RESUMEN
STUDY DESIGN: Retrospective review of patients ages 10-18 who underwent posterior fusion for adolescent idiopathic scoliosis (AIS) at a single institution from 2014 to 2019. OBJECTIVE: The aim was to evaluate a standardized Care Path to determine its effects on perioperative outcomes in patients undergoing spinal fusion for AIS. SUMMARY OF BACKGROUND DATA: AIS is the most common pediatric spinal deformity and thousands of posterior fusions are performed annually. Surgery presents several postoperative challenges, such as pain control, delayed mobilization, and opioid-related morbidity. Optimizing perioperative care of AIS is a high priority to reduce morbidity and improving health care efficiency. MATERIALS AND METHODS: A total of 336 patients ages 10-18 were included in this study; 117 in the pre-Care Path cohort (2014-2015) and 219 in the post-Care Path cohort (2016-2019). Data compared included intraoperative details, length of stay, timing of mobilization, inpatient complications, emergency room (ER) visits, readmissions after discharge, postoperative complications, and reoperations. RESULTS: The post-Care Path cohort had improved mobilization on postoperative day 0 (pre 16.7%, post 53.3%, P<0.00001), reduced length of stay (pre 4.14 days, post 3.36 days, P=0.00006), fewer total inpatient complications (pre 17.1%, post 8.1%, P=0.0469), and fewer instances of postoperative ileus (pre 8.5%, post 1.9%, P=0.0102). Within 60 days of surgery, the post-Care Path cohort had fewer ER visits (pre 12.8%, post 7.2%, P=0.0413), decreased postoperative infections (pre 5.1%, post 0.48%, P=0.00547), decreased readmissions (pre 6.0%, post 0.48%, P=0.0021), and decreased reoperations (pre 5.1%, post 0.96%, P=0.0195). There was a decrease in inpatient oral morphine equivalents in the Care Path cohort (pre 118.7, post 84.7, P=0.0003). CONCLUSIONS: Our Care Path for AIS patients demonstrated significant improvements in postoperative mobilization and decreases in length of stay, complications, infections, ER visits, readmissions, and reoperations.
Asunto(s)
Cifosis , Escoliosis , Fusión Vertebral , Adolescente , Niño , Humanos , Tiempo de Internación , Readmisión del Paciente , Atención Perioperativa , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Escoliosis/cirugía , Fusión Vertebral/efectos adversosRESUMEN
Knee injuries are common in children, but epiphyseal and physeal injuries involving the distal femur and proximal tibia are relatively rare. This can make diagnosis and evaluation of pediatric knee injuries challenging. Pediatric knee physeal injuries can also be complicated by vascular injuries with potentially devastating consequences, and thus, a heightened suspicion for these injuries is indicated. Distal femoral and proximal tibial physeal injuries can be diagnosed with plain radiographs or with advanced imaging if the initial findings are equivocal. Physeal fractures of the distal femur and proximal tibia can be managed nonsurgically if nondisplaced or surgically with cannulated screw fixation or smooth, percutaneous pin fixation. Tibial tubercle injuries can have point tenderness or an extensor lag, are diagnosed with plain radiographs, and are often managed with physeal-sparing cannulated screw fixation. These injuries have an increased risk of compartment syndrome. Tibial eminence fractures are epiphyseal avulsion injuries caused by traction from the anterior cruciate ligament. Arthroscopic and open techniques for reduction and stable fixation yield good outcomes. Patellar sleeve injuries are often misdiagnosed and may require advanced imaging for diagnosis. They represent pediatric extensor mechanism injuries that often necessitate open reduction and fixation or patellar tendon advancement. Understanding the relevant anatomy, diagnosis, and management options can help guide the treating physician in the management of the fractures of the pediatric knee.
Asunto(s)
Traumatismos de la Rodilla , Fracturas de la Tibia , Ligamento Cruzado Anterior , Niño , Humanos , Articulación de la Rodilla , TibiaRESUMEN
Physeal fractures of the distal femoral are rare injuries accounting for less than 2% of all physeal injuries, and tend to have a worse prognosis than similar injuries in other locations. This article reviews the evaluation (including imaging), classification, and treatment of these injuries, and discusses their most important complications and their management, including vascular injury and growth arrest.
