to union was 9.1 weeks (95% CI, 7.7-10.4 weeks). The time to union with IM screw fixation (8.2 weeks [95% CI, 7.5-9.0 weeks]) was shorter than that with nonoperative treatment (13.7 weeks [95% CI, 12.7-14.6 weeks]). The rate of delayed union was 2.5% (95% CI, 1.2%-3.7%), and the overall refracture rate was 10.2% (95% CI, 5.9%-14.5%). CONCLUSION: The RTP rate and time to RTP after the surgical management of Jones fractures in athletes were excellent, regardless of the implant used and type of sport. IM screw fixation was superior to nonoperative management, as it led to a higher rate of RTP, shorter time to RTP, higher rate of union, shorter time to union, and improved functional outcomes. We recommend surgical fixation for all Jones fractures in athletes.
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Fraturas Ósseas , Ossos do Metatarso , Atletas , Fraturas Ósseas/cirurgia , Humanos , Ossos do Metatarso/cirurgia , Estudos Retrospectivos , Volta ao EsporteRESUMO
BACKGROUND: Dexmedetomidine is a sedative and analgesic medication which has gained an increased usage as an adjuvant to both general and regional anaesthesia in recent years. In this systematic review and meta-analysis, we examined the changes to the characteristics of subarachnoid block when accompanied with intravenous dexmedetomidine. Our aim is to evaluate the effects of different doses of intravenous dexmedetomidine on the sensory and motor blockade duration of a single shot spinal anaesthetic and the incidence of any associated side effects. METHODS: We searched published randomized clinical trials (RCTs) from January 1992 to April 2019 that investigated the use of IV dexmedetomidine with spinal anaesthesia. After considering our inclusion and exclusion criteria, we included 15 RCTs with 985 patients. We analyzed the duration of sensory and motor blockade and the related adverse effects in relation to different doses of IV dexmedetomidine. RESULTS: Intravenous dexmedetomidine, with loading dose of 1 mcg/kg, prolonged the sensory blockade duration of spinal anaesthesia by a mean difference of 49.6 min, P<0.001, and motor blockade duration by a mean difference of 44.7 min, P<0.001, while a loading dose of 0.5 mcg/kg prolonged the sensory blockade by a mean difference of 43.06 min, P<0.001, and motor blockade duration by a mean difference of 29.09 min, P<0.001. Dexmedetomidine-related side effects were higher in patients receiving larger doses; the incidence of bradycardia was higher (OR=3.53, P<0.001) and incidence of hypotension showed a 1.29 fold increase when compared to the control group (P=0.065). CONCLUSION: The administration of intravenous dexmedetomidine in conjunction with spinal anaesthesia can significantly prolong the duration of both sensory and motor blockade. The use of larger loading doses of dexmedetomidine was associated with a larger side-effect profile with minimal beneficial changes when compared to lower loading doses.
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The COVID-19 pandemic has changed the strategies of most of the teaching hospitals worldwide, affecting the educational process in residency programs. The System Wide Incident Command Committee in the state of Qatar has set the country's medical response to the crisis. In line with command committee directives, the orthopedic surgery residency program planned an educational strategy keeping the trainees' wellbeing and education a priority and taking advantage of the pandemic as a tool of personal and professional growth.
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BACKGROUND: Traumatic pelvic fracture (TPF) is a significant injury that results from high energy impact and has a high morbidity and mortality. PURPOSE: We aimed to describe the epidemiology, incidence, patterns, management, and outcomes of TPF in multinational level 1 trauma centers. METHODS: We conducted a retrospective analysis of all patients with TPF between 2010 and 2016 at two trauma centers in Qatar and Germany. RESULTS: A total of 2112 patients presented with traumatic pelvic injuries, of which 1814 (85.9%) sustained TPF, males dominated (76.5%) with a mean age of 41 ± 21 years. In unstable pelvic fracture, the frequent mechanism of injury was motor vehicle crash (41%) followed by falls (35%) and pedestrian hit by vehicle (24%). Apart from both extremities, the chest (37.3%) was the most commonly associated injured region. The mean injury severity score (ISS) of 16.5 ± 13.3. Hemodynamic instability was observed in 44%. Blood transfusion was needed in one third while massive transfusion and intensive care admission were required in a tenth and a quarter of cases, respectively. Tile classification was possible in 1228 patients (type A in 60%, B in 30%, and C in 10%). Patients with type C fractures had higher rates of associated injuries, higher ISS, greater pelvis abbreviated injury score (AIS), massive transfusion protocol activation, prolonged hospital stay, complications, and mortality (p value < 0.001). Two-thirds of patients were managed conservatively while a third needed surgical fixation. The median length of hospital and intensive care stays were 15 and 5 days, respectively. The overall mortality rate was 4.7% (86 patients). CONCLUSION: TPF is a common injury among polytrauma patients. It needs a careful, systematic management approach to address the associated complexities and the polytrauma nature.
