Selective thoracolumbar fusion in adult spinal deformity double curves with circumferential minimally invasive surgery: 2-year minimum follow-up.

OBJECTIVE: Selection of the upper instrumented vertebra (UIV) level for adult spinal deformity (ASD) remains controversial. Although selective fusion attempts have been described for fractional curves or adolescent curves, no authors have described selective thoracolumbar fusion performance for ASD with double curves. This study evaluated the clinical impact of selective fusion constructs within the lower thoracic and/or lumbar spine on ASD with double curves. METHODS: A retrospective review was performed on an ASD (Cobb angle > 20°, sagittal vertical axis [SVA] > 50 mm, and pelvic incidence minus lumbar lordosis mismatch [PI-LL] > 10°) database consisting of 438 patients who underwent correction with circumferential minimally invasive surgery (CMIS) between 2007 and 2020. The inclusion criteria were ASD double curves (lumbar Cobb angle > 35° and thoracic Cobb angle > 30°), 4 or more levels fused, and minimum 2-year follow-up. Analyses were performed on spinopelvic data and clinical outcome scores. Complications were recorded, specifically the need for revision surgery and hardware-related complications. RESULTS: Twenty-one ASD double curve patients underwent selective correction with a mean ± SD (range) follow-up of 91 ± 43 (24-174) months. A total of 141 levels were fused with a mean of 6.7 ± 1.3 (4-8) levels. T10 was the most proximal and most common UIV (10/21 [48%]). Pelvic fixation was performed in 12 patients (57%). Significant improvements in lumbar Cobb angle, thoracic Cobb angle, coronal balance, lumbar lordosis, thoracic kyphosis, SVA, and PI-LL were achieved. The uninstrumented thoracic spine demonstrated 14.5° of mean coronal correction and a mean increase of 9.4° in kyphosis. Significant improvements in visual analog scale (VAS) and Oswestry Disability Index (ODI) scores were observed. Four patients required revision for the following reasons: 1) superficial wound infection requiring irrigation and debridement; 2) bilateral L5 pars fractures requiring L5-S1 anterior lumbar interbody fusion and pelvic fixation; 3) adjacent-segment degeneration at L5-S1 requiring anterior lumbar interbody fusion and pelvic fixation; and 4) proximal junctional kyphosis requiring revision fusion to include the entire thoracic curve. There were no instances of hardware failure such as rod breakage or screw loosening. CONCLUSIONS: Selective thoracolumbar fusion with CMIS for ASD double curves can provide significant clinical improvements. Despite limiting fusion constructs to within the lower thoracic and/or lumbar spine, significant correction can be observed in the uninstrumented thoracic curve. The rate of mechanical complications was low, and the 2-year follow-up results suggested that limited fusion constructs are viable options for ASD double curve patients.

Does the Global Alignment and Proportion score predict mechanical complications in circumferential minimally invasive surgery for adult spinal deformity?

OBJECTIVE: The Global Alignment and Proportion (GAP) score was developed to serve as a tool to predict mechanical complication probability in patients undergoing surgery for adult spinal deformity (ASD), serving as an aid for setting surgical goals to decrease the prevalence of mechanical complications in ASD surgery. However, it was developed using ASD patients for whom open surgical techniques were used for correction. Therefore, the purpose of this study was to assess the applicability of the score for patients undergoing circumferential minimally invasive surgery (cMIS) for correction of ASD. METHODS: Study participants were patients undergoing cMIS ASD surgery without the use of osteotomies with a minimum of four levels fused and 2 years of follow-up. Postoperative GAP scores were calculated for all patients, and the association with mechanical failure was analyzed. RESULTS: The authors identified 182 patients who underwent cMIS correction of ASD. Mechanical complications were found in 11.1% of patients with proportioned spinopelvic states, 20.5% of patients with moderately disproportioned spinopelvic states, and 18.8% of patients with severely disproportioned spinopelvic states. Analysis with a chi-square test showed a significant difference between the cMIS and original GAP study cohorts in the moderately disproportioned and severely disproportioned spinopelvic states, but not in the proportioned spinopelvic states. CONCLUSIONS: For patients stratified into proportioned, moderately disproportioned, and severely disproportioned spinopelvic states, the GAP score predicted 6%, 47%, and 95% mechanical complication rates, respectively. The mechanical complication rate in patients undergoing cMIS ASD correction did not correlate with the calculated GAP spinopelvic state.

Spine patients demystified: what are the predictive factors of poor surgical outcome in patients after elective cervical and lumbar spine surgery?