Asunto(s)
Fracturas del Fémur , Traumatismos de la Rodilla , Fracturas de Salter-Harris , Niño , Fracturas del Fémur/clasificación , Fracturas del Fémur/complicaciones , Fracturas del Fémur/diagnóstico , Fracturas del Fémur/terapia , Fémur/crecimiento & desarrollo , Fémur/lesiones , Trastornos del Crecimiento/etiología , Humanos , Traumatismos de la Rodilla/clasificación , Traumatismos de la Rodilla/complicaciones , Traumatismos de la Rodilla/diagnóstico , Traumatismos de la Rodilla/terapia , Fracturas de Salter-Harris/clasificación , Fracturas de Salter-Harris/complicaciones , Fracturas de Salter-Harris/diagnóstico , Fracturas de Salter-Harris/terapia , Lesiones del Sistema Vascular/etiologíaRESUMEN
Talocalcaneal tarsal coalitions are a common source of foot pain, stiffness, and deformity. These coalitions are treated symptomatically with rest and periods of immobilization. When those measures fail, surgical resection is attempted. This procedure is an anatomic challenge with the consequence of leaving residual coalition. The residual coalition primarily results from difficulty with intraoperative imaging because fluoroscopy does not provide adequate detail of this area. Some investigators have recommended intraoperative computed tomography after resection with reasonable results. We describe the combination of an intraoperative computed tomography with a navigated instrument system for resection of talocalcaneal coalitions. The use of a navigated probe and burr aids in defining the most anterior, posterior, and medial extents of the coalition. This technique reduces the morbidity, with less bone removed and preservation of intact subtalar articulations and allows for an efficient, thorough, and controlled resection.
Asunto(s)
Imagenología Tridimensional , Articulación Talocalcánea/diagnóstico por imagen , Articulación Talocalcánea/cirugía , Cirugía Asistida por Computador/métodos , Coalición Tarsiana/cirugía , Adolescente , Femenino , Estudios de Seguimiento , Humanos , Monitoreo Intraoperatorio/métodos , Articulación Talocalcánea/fisiopatología , Coalición Tarsiana/diagnóstico por imagen , Tomografía Computarizada por Rayos X/métodos , Resultado del TratamientoRESUMEN
BACKGROUND: Noninvasive hemoglobin (nHgb) monitoring was initially introduced in the intensive care setting as a means of rapidly assessing Hgb values without performing a blood draw. We conducted a prospective analysis to compare reliability, cost, and patient preference between nHgb monitoring and invasive Hgb (iHgb) monitoring performed via a traditional blood draw. METHODS: We enrolled 100 consecutive patients undergoing primary or revision total hip or total knee arthroplasty. On postoperative day 1, nHgb and iHgb values were obtained within thirty minutes of one another. iHgb and nHgb values, cost, patient satisfaction, and the duration of time required to obtain each reading were recorded. The concordance correlation coefficient (CCC) was utilized to evaluate the agreement of the two Hgb measurement methods. Paired t tests and Wilcoxon signed-rank tests were utilized to compare mean Hgb values, time, and pain for all readings. RESULTS: The mean Hgb values did not differ significantly between the two measurement methods: the mean iHgb value (and standard deviation) was 11.3 ± 1.4 g/dL (range, 8.2 to 14.3 g/dL), and the mean nHgb value was 11.5 ± 1.8 g/dL (range, 7.0 to 16.0 g/dL) (p = 0.11). The CCC between the two Hgb methods was 0.69. One hundred percent of the patients with an nHgb value of ≥ 10.5 g/dL had an iHgb value of >8.0 g/dL. The mean time to obtain an Hgb value was 0.9 minute for the nHgb method and 51.1 minutes for the iHgb method (p < 0.001). At our institution, the cost of iHgb monitoring is approximately $28 per blood draw compared with $2 for each nHgb measurement, resulting in a savings of $26 per Hgb assessment when the noninvasive method is used. CONCLUSIONS: Noninvasive Hgb monitoring was found to be more efficient, less expensive, and preferred by patients compared with iHgb monitoring. Providers could consider screening total joint arthroplasty patients with nHgb monitoring and only order iHgb measurement if the nHgb value is <10.5 g/dL. If this protocol had been applied to the first blood draw in our 100 patients, approximately $2000 would have been saved. Extrapolated to the U.S. total joint arthroplasty practice, approximately $20 million could be saved annually.
