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Zhao E, Hirase T, Kim AG, Du JY, Amen TB, Araghi K, Subramanian T, Kamil R, Shahi P, Fourman MS, Asada T, Simon CZ, Singh N, Korsun M, Tuma OC, Zhang J, Lu AZ, Mai E, Kim AYE, Allen MRJ, Kwas C, Dowdell JE, Sheha ED, Qureshi SA, Iyer S. The Impact of Posterior Intervertebral Osteophytes on Patient-Reported Outcome Measures After L5-S1 Anterior Lumbar Interbody Fusion and Transforaminal Lumbar Interbody Fusion. Spine (Phila Pa 1976) 2024; 49:652-660. [PMID: 38193931 DOI: 10.1097/brs.0000000000004904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 12/11/2023] [Indexed: 01/10/2024]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE (1) To develop a reliable grading system to assess the severity of posterior intervertebral osteophytes and (2) to investigate the impact of posterior intervertebral osteophytes on clinical outcomes after L5-S1 decompression and fusion through anterior lumbar interbody fusion (ALIF) and minimally-invasive transforaminal lumbar interbody fusion (MIS-TLIF). BACKGROUND There is limited evidence regarding the clinical implications of posterior lumbar vertebral body osteophytes for ALIF and MIS-TLIF surgeries and there are no established grading systems that define the severity of these posterior lumbar intervertebral osteophytes. PATIENTS AND METHODS A retrospective analysis of patients undergoing L5-S1 ALIF or MIS-TLIF was performed. Preoperative and postoperative patient-reported outcome measures of the Oswestry Disability Index (ODI) and leg Visual Analog Scale (VAS) at 2-week, 6-week, 12-week, and 6-month follow-up time points were assessed. Minimal clinically important difference (MCID) for ODI of 14.9 and VAS leg of 2.8 were utilized. Osteophyte grade was based on the ratio of osteophyte length to foraminal width. "High-grade" osteophytes were defined as a maximal osteophyte length >50% of the total foraminal width. RESULTS A total of 70 consecutive patients (32 ALIF and 38 MIS-TLIF) were included in the study. There were no significant differences between the two cohorts in patient-reported outcome measures or achievement of MCID for Leg VAS or ODI preoperatively or at any follow-ups. On multivariate analysis, neither the surgical approach nor the presence of high-grade foraminal osteophytes was associated with leg VAS or ODI scores at any follow-up time point. In addition, neither the surgical approach nor the presence of high-grade foraminal osteophytes was associated with the achievement of MCID for leg VAS or ODI at 6 months. CONCLUSION ALIF and MIS-TLIF are both valid options for treating degenerative spine conditions and lumbar radiculopathy, even in the presence of high-grade osteophytes that significantly occupy the intervertebral foramen. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Eric Zhao
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
- Department of Spine Surgery, Weill Cornell Medicine, New York, NY
| | - Takashi Hirase
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Andrew G Kim
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Jerry Y Du
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Troy B Amen
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Kasra Araghi
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Tejas Subramanian
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
- Department of Spine Surgery, Weill Cornell Medicine, New York, NY
| | - Robert Kamil
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Pratyush Shahi
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | | | - Tomoyuki Asada
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Chad Z Simon
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Nishtha Singh
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Maximilian Korsun
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Olivia C Tuma
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Joshua Zhang
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Amy Z Lu
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
- Department of Spine Surgery, Weill Cornell Medicine, New York, NY
| | - Eric Mai
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
- Department of Spine Surgery, Weill Cornell Medicine, New York, NY
| | - Ashley Yeo Eun Kim
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
- Department of Spine Surgery, Weill Cornell Medicine, New York, NY
| | - Myles R J Allen
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Cole Kwas
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - James E Dowdell
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Evan D Sheha
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Sheeraz A Qureshi
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Sravisht Iyer
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
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Ryvlin J, Kim SW, De la Garza Ramos R, Hamad M, Stock A, Owolo E, Fourman MS, Eleswarapu A, Gelfand Y, Murthy S, Yassari R. External Validation of an Online Wound Infection and Wound Reoperation Risk Calculator After Metastatic Spinal Tumor Surgery. World Neurosurg 2024; 185:e351-e356. [PMID: 38342175 DOI: 10.1016/j.wneu.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 02/01/2024] [Accepted: 02/02/2024] [Indexed: 02/13/2024]
Abstract
STUDY DESIGN This was a single-institutional retrospective cohort study. OBJECTIVE Wound infections are common following spine metastasis surgery and can result in unplanned reoperations. A recent study published an online wound complication risk calculator but has not yet undergone external validation. Our aim was to evaluate the accuracy of this risk calculator in predicting 30-day wound infections and 30-day wound reoperations using our operative spine metastasis population. METHODS An internal operative database was used to identify patients between 2012 and 2022. The primary outcomes were 1) any surgical site infection and 2) wound-related revision surgery within 30 days following surgery. Patient details were manually collected from electronic medical records and entered into the calculator to determine predicted complication risk percentages. Predicted risks were compared to observed outcomes using receiver operator characteristic (ROC) curves with areas under the curve (AUC). RESULTS A total of 153 patients were included. The observed 30-day postoperative wound infection incidence was 5% while the predicted wound infection incidence was 6%. In ROC analysis, good discrimination was found for the wound infection model (AUC = 0.737; P = 0.024). The observed wound reoperation rate was 5% and the predicted wound reoperation rate was 6%. ROC analysis demonstrated poor discrimination for wound reoperations (AUC = 0.559; P = 0.597). CONCLUSIONS The online wound-related risk calculator was found to accurately predict wound infections but not wound reoperations within our metastatic spine surgery cohort. We suggest that the model may be clinically useful despite underlying population differences, but further work must be done to generate and validate accurate prediction tools.