Assuntos
Fixação Interna de Fraturas/métodos , Fraturas Ósseas/mortalidade , Fraturas Ósseas/cirurgia , Traumatismo Múltiplo/cirurgia , Administração dos Cuidados ao Paciente/métodos , Ossos Pélvicos/lesões , Acidentes por Quedas , Acidentes de Trânsito , Adulto , Transfusão de Sangue/estatística & dados numéricos , Feminino , Fraturas Ósseas/fisiopatologia , Alemanha , Hemodinâmica , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Morbidade , Estudos Multicêntricos como Assunto , Traumatismo Múltiplo/mortalidade , Traumatismo Múltiplo/fisiopatologia , Prognóstico , Catar , Estudos Retrospectivos , Fatores de Tempo , Índices de Gravidade do Trauma , Adulto JovemRESUMO
AIM: This study aims to assess the results of open versus closed reduction in intramedullary nailing for femoral fractures and whether it delays union, predisposes to nonunion, or increases the rate of infection. MATERIALS AND METHODS: A retrospective review of all adult patients with isolated femoral shaft fractures treated by intramedullary nailing was done. The primary outcome is union rate, and the secondary outcomes are operation time and the infection rate. RESULTS: 110 isolated femoral shaft fractures, with 73 (66.4%) in the closed reduction group and 37 (33.6%) in the open reduction group, 90.4% males and 9.6% females, and the average age was 32.6 years. RTA is the most common cause of these injuries followed by the fall from height. The delayed union rate was 20% (22/110) with no difference between the two groups, p value 0.480, and the nonunion rate was 5.5% (6/110), and no statistical difference was observed between the two groups. The operation time was shorter in the closed groups, and no difference in the time to union was observed between two groups. No infection was found in the two groups. CONCLUSIONS: There is no statistical difference between the healing rates in closed and open reduction in femoral shaft fractures. In cases where closed reduction is difficult, it is better to open reduce the fracture if closed reduction cannot be achieved in 15 minutes, especially in polytrauma.
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BACKGROUND: Transforaminal lumbar interbody fusion (TLIF) is the treatment of choice for lumbar spinal stenosis and spondylolisthesis. The procedure can be performed through a traditional open approach (O-TLIF) or through minimally invasive techniques (MI-TLIF). Spinal surgeries in obese patients can pose risks, including increased rates of infection and thromboembolic events. QUESTIONS/PURPOSES: We sought to systematically review the literature on the differences between MI-TLIF and O-TLIF in the obese patient in terms of complication rate, functional outcomes, blood loss, and length of hospital stay. METHODS: We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to systematically search PubMed, Embase, Web of Science, and the Cochrane Library for studies published through February 2019 and identified those comparing the outcomes of O-TLIF and MI-TLIF in obese patients. The primary outcome was complication rate (total, infections, dural tears); secondary outcomes were blood loss, length of hospital stay, and functional scores. Two authors independently reviewed the studies using the Newcastle-Ottawa Scale, and data were pooled using the Mantel-Haenszel random-effects model. RESULTS: In the sample of 430 patients, the average age was 53.5 years, there were 153 men and 203 women, and the average body mass index was 33.6. Complications were significantly higher in O-TLIF than in MI-TLIF (OR = 0.420 [95% CI: 0.199, 0.887]; I 2 = 45.20%). No difference was detected between the two groups for visual analog scale back pain scores and Oswestry Disability Index scores between the pre-operative and last follow-up visits (SMD = -0.034 [95% CI -0.695, 0.627]; I 2 = 62.14% and SMD = 0.617 [95% CI: -1.082, 2.316]; I 2 = 25%, respectively). Blood loss was significantly lower in MI-TLIF compared to O-TLIF (SMD = -426.736 [95% CI: -490.720, -362.752]; I 2 = 70.53%), as was the duration of hospital stay (SMD = -1.079 [95% CI: -1.591, -0.208]; I 2 = 84.3%). CONCLUSION: MI-TLIF has equivalent efficacy to O-TLIF in obese patients at long-term follow-up. In addition, complication rate, blood loss, and length of hospital stay were lower in MI-TLIF than in O-TLIF.