Confirmed: TXA Works Well in Adolescent Scoliosis Surgery
The evidence favoring tranexamic acid (TXA) for reducing surgical blood loss is ample and growing, but until now robust data were sparse regarding its efficacy in the setting of adolescent idiopathic scoliosis surgery. In the December 5, 2018 issue of The Journal of Bone & Joint Surgery, Goobie et al. report on a randomized, blinded, placebo-controlled trial showing that, in that population, TXA reduced perioperative blood loss by 27%, compared with blood loss in a placebo group.
Even with recent advances in scoliosis surgical technique, blood transfusions are common. And, because transfusions are associated with significant morbidity and mortality, limiting operative blood loss and reducing the need for transfusion have become focal points for orthopaedic surgeons.
In this Level-I trial, >100 patients between the ages of 10 and 18 years undergoing elective posterior instrumented spinal fusion were randomized to receive either TXA (infusion of a 50-mg/kg loading dose and a 10-mg/kg/h maintenance dose) or normal saline (delivered in the same way and dose) during surgery. The TXA group demonstrated an overall 27% reduction in cumulative blood loss and a 2-fold reduction in the percentage of patients with clinically relevant blood loss (defined as >20 mL/kg).
The cumulative effect of reduced blood loss was enhanced over time, with the positive effect of TXA being most evident in procedures lasting >4 hours. None of the patients in the TXA group required a transfusion or developed side effects such as thromboembolism or seizures.
In an interesting sidenote, the authors asked the participating orthopaedic surgeons, who were blinded to the randomization, to guess which group each patient had been assigned to by evaluating the relative ooziness of the surgical field. The surgeons guessed correctly 72% of the time.
Overall, these findings prompted the authors to conclude that “the use of TXA as part of a multimodal blood management strategy, as was employed in this study, should be considered the standard of care for patients undergoing surgery for adolescent idiopathic scoliosis.”
JBJS 100: Blount Disease, Low Back Pain
Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.
Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original full-text content openly accessible for a limited time.
Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.
We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:
Tibia Vara: Osteochondrosis Deformans Tibia
WP Blount: JBJS, 1937 January; 19 (1): 1
In this classic article, Blount detailed clinical and radiologic features of the affected lower extremities of 13 children with bowlegs. Nearly 80 years have passed since Blount’s original description, and not much more is known about this enigmatic developmental disorder. Given the potential for less postoperative morbidity, there has been a resurgence of “guided growth” strategies to treat this and other pediatric limb deformities.
Lumbar Disc Disorders and Low-back Pain: Socioeconomic Factors and Consequences
JN Katz: JBJS, 2006 April; 88 (Suppl 2): 21
The 21st century has brought with it a sharper focus on both the socioeconomic factors contributing to medical conditions and the socioeconomic consequences of those conditions. Back in 2006, Dr. Katz found that the total annual costs of low back pain in the US exceeded $100 billion, two-thirds of that in the form of indirect costs (e.g., lost wages and reduced productivity). He also found that fewer than 5% of patients who have a low back pain episode account for 75% of the total costs, prompting Dr. Katz to emphasize the ongoing “critical importance of identifying strategies to prevent these disorders and their consequences.”
More Evidence: Coordinated Care Reduces Risk of Second Fragility Fracture
Fracture liaison services and similar coordinated, multidisciplinary fragility-fracture reduction programs for patients with osteoporosis work (see related OrthoBuzz posts), but until now, the data corroborating that have come from either academic medical centers or large integrated health care systems. The November 7, 2018 issue of The Journal of Bone and Joint Surgery presents solid evidence from a retrospective cohort study that a private orthopaedic practice-based osteoporosis management service (OP MS) also successfully reduces the risk of subsequent fragility fractures in older patients who have already sustained one.
Sietsema et al. collected fee-for-service Medicare data for Michigan residents who had any fracture from April 1, 2010 to September 30, 2014 (mean age of 75 years). From that data, they compared outcomes for patients who received nurse-practitioner-led OP MS care from a single-specialty private orthopaedic practice within 90 days of the first fracture to outcomes among a propensity-score-matched cohort of similar patients who did not receive OP MS care. There were >1,300 patients in each cohort, and both groups were followed for an average of 2 years. The private practice’s OP MS services incorporated the multidisciplinary protocols promulgated by the American Orthopaedic Association’s “Own the Bone” program.