Asunto(s)
Artroplastia de Reemplazo de Cadera , Artroplastia de Reemplazo de Rodilla , Hemoglobinas/análisis , Cuidados Posoperatorios/métodos , Adulto , Anciano , Anciano de 80 o más Años , Biomarcadores/sangre , Análisis Costo-Beneficio , Femenino , Humanos , Masculino , Persona de Mediana Edad , Minnesota , Monitoreo Fisiológico/economía , Monitoreo Fisiológico/métodos , Prioridad del Paciente , Cuidados Posoperatorios/economía , Estudios Prospectivos , Reproducibilidad de los ResultadosRESUMEN
BACKGROUND: Coxa magna, the asymmetrical circumferential enlargement of the femoral head, is an important sequela of pediatric disorders such as Legg-Calvé-Perthes disease. Definitions vary because of lack of controls and a scarcity of research on the distribution of the femoral head asymmetry. This study aims at defining the normal distribution of asymmetry between the left and the right femoral head and neck in the population and how demographics affect these properties. The study also looked at the distribution of side dominance (left or right). METHODS: This study measured 230 paired femurs from individuals (20 to 40 y old) distributed for sex and ethnicity. The height and weight of the individuals were also recorded. The femoral head diameter and minimal femoral neck diameter in the anteroposterior view were measured on each paired femurs. The absolute and percent differences were determined to define asymmetry. RESULTS: Most of the population fell within 3% of asymmetry for the femoral head and 4% for the femoral neck. The maximum head percent asymmetry was 7.4%. Absolute difference in millimeters to percent asymmetry showed a ratio of 2:1 for the femoral head and 3:1 for the femoral neck. African Americans showed greater femoral head symmetry and a bias toward left-sided femoral head and neck enlargement when compared with their white counterparts. CONCLUSIONS: There was a high degree of symmetry between the left and right femoral heads and necks, which supports definitions found in the literature that define coxa magna above 10%. This study defines asymmetry in the femoral head in the normal population, which will help to define a quantitative definition of coxa magna.
Asunto(s)
Cabeza Femoral/anomalías , Cabeza Femoral/anatomía & histología , Cuello Femoral/anomalías , Cuello Femoral/anatomía & histología , Adulto , Negro o Afroamericano , Análisis de Varianza , Peso Corporal , Cadáver , Femenino , Cadera/anatomía & histología , Humanos , Masculino , Variaciones Dependientes del Observador , Valores de Referencia , Reproducibilidad de los Resultados , Caracteres Sexuales , Población BlancaRESUMEN
It is not clear whether spinal degeneration leads to hip arthritis, or hip arthritis leads to spinal degeneration. We conducted a study to determine which degenerative process precedes the other. We examined 340 cadaveric human specimens from the Hamann-Todd Osteological Collection (Cleveland, Ohio). Lumbar endplate degeneration was graded on a scale of 0 to 4, and hip degeneration on a scale of 0 to 3. Linear regression was used to analyze the relationship between hip osteoarthritis (OA) and lumbar degenerative disk disease (DDD). Exact tests were used to identify differences in each age group. Hip OA was significantly associated with endplate degeneration at the L1, L3, and L5 levels (P<.02). Of the specimens younger than 29 years, 35% had evidence of DDD in at least 1 lumbar level, and 17% of hip OA changes. At 70 years, 100% of the specimens had evidence of DDD and 50% of hip OA changes. There was a significant association between lumbar DDD and hip OA changes (P<.05). Early lumbar DDD was twice as common as hip OA changes in the early 20s age range. These findings suggest that lumbar degeneration precedes hip degeneration and may be a causative factor for hip OA.
