In the October 7, 2020 issue of The Journal, Du et al. report on a multicenter database-derived cohort of 167 patients with early-onset scoliosis treated with traditional growing rods and followed for ≥2 years after “final” fusion. These researchers report that 19% of those patients required a repeat surgery following fusion, most commonly for surgical-site infection and anchor-site failure. Multivariate analysis of risk factors for reoperation following final fusion revealed the following:
- Curve progression requiring revision surgery during the spine-lengthening process
- The number of levels spanned with the growing rods
- The duration of treatment
Du et al. report these results without spin in a way that is most useful for surgeons who are considering using these implants in their armamentarium. This is the way all new technology, especially complex advances in surgical care, should be reported.
Orthopaedic implants and instruments continue to evolve, almost always toward more sophisticated digital technology, complex engineering, and more numerous moving parts. The advent of magnetic growing rods for treating early-onset scoliosis is just one example. Often such advances are reported on by surgeons who are conflicted by personal and financial interests in the technology. This leads to all manner of potential bias–indication bias, reporting bias, selection bias, and detection bias to name just a few. Readers should evaluate this type of data with a high degree of suspicion.
What we need throughout orthopaedics are more multicenter, multisurgeon, “deconflicted” cohort studies and clinical trials. When such rigorous studies are conducted to investigate “high-tech” growing rods in patients with early-onset scoliosis, I will not be surprised if researchers find the same risk factors for reoperation after fusion that Du et al. found.
Marc Swiontkowski, MD
The treatment of early-onset scoliosis with Mehta casting is a long process, but if successful, it can delay or obviate the need for surgery. In the September 4, 2019 issue of JBJS, Fedorak et al. examine outcomes among 38 patients (mean age of 24 ± 15 months at time of first casting) who were treated with Mehta casting and followed for a mean of 8 ± 2 years. The retrospective review identified differences between patients who had a Cobb angle ≤15° (improvement group) at the most recent follow-up and those who had a Cobb angle of >15° (no-improvement group).
Forty-nine percent of children had achieved and maintained scoliosis of ≤15° at the time of the most recent follow-up, and 73% were improved by at least 20°, although 3 children ended up relapsing after meeting recommended criteria for discontinuation of casting. There was no significant difference in thoracic-height gain between the groups, demonstrating that even when scoliosis was not corrected, growth was maintained during cast treatment.
Patients in the improvement group had a mean age of 18.9 ± 12 months and scoliosis of 48.2° ± 14° at the initiation of treatment. Here are 3 additional factors that were associated with a greater likelihood of scoliosis of ≤15°:
- A lower pre-treatment Cobb angle and traction Cobb angle
- A smaller rib-vertebral angle difference on first-in-cast radiograph
- A lower Cobb angle on first-in-cast radiograph
The authors note that although this study analyzed longer-term follow-up data than most other similar investigations, “treatment of early-onset scoliosis is not truly finished until skeletal maturity has been reached.”
Every month, JBJS publishes 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, Jacob M. Buchowski, MD, MS, coauthor of the June 19, 2019 “What’s New in Spine Surgery,” selected the five most clinically compelling findings from among the 47 noteworthy studies summarized in the article.
Predictive Analytics for Deformity Conditions
–A validated model for predicting outcomes after lumbar spine surgery1 found that patients with lower preoperative disability scores, those covered by Medicaid or Workers’ Compensation, and current and previous smokers were less likely to improve with lumbar fusion surgery. Invasiveness of surgery and surgeon and hospital type had lower predictive value.
Early-Onset Scoliosis (EOS)
–A 5-year direct-cost estimate2 comparing magnetic growing rods and conventional growing rods for the treatment of EOS found the total cost for magnetic growing rods to be £34,741 compared with £52,293 for conventional growing rods.
Pediatric Neuromuscular Scoliosis
–A Level-II study investigated patient factors associated with postoperative pulmonary complications among patients with neuromuscular scoliosis who underwent posterior spinal fusion.3 Patients with a history of pneumonia or gastrotomy tube at the time of surgery had an elevated risk of postoperative respiratory infections.
–Findings from a retrospective study of >27,000 patients who underwent lumbar decompression with or without fusion revealed that the majority of patients using prescription opioids discontinued those medications postoperatively. However, among the patients with opioid use >90 days after surgery, the duration of preoperative opioid use was the most important predictor of postoperative opioid use.
Neurological Decline after Adult Spinal Deformity Surgery
–In a retrospective analysis of 265 patients who underwent corrective surgery for adult spinal deformity,4 23% of patients experienced a neurological injury; among those, 33% experienced a major neurological decline. Among the patients with major decline, full recovery was observed in 24% at 6 weeks and 65% at 6 months, but one-third of those patients experienced persistent neurological deficits at 24 months postoperatively. Among patients who experienced a minor neurological injury, 49% reported full recovery at 6 weeks and 70% reported full recovery at 6 months. About one-quarter of those patients showed no improvement at 24 months.
- Khor S, Lavallee D, Cizik AM, Bellabarba C, Chapman JR, Howe CR, Lu D, Mohit AA, Oskouian RJ, Roh JR, Shonnard N,Dagal A, Flum DR. Development and validation of a prediction model for pain and functional outcomes after lumbar spine surgery. JAMA Surg.2018 Jul 1;153(7):634-42.