BACKGROUND CONTEXT: Pre-existing comorbid psychiatric mood disorders are a known risk factor for impaired health-related quality of life and poor long-term outcomes after spine surgery. PURPOSE: The purpose of this study was to investigate the effect of preexisting mood disorders on (1) pre- and postoperative patient-reported outcomes, (2) complications, and (3) pre- and postoperative opioid consumption in patients undergoing elective cervical or lumbar spine surgery. STUDY DESIGN/SETTING: Retrospective review at a single academic institution from 2014 to 2017. PATIENT SAMPLE: Consecutive adult patients who underwent cervical or lumbar surgery. OUTCOME MEASURES: Quantitative measurements of pain (visual analog scale [VAS]) and spinal region-specific disability scores (Neck Disability Index [NDI] and Oswestry Disability Index [ODI]). METHODS: This is a retrospective review of 435 consecutive patients (179 cervical, 256 lumbar) who underwent elective spine surgery at a single academic institution from 2014 to 2017. Patient preoperative diagnosis of psychiatric mood disorder (eg, depression, anxiety, schizophrenia, bipolar, or dementia), baseline characteristics, medical (nonpsychiatric) comorbidities, operative variables, and surgical complications (eg, superficial and deep infection, wound complication, emergency department [ED] visits, readmissions, and repeat operations) were recorded. Additionally, preoperative ED visits, pre- and postoperative opioid requirements, total opioid prescription quantities and most recent dateof opioid prescription were collected. VAS, NDI, and ODI scores were recorded preoperatively and at 2, 6, and 12 weeks after surgery. Continuous variables were compared between those with and without diagnosed psychiatric comorbidity using two-tailed independent t test, and categorical variables were compared using chi-square or Fisher's exact tests. Analyses of variance and analysis of covariance were used to compare patient-reported outcomes between groups. A multivariate approach was taken to account for contribution of potential covariates in significant findings. Multiple linear regressions were used to determine variables associated with the number of postoperative opioid prescriptions. RESULTS: Of the cervical and lumbar cohorts, 78 (43.6%) and 113 (44.1%), respectively, had a preoperative diagnosis of comorbid psychiatric mood disorder. Cervical patients with mood disorders received a significantly higher total number of opioid prescriptions post-operatively (4.6±5.2 vs. 2.8±3.9; p=.002). Patients with mood disorders had worse NDI scores at all time points (p=.04), however there were no differences in VAS pain scores (p=.5). There were no statistical differences between patients with and without mood disorders regarding baseline characteristics, medical (nonpsychiatric) comorbidities, operative variables, surgical complications, preoperative ED visits or prior opioid use (p>.05). For lumbar patients, patients with mood disorders were more commonly females (p=.04), tobacco users (p=.003), alcohol dependent (p=.01) and illicit-drug abusers (p=.03). There were no differences regarding surgical complications or opioid consumption. Tobacco use (p<.001) was the sole contributor to postoperative VAS pain scores. Patients with mood disorders had significantly higher VAS values both before and 3 months following surgery (p=.01), but there was no difference in ODI scores. CONCLUSIONS: Patients with preoperative psychiatric mood disorders undergoing elective cervical surgery had worse NDI scores and received more opioid prescriptions, despite similar VAS scores as those without mood disorders. Lumbar surgery patients with mood disorders were demographically different than those without mood disorders and had worse pain before and after surgery, though ODI scores were not different. Tobacco use was the sole contributor to postoperative VAS pain scores. This information can be useful in counseling patients with mood disorders before elective spinal surgery.

Ceramic Femoral Heads for All Patients? An Argument for Cost Containment in Hip Surgery.

Trunnionosis and taper corrosion have recently emerged as problems in total hip arthroplasty (THA). No longer restricted to metal-on-metal bearings, these phenomena now affect an increasing number of metal-on-polyethylene THAs and are exacerbated by modularity. Resulting increases in metal toxicity and patient morbidity, and the added costs of toxicity surveillance and revision surgery, will place a substantial economic burden on many health systems. Although they are more expensive than cobalt-chrome heads, ceramic femoral heads make metal toxicity a nonissue. In this article, we provide a theoretical framework for debating whether use of ceramic femoral heads in all THA patients could represent a more cost-effective option.

Is Local Infiltration Analgesia Superior to Peripheral Nerve Blockade for Pain Management After THA: A Network Meta-analysis.