Asunto(s)
Degeneración del Disco Intervertebral/diagnóstico , Vértebras Lumbares/patología , Osteoartritis de la Cadera/diagnóstico , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Progresión de la Enfermedad , Femenino , Humanos , Degeneración del Disco Intervertebral/patología , Masculino , Persona de Mediana Edad , Osteoartritis de la Cadera/patologíaRESUMEN
BACKGROUND CONTEXT: The use of oral anticoagulation therapy such as warfarin is projected to increase significantly as the population ages and the prevalence of cardiovascular disease increases. Current recommendations state that warfarin be discontinued before surgery and the international normalized ratio (INR) normalized. PURPOSE: To determine if stopping warfarin 7 days before surgery and correcting INR had any effect on intraoperative blood loss or the requirements for blood product transfusion. STUDY DESIGN/SETTING: This was a retrospective cohort study in a high-volume tertiary care center. PATIENT SAMPLE: Sample comprised 263 consecutive patients who underwent elective lumbar spinal surgery. OUTCOME MEASURE: The outcome measures were intraoperative blood loss, intraoperative blood transfusion, postoperative blood transfusion, and the number of blood products transfused. METHODS: The records of patients undergoing elective spinal surgery were analyzed for patient demographic data, comorbidities, coagulation panel laboratory findings, operative characteristics, blood loss, and blood transfusion requirements. These included patients undergoing full laminectomies with or without posterolateral fusion and instrumentation. Patients on warfarin were analyzed for the mean dosage of warfarin and underlying pathology that required anticoagulation. All patients on warfarin had their anticoagulation therapy stopped 7 days before surgery and their INR checked preoperatively to confirm normalization. Both univariate and multiple linear regression analyses were performed. RESULTS: The patients on warfarin had a mean intraoperative blood loss of 839 mL compared with 441 mL for patients not on warfarin (p<.01). Multiple regression analysis determined that warfarin and number of spinal levels decompressed/fused/instrumented were predictors for increased blood loss (R(2)=0.37). Patients on warfarin also had increased postoperative blood transfusions (23.1% compared with 7.4%, p=.04). There was no significant difference between groups in terms of intraoperative blood transfusion or number of units transfused. CONCLUSIONS: Patients on chronic anticoagulation therapy with warfarin who have their therapy stopped 7 days before surgery and have their INR normalized still demonstrated increased intraoperative blood loss and requirement for postoperative transfusion. Surgeons should be aware of the increased propensity of these patients to bleed despite adherence to protocols and should attempt to mitigate this risk.
Asunto(s)
Anticoagulantes/efectos adversos , Pérdida de Sangre Quirúrgica , Transfusión Sanguínea , Vértebras Lumbares/cirugía , Warfarina/efectos adversos , Anciano , Anticoagulantes/administración & dosificación , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Procedimientos Ortopédicos , Estudios Retrospectivos , Warfarina/administración & dosificaciónRESUMEN
BACKGROUND: The contralateral femur frequently is used for preoperative templating for THA or hemiarthroplasty when the proximal femur is deformed by degenerative changes or fracture. Although femoral symmetry is assumed in these situations, it is unclear to what degree the contralateral femur is symmetrical. QUESTIONS/PURPOSE: We therefore defined the degree of asymmetry between left and right proximal femurs and determined whether it was affected by demographics and proximal femoral anatomy. METHODS: We obtained 160 paired femurs from individuals (20-40 years old), evenly distributed for gender and ethnicity (African-American and Caucasian). The height and weight of the individuals were recorded. We measured the femoral head diameter, minimal femoral neck diameter in the AP and cephalocaudal (CC) planes, and the AP femoral diaphyseal diameter. The absolute and percent differences were determined. RESULTS: All femoral measurements showed an absolute difference less than 2 mm and a percent asymmetry and difference less than 2% for the femoral head, less than 4% for the femoral neck, and less than 3.5% for the femoral shaft. We found no correlation or predictive value between absolute differences and asymmetry and age, ethnicity, gender, or weight. Height was negatively associated with femoral head differences and thus increased symmetry of the femoral head. CONCLUSIONS: Our data support assumptions of substantial symmetry of the proximal femur and highlights that asymmetry is not affected by demographics or the size of the proximal femur. Asymmetry tends not to occur in isolated segments of the femur.