- Harshavardhana NS, Noordeen MHH, Dormans JP. Cost analysis of magnet-driven growing rods for early-onset scoliosis at 5 years. Spine (Phila Pa 1976).2019 Jan 1;44(1):60-7.
- Luhmann SJ, Furdock R. Preoperative variables associated with respiratory complications after pediatric neuromuscular spine deformity surgery. Spine Deform.2019 Jan;7(1):107-11.
- Kato S, Fehlings MG, Lewis SJ, Lenke LG, Shaffrey CI, Cheung KMC, Carreon LY, Dekutoski MB, Schwab FJ, Boachie-Adjei O, Kebaish KM, Ames CP, Qiu Y, Matsuyama Y, Dahl BT, Mehdian H, Pellisé F, Berven SH. An analysis of the incidence and outcomes of major versus minor neurological decline after complex adult spinal deformity surgery: a subanalysis of Scoli-RISK-1 study. Spine (Phila Pa 1976).2018 Jul 1;43(13):905-12.
Every month, JBJS publishes a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in one of 13 subspecialties. Click here for a collection of all OrthoBuzz subspecialty summaries.
This month, Kelly L. VanderHave, MD, co-author of the February 20, 2019 “What’s New in Pediatric Orthopaedics,” selected the five most compelling findings from among the more than 50 noteworthy studies summarized in the article.
—A before-and-after comparison found that, after implementation of a dedicated, weekday operating room reserved for pediatric trauma, length of stay for 5 common pediatric orthopaedic fractures was reduced by >5 hours. In addition, cost was reduced by about $1,200 per patient; complication rates improved slightly; frequency of after-hours surgery decreased by 48%; and wait times for surgery were significantly reduced.
—Forty-two patients with a distal radial buckle fracture received a removable wrist brace during an initial clinic visit, along with instructions to wear it for 3 to 4 weeks. No follow-up was scheduled, but the family was contacted at 1 week and at 5 to 10 months following treatment. No complications or refractures occurred; 100% of respondents said they would select the same treatment.1
Pediatric Sports Medicine
—Among a continuous cohort of 85 patients (mean age 13.9 years) who underwent primary ACL reconstruction (77% with open physes at time of surgery) and who were followed for a minimum of 2 years, overall prevalence of a second ACL surgery was 32%, including 16 ACL graft ruptures and 11 contralateral ACL tears. A slower return to sport was found to be protective against a second ACL injury.
Infection and Scoliosis Surgery
—A preliminary study of 36 pediatric patients who underwent a total of 191 procedures for early-onset scoliosis found that the use of vancomycin powder during closure significantly decreased the rate of surgical site infection (13.8% per procedure in the control group versus 4.8% per procedure in the vancomycin group).
—A retrospective review of >1,100 clubfeet that were presumed to be idiopathic upon presentation found that the condition in 112 feet (8.9%) was later determined to be associated with neurological, syndromic, chromosomal, or spinal abnormalities—and therefore nonidiopathic.2 The nonidiopathic group was less likely to have a good result at the 2- and 5-year follow-up, and more likely to require surgery. The authors conclude, however, that surgery is avoidable for most patients with nonidiopathic clubfoot.
- Kuba MHM, Izuka BH. One brace: one visit: treatment of pediatric distal radius fractures with a removable wrist brace and no follow-up visit. J Pediatr Orthop.2018 Jul;38(6):e338-42.
- Richards BS, Faulks S. Clubfoot infants initially thought to be idiopathic, but later found not to be. How do they do with nonoperative treatment?J Pediatr Orthop. 2017 Apr 10. [Epub ahead of print].
When >10% of patients undergoing procedures to correct a spinal deformity develop one or more surgical-site infections, investigations into how to mitigate such infections seem warranted. This is especially true when a single such infection can cost nearly $1 million to treat—not to mention the physical and psychological burdens.
In the March 21, 2018 edition of JBJS, Thompson et al. report important findings from a retrospective study that sought to evaluate the efficacy of adding topical vancomycin powder to the wounds of patients undergoing growing-spine surgeries to address early-onset scoliosis. The mean patient age at the beginning of the study was 7.1 years.
Cases in which topical vancomycin powder was placed into the wounds at the time of fascial closure (n = 104 cases) had a significantly lower surgical-site infection rate (4.8%), compared with the rate in the 87 cases in which no vancomycin was used (13.8%). Furthermore, the “number needed to treat” found in this study was 11, meaning that for every 11 cases in which vancomycin powder was used, a surgical-site infection was prevented. The authors found no complications related to the use of topical vancomycin and note that their study provides the first evidence supporting the efficacy of vancomycin powder in pediatric spine patients.
Because this study was retrospective and based out of one center, further multicenter, prospective studies are needed to verify these results and to address open questions such as appropriate vancomycin dosages. Still, considering the extremely high costs (economic, physical, social, and psychological) associated with surgical-site infections in these complex patients, it appears that a vial of vancomycin powder costing between $10 and $40 may deliver outstanding value in these scenarios.
Chad A. Krueger, MD
JBJS Deputy editor for Social Media