The cohort exposed to OP MS had a longer median time to subsequent fracture (998 versus 743 days), a lower incidence rate of any subsequent fracture (300 versus 381 fractures per 1,000 person-years), and higher incidence rates of osteoporosis medication prescriptions filled (159 versus 90 per 1,000 person-years). Over the first 12 months of the follow-up period, total medical costs did not differ significantly between the 2 cohorts.
These findings are consistent with those reported from academic or integrated health-system settings. According to the authors, this preponderance of evidence “emphasize[s] the importance of coordinated care in reducing subsequent fractures, lengthening the time to their occurrence, and improving patient outcomes.” Sietsema et al. conclude further that “the U.S. Medicare population would benefit from widespread implementation of such models in collaboration with orthopaedic providers and payers.”
JBJS 100: Epiphyseal Plate Injuries, Spinal Osteomyelitis
Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.
Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original full-text content openly accessible for a limited time.
Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.
We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:
Injuries Involving the Epiphyseal Plate
RB Salter, WR Harris: JBJS, 1963 April; 45 (3): 587
In addition to presenting the fracture classification, the authors laid the groundwork with basic principles of mechanical failure and vascularity of the physis. The authors then explain how physeal damage may arise from misalignment, crushing, or vascular interruption. This enduring orthopaedic schema lives on because of its clarity of presentation and its implications for treatment.
Pyogenic Osteomyelitis of the Spine
J Kulowski: JBJS, 1936 April; 18 (2): 343
In this 22-page analysis and discussion of 102 cases, the author notes that pyogenic osteomyelitis of the spine can affect any part of the vertebral system. In 1936—8 years after the discovery of penicillin—Kulowski said, “It may be axiomatically stated that operative intervention is imperative, as soon as the diagnosis is made with a reasonable degree of accuracy, when suppuration is present…,” adding that “the primary spinal focus requires the first attention of the surgeon.”
JBJS 100: Approach to the Lumbar Spine, Knee Flexion Contracture
Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.
Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original full-text content openly accessible for a limited time.
Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.
We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:
The Paraspinal Sacrospinalis-Splitting Approach to the Lumbar Spine
LL Wiltse, JG Bateman, RH Hutchinson, WE Nelson: JBJS, 1968 July; 50 (5): 919
In this classic 1968 JBJS paper, Wiltse and co-authors described a novel and innovative access route to the lumbar spine. Advantages included reduced blood loss, less muscle ischemia, and the preservation of spinous processes and intra-/supraspinous ligaments. The Wiltse approach still represents one of the main access routes to the lumbar spine.
Treatment of Knee Flexion Contracture Due to Central Nervous System Disorders in Adults
JN Martin, R Vialle, P Denormandie, G Sorriaux, H Gad, I Harding, O Dizien, T Judet: JBJS, 2006 April; 88 (4): 840
To address what was at the time a lack of interest among orthopaedic surgeons in treating spasticity in adults, these authors expanded upon earlier work studying the treatment of knee flexion contractures in this population. Their procedure included distal hamstring lengthening, a posterior capsulotomy in some of the knees, and use of a unilateral external fixator in most of the knees. Mean flexion contracture improved from a mean of 69° preoperatively to a mean of 6.2° at 1 to 5 years after surgery.
August 2018 Article Exchange with JOSPT
In 2015, JBJS launched an “article exchange” collaboration with the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) to support multidisciplinary integration, continuity of care, and excellent patient outcomes in orthopaedics and sports medicine.
During the month of August 2018, JBJS and OrthoBuzz readers will have open access to the JOSPT article titled “Impact of Risk Adjustment on Provider Ranking for Patients With Low Back Pain Receiving Physical Therapy.”
The authors’ findings confirmed their hypothesis that robust risk adjustment is essential for objective comparison of patient-reported outcomes and for accurately reflecting quality of care among patients treated for low back pain.
What’s New in Spine Surgery 2018, Part II
Previously, Chad A. Krueger, MD, JBJS Deputy Editor for Social Media, selected what he deemed to be the most clinically compelling findings from among the more than 25 studies cited in the June 20, 2018 Specialty Update on Spine Surgery. In this OrthoBuzz post, Theodore J. Choma, MD, author of the Specialty Update on Spine Surgery, selected his “top five.”
Spondylolisthesis
–A registry study of 765 patients with adult isthmic spondylolisthesis and at least 2 years of post-treatment outcome data found that at 1 year, global-assessment improvements were reported in 54% of patients who underwent uninstrumented posterolateral fusion, 68% of patients who underwent instrumented posterolateral fusion, and 70% of patients who underwent interbody fusion. Although similar patterns were seen in VAS back pain scores and in 2-year data, fusion with instrumentation was associated with a higher risk of reoperation.