BACKGROUND: Local infiltration analgesia and peripheral nerve blocks are common methods for pain management in patients after THA but direct head-to-head, randomized controlled trials (RCTs) have not been performed. A network meta-analysis allows indirect comparison of individual treatments relative to a common comparator; in this case placebo (or no intervention), epidural analgesia, and intrathecal morphine, yielding an estimate of comparative efficacy. QUESTIONS/PURPOSES: We asked, when compared with a placebo, (1) does use of local infiltration analgesia reduce patient pain scores and opioid consumption, (2) does use of peripheral nerve blocks reduce patient pain scores and opioid consumption, and (3) is local infiltration analgesia favored over peripheral nerve blocks for postoperative pain management after THA? METHODS: We searched six databases, from inception through June 30, 2014, to identify RCTs comparing local infiltration analgesia or peripheral nerve block use in patients after THA. A total of 35 RCTs at low risk of bias based on the recommended Cochrane Collaboration risk assessment tool were included in the network meta-analysis (2296 patients). Primary outcomes for this review were patient pain scores at rest and cumulative opioid consumption, both assessed at 24 hours after THA. Because of substantial heterogeneity (variation of outcomes between studies) across included trials, a random effect model for meta-analysis was used to estimate the weighted mean difference (WMD) and 95% CI. The gray literature was searched with the same inclusion criteria as published trials. Only one unpublished trial (published abstract) fulfilled our criteria and was included in this review. All other studies included in this systematic review were full published articles. Bayesian network meta-analysis included all RCTs that compared local infiltration analgesia or peripheral nerve blocks with placebo (or no intervention), epidural analgesia, and intrathecal morphine. RESULTS: Compared with placebo, local infiltration analgesia reduced patient pain scores (WMD, -0.61; 95% CI, -0.97 to -0.24; p = 0.001) and opioid consumption (WMD, -7.16 mg; 95% CI, -11.98 to -2.35; p = 0.004). Peripheral nerve blocks did not result in lower pain scores or reduced opioid consumption compared with placebo (WMD, -0.43; 95% CI, -0.99 to 0.12; p = 0.12 and WMD, -3.14 mg, 95% CI, -11.30 to 5.02; p = 0.45). However, network meta-analysis comparing local infiltration analgesia with peripheral nerve blocks through common comparators showed no differences between postoperative pain scores (WMD, -0.36; 95% CI, -1.06 to 0.31) and opioid consumption (WMD, -4.59 mg; 95% CI, -9.35 to 0.17), although rank-order analysis found local infiltration analgesia to be ranked first in more simulations than peripheral nerve blocks, suggesting that it may be more effective. CONCLUSIONS: Using the novel statistical network meta-analysis approach, we found no differences between local infiltration analgesia and peripheral nerve blocks in terms of analgesia or opioid consumption 24 hours after THA; there was a suggestion of a slight advantage to peripheral nerve blocks based on rank-order analysis, but the effect size in question is likely not large. Given the slight difference between interventions, clinicians may choose to focus on other factors such as cost and intervention-related complications when debating which analgesic treatment to use after THA. LEVEL OF EVIDENCE: Level I, therapeutic study.

The Cumulative Risk of Re-dislocation After Revision THA Performed for Instability Increases Close to 35% at 15years.

A retrospective analysis was conducted on 539 hips undergoing revision total hip arthroplasty done for instability to report the cumulative risk and factors associated with re-dislocation and re-revision. The cumulative risk of re-dislocation and re-revision for all cause was 34.5% and 45.9% at 15 years, respectively. Multiple variable analyses revealed history of 2 or more previous surgeries, use of head size less than 36 mm, and cup retention to be risk factors for re-dislocation and re-revision. The use of a constrained liner was protective against re-dislocation but was not associated with a lower re-revision rate. Understanding the risk factors associated with re-dislocation or re-revision may help with perioperative decision making in order to decrease the high failure rate seen in this study.

There Are No Differences in Short- to Mid-term Survivorship Among Total Hip-bearing Surface Options: A Network Meta-analysis.

BACKGROUND: Total hip arthroplasty (THA) is increasingly being performed in patients with long life expectancies and active lifestyles. Newer implant bearing surfaces, with superior wear characteristics, often are used in this cohort with the goal of improving longevity of the prosthesis, but comparisons across the numerous available bearing surfaces are limited, so the surgeon and patient may have difficulty deciding which implants to use. QUESTIONS/PURPOSES: The purpose of this study was to answer the following question: Is there a short- to mid-term survivorship difference between common THA bearings used in patients younger than age 65 years? METHODS: We conducted a systematic review to identify randomized clinical trials (RCTs) published after 2000 that reported survivorship of ceramic-on-ceramic (CoC), ceramic-on-highly crosslinked polyethylene (CoPxl), or metal-on-highly crosslinked polyethylene (MoPxl) bearings. To qualify for our review, RCTs had to have a minimum 2-year followup and study patients were required to have an average age younger than 65 years. Direct-comparison meta-analysis and network meta-analysis were performed to combine direct and indirect evidence. RESULTS: Direct-comparison meta-analysis found no differences among the bearing surfaces in terms of the risk of revision; this approach demonstrated a risk ratio for revision of 0.65 (95% confidence interval [CI], 0.19-2.23; p = 0.50) between CoC and CoPxl and a risk ratio for revision of 0.40 (95% CI, 0.06-2.63; p = 0.34) between CoC and MoPxl. Network meta-analysis (with post hoc modification) likewise found no differences in survivorship across the three implant types, demonstrating the following probabilities of most effective implant with 95% credible intervals (CrI): CoC = 64.6% (0%-100%); CoPxl = 24.9% (0%-100%); and MoPxl = 9.9% (0%-100%). The CrIs ranged from 0% to 100% for all three bearing surfaces. Direct-comparison meta-analysis allowed for pooling of five RCTs, including 779 THAs, whereas network meta-analysis (before post hoc analysis) enabled pooling of 18 RCTs, including 2599 THAs. CONCLUSIONS: Current published evidence does not support survivorship differences among commonly used bearing surfaces in patients younger than age 65 years undergoing THA at short- to mid-term followup. Long-term RCT data will be needed to determine if a survivorship benefit is realized in younger, more active patients over time. LEVEL OF EVIDENCE: Level I, therapeutic study.