Asunto(s)
Fémur/anatomía & histología , Adulto , Negro o Afroamericano , Estatura , Peso Corporal , Cadáver , Femenino , Fémur/diagnóstico por imagen , Cabeza Femoral/anatomía & histología , Cuello Femoral/anatomía & histología , Humanos , Modelos Lineales , Masculino , Radiografía , Población Blanca , Adulto JovenRESUMEN
PURPOSE: Congenital cervical stenosis (CCS) occurs when the bony anatomy of the cervical canal is smaller than expected in the general population predisposing an individual to symptomatic neural compression. No studies have defined CCS based on the normal population. The diagnosis is currently made based on clinical impression from radiographic studies. The aim of this study is to establish parameters that are associated with CCS, based on anatomic measurements on a large sample of skeletal specimens. METHODS: From the Hamann-Todd collection at the Cleveland Museum of Natural History, 1,066 skeletal specimens were selected. Digital calipers were used to measure the sagittal canal diameter (SCD), interpedicular distance (IPD), and pedicle length. Canal area at each level was calculated using a geometric formula. A standard distribution was created and values that were 2 SD below mean were considered as congenitally stenotic. An analysis of deviance was performed to identify parameters that were associated with CCS. Regression analysis was used to determine odds ratios (OR) for CCS using these parameters. RESULTS: CCS was defined at each level as: C3/4 = 1.82 cm(2), C4/5 = 1.80 cm(2), C5/6 = 1.84 cm(2), C6/7 = 1.89 cm(2), C7/T1 = 1.88 cm(2). Values of SCD < 13 mm and IPD < 22.5 mm were associated with CCS and yielded sensitivities and specificities of 88-100 % at each level. Logistic regression demonstrated a significant association between these parameters and presence of CCS with OR > 18 at each level. CONCLUSIONS: Based on our study of a large population of adult skeletal specimens, we have defined CCS at each level. Values of SCD < 13 mm and IPD < 23 mm are strongly associated with the presence of CCS at all levels.
Asunto(s)
Vértebras Cervicales/anatomía & histología , Estenosis Espinal/congénito , Adulto , Anciano , Anciano de 80 o más Años , Antropometría , Cadáver , Vértebras Cervicales/patología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Adulto JovenRESUMEN
OBJECT: Congenital cervical and lumbar stenosis occurs when the bony anatomy of the spinal canal is smaller than expected, predisposing an individual to symptomatic neural compression. While tandem stenosis is known to occur in 5%-25% of individuals, it is not known whether this relationship is due to an increased risk of degenerative disease in these individuals or whether this finding is due to the tandem presence of a congenitally small cervical and lumbar canal. The purpose of the present study was to determine if the presence of congenital cervical stenosis is associated with congenital lumbar stenosis. METHODS: One thousand seventy-two adult skeletal specimens from the Hamann-Todd Collection in the Cleveland Museum of Natural History were selected. The canal area at each level was calculated using a formula that was verified by computerized measurements. Values that were 2 standard deviations below the mean were considered to represent congenitally stenotic regions. Linear regression analysis was used to determine the association between the sum of canal areas at all levels in the cervical and lumbar spine. Logistic regression was used to calculate odds ratios for congenital stenosis in one area if congenital stenosis was present in the other. RESULTS: A positive association was found between the additive area of all cervical (that is, the sum of C3-7) and lumbar (that is, the sum of L1-5) levels (p < 0.01). A positive association was also found between the number of cervical and lumbar levels affected by congenital stenosis (p < 0.01). Logistic regression also demonstrated a significant association between congenital stenosis in the cervical and lumbar spine, with an odds ratio of 0.2 (p < 0.05). CONCLUSIONS: Based on the authors' findings in a large population of adult skeletal specimens, it appears that congenital stenosis of the cervical spine is associated with congenital stenosis of the lumbar spine. Thus, the presence of tandem stenosis appears to be, at least in part, related to the tandem presence of a congenitally small cervical and lumbar canal.