Acute Low Back Pain
–In a cost analysis using data from a previously published Level-II study that randomized 220 patients with acute low back pain to early physical therapy or usual (delayed-referral) care, authors concluded that the incremental cost of early PT was $32,058 per quality-adjusted life year and that early PT is therefore cost-effective.1
Metabolic Bone Disease
–A randomized trial of 66 women ≥50 years of age who had osteoporosis and had undergone lumbar interbody arthrodesis found that those who received once-weekly teriparatide for 6 months following surgery demonstrated higher fusion rates than those in the control cohort (69% versus 35%). Once weekly teriparatide may be worth considering to improve fusion rates in this challenging patient population.
Adult Deformity Correction
–To test the hypothesis that performing 3-column osteotomies more caudally in the lumbar spine might improve sagittal malalignment correction, authors analyzed 468 patients from a spine deformity database who underwent 3-column osteotomies.2 The mean resection angle was 25.1° and did not vary by osteotomy level. No variations were found in the amount of sagittal vertical axis or pelvic tilt correction, but lower-level osteotomies were associated with more frequent pseudarthroses and postoperative motor deficits.
Spinal Cord Injury
–Authors directly measured the mean arterial pressure and cerebrospinal fluid pressure in 92 consecutive patients with traumatic spinal cord injury. Using that data to indirectly monitor the patients’ spinal cord perfusion pressure,3 the authors found that patients who experienced more episodes of spinal cord perfusion pressures <50 mm Hg were less likely to manifest objective improvements in spinal cord function.
References
- Fritz JM, Kim M, Magel JS, Asche CV. Cost-effectiveness of primary care management with or without early physical therapy for acute low back pain: economic evaluation of a randomized clinical trial. Spine (Phila Pa 1976).2017 Mar;42(5):285-90.
- Ferrero E, Liabaud B, Henry JK, Ames CP, Kebaish K, Mundis GM, Hostin R, Gupta MC, Boachie-Adjei O,Smith JS, Hart RA, Obeid I, Diebo BG, Schwab FJ, Lafage V. Sagittal alignment and complications following lumbar 3-column osteotomy: does the level of resection matter?J Neurosurg Spine. 2017 Nov;27(5):560-9. Epub 2017 Sep 8.
- Squair JW, Bélanger LM, Tsang A, Ritchie L, Mac-Thiong JM, Parent S, Christie S, Bailey C, Dhall S, Street J,Ailon T, Paquette S, Dea N, Fisher CG, Dvorak MF, West CR, Kwon BK. Spinal cord perfusion pressure predicts neurologic recovery in acute spinal cord injury. 2017 Oct 17;89(16):1660-7. Epub 2017 Sep 15.
JBJS 100: SCFE Outcomes, Scoliosis Treatment
Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.
Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.
Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.
We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:
Long-term Follow-up of Slipped Capital Femoral Epiphysis
B T Carney, S L Weinstein, J Noble: JBJS, 1991 January; 73 (5): 667
In this retrospective study of 155 hips with SCFE followed for a mean of 41 years after onset of symptoms, Carney et al. found that pinning in situ provided the best long-term function and delay of degenerative arthritis—and that realignment techniques were associated with a risk of substantial complications.
Treatment of Scoliosis: Correction and Internal Fixation by Spine Instrumentation
P R Harrington: JBJS, 1962 June; 44 (4): 591
The need for this at-the-time revolutionary instrumented approach was the polio epidemic, which left Dr. Harrington caring for many patients with severe, collapsing curves that threatened their health. Just as current hip arthroplasty techniques represent incremental improvements to the contribution of Charnley, current techniques in scoliosis surgery are stepwise improvements to Harrington’s work.
What’s New in Spine Surgery 2018
Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of all OrthoBuzz Specialty Update summaries.
This month, OrthoBuzz asked Chad Krueger, MD, JBJS Deputy Editor for Social Media, to select the five most clinically compelling findings from among the more than 25 studies cited in the June 20, 2018 Specialty Update on Spine Surgery.
Cervical Spine
—A Level-III retrospective analysis found that patients who received a preoperative cervical epidural steroid injection prior to an anterior cervical discectomy and fusion or a posterior cervical fusion had a significantly greater risk of postoperative infection than those who did not receive a preoperative steroid injection.1 Prospective studies are needed to further clarify the perioperative infection risk associated with cervical epidural steroid injections.
Lumbar Spine
—A Level-II randomized pilot trial comparing titanium-coated PEEK interbody spacers with non-coated PEEK spacers among 40 patients who underwent transforaminal lumbar interbody fusion found that patients in both groups had 92% fusion at 3 months, with no significant between-group differences in pain and disability outcomes.2
—A Level-II randomized study of 108 patients who underwent lumbar discectomy compared outcomes among those who experienced 2 weeks versus 6 weeks of postoperative activity restriction. At the 1-year follow-up there was a nonsignificant difference in recurrent herniation (11% in the 2-week group versus 7% in the 6-week group) and no significant between-group differences in pain or disability scores.3
RF Ablation for Chronic Low Back Pain
—A Level-II meta-analysis involving 454 patients with chronic low back pain found that those who underwent radiofrequency (RF) lumbar-facet denervation had significantly reduced VAS back pain compared to a group that underwent a sham procedure or epidural block. Those in the denervation group who benefited most were those who had responded favorably to an initial diagnostic facet block.4
Adolescent Idiopathic Scoliosis
—A Level-II study assessing the ability of surface topography to evaluate spinal deformity in children with adolescent idiopathic scoliosis followed 45 patients for 1 year. This method plus radiography allowed researchers to determine mild curves with strong negative predictive value and sensitivity. The authors estimated that surface topographic analyses could reduce patient exposure to ionizing radiation by eliminating 31% of surveillance radiographs in these patients.5
References
- Cancienne JM, Werner BC, Puvanesarajah V, Hassanzadeh H, Singla A, Shen FH, Shimer AL. Does the timing of preoperative epidural steroid injection affect infection risk after ACDF or posterior cervical fusion?Spine (Phila Pa 1976). 2017 Jan 15;42(2):71-7.
- Rickert M, Fleege C, Tarhan T, Schreiner S, Makowski MR, Rauschmann M, Arabmotlagh M. Transforaminal lumbar interbody fusion using polyetheretherketone oblique cages with and without a titanium coating: a randomised clinical pilot study. Bone Joint J.2017 Oct;99-B(10):1366-72.
- Bono CM, Leonard DA, Cha TD, Schwab JH, Wood KB, Harris MB, Schoenfeld AJ. The effect of short (2-weeks) versus long (6-weeks) post-operative restrictions following lumbar discectomy: a prospective randomized control trial. Eur Spine J.2017 Mar;26(3):905-12. Epub 2016 Nov 2.
- Lee CH, Chung CK, Kim CH. The efficacy of conventional radiofrequency denervation in patients with chronic low back pain originating from the facet joints: a meta-analysis of randomized controlled trials. Spine J.2017 Nov;17(11):1770-80. Epub 2017 May 30.
- Hong A, Jaswal N, Westover L, Parent EC, Moreau M, Hedden D, Adeeb S. Surface topography classification trees for assessing severity and monitoring progression in adolescent idiopathic scoliosis. Spine (Phila Pa 1976).2017 Jul 1;42(13):E781-7.
Quantitative Guidance for Treating Patients with Spinal Epidural Abscess
Any patient presenting with a spinal epidural abscess is in a high-risk situation, but decisions about operative versus nonoperative management in such cases are influenced largely by the presence, absence, or imminent risk of a motor deficit. This is why the identification by Shah et al. of 8 independent predictors of pre-treatment motor deficit and 7 independent predictors of 90-day mortality among patients with spinal epidural abscess is so important. The findings appear in the June 20, 2018 issue of JBJS.
The authors retrospectively analyzed data from 1,053 patients admitted with spinal epidural abscess at 2 tertiary medical centers and 3 regional community hospitals. Using multivariable logistic regression, they identified the following 8 significant risk factors for pre-treatment motor deficits in these patients:
- Diabetes
- Sensory changes
- Urinary incontinence/retention
- Fecal incontinence/retention
- Abscess location proximal to conus medullaris
- Abscess location dorsal to the thecal sac
- Abscess in multiple locations
- White blood cell (WBC) count >12 X 109 cells/L
Similarly, the authors identified the following 7 significant risk factors for 90-day mortality:
- Diabetes
- Age >65 years
- Active malignancy
- Renal disease requiring hemodialysis
- Pre-treatment motor deficit
- Endocarditis
- WBC count >15 X 109 cells/L
By themselves, these predictors are not prognostic, but the authors provide an algorithm that clinicians can use to generate an individualized probability of pre-treatment motor deficit or 90-day mortality for a given patient. The authors express hope that the resulting quantitative information will help guide management decisions for patients with spinal epidural abscess.
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