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Affiliation(s)
- Jessica Ryvlin
- Department of Neurological Surgery, Montefiore Medical Center Albert Einstein College of Medicine, Bronx, New York, New York, USA.
| | - Seung Woo Kim
- Department of Neurological Surgery, Montefiore Medical Center Albert Einstein College of Medicine, Bronx, New York, New York, USA
| | - Rafael De la Garza Ramos
- Department of Neurological Surgery, Montefiore Medical Center Albert Einstein College of Medicine, Bronx, New York, New York, USA
| | - Mousa Hamad
- Department of Neurological Surgery, Montefiore Medical Center Albert Einstein College of Medicine, Bronx, New York, New York, USA
| | - Ariel Stock
- Department of Neurological Surgery, Montefiore Medical Center Albert Einstein College of Medicine, Bronx, New York, New York, USA
| | - Edwin Owolo
- Department of Orthopedic Surgery, Montefiore Medical Center Albert Einstein College of Medicine, Bronx, New York, New York, USA
| | | | | | - Yaroslav Gelfand
- Department of Neurological Surgery, Montefiore Medical Center Albert Einstein College of Medicine, Bronx, New York, New York, USA
| | - Saikiran Murthy
- Department of Neurological Surgery, Montefiore Medical Center Albert Einstein College of Medicine, Bronx, New York, New York, USA
| | - Reza Yassari
- Department of Neurological Surgery, Montefiore Medical Center Albert Einstein College of Medicine, Bronx, New York, New York, USA
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Mani K, Kleinbart E, Goldman SN, Golding R, Gelfand Y, Murthy S, Eleswarapu A, Yassari R, Fourman MS, Krystal J. Projections of Single-level and Multilevel Spinal Instrumentation Procedure Volume and Associated Costs for Medicare Patients to 2050. J Am Acad Orthop Surg Glob Res Rev 2024; 8:01979360-202405000-00011. [PMID: 38743853 PMCID: PMC11095963 DOI: 10.5435/jaaosglobal-d-24-00053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 02/11/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Instrumented spinal fusions can be used in the treatment of vertebral fractures, spinal instability, and scoliosis or kyphosis. Construct-level selection has notable implications on postoperative recovery, alignment, and mobility. This study sought to project future trends in the implementation rates and associated costs of single-level versus multilevel instrumentation procedures in US Medicare patients aged older than 65 years in the United States. METHODS Data were acquired from the Centers for Medicare & Medicaid Services from January 1, 2000, to December 31, 2019. Procedure costs and counts were abstracted using Current Procedural Terminology codes to identify spinal level involvement. The Prophet machine learning algorithm was used, using a Bayesian Inference framework, to generate point forecasts for 2020 to 2050 and 95% forecast intervals (FIs). Sensitivity analyses were done by comparing projections from linear, log-linear, Poisson and negative-binomial, and autoregressive integrated moving average models. Costs were adjusted for inflation using the 2019 US Bureau of Labor Statistics' Consumer Price Index. RESULTS Between 2000 and 2019, the annual spinal instrumentation volume increased by 776% (from 7,342 to 64,350 cases) for single level, by 329% (from 20,319 to 87,253 cases) for two-four levels, by 1049% (from 1,218 to 14,000 cases) for five-seven levels, and by 739% (from 193 to 1,620 cases) for eight-twelve levels (P < 0.0001). The inflation-adjusted reimbursement for single-level instrumentation procedures decreased 45.6% from $1,148.15 to $788.62 between 2000 and 2019, which is markedly lower than for other prevalent orthopaedic procedures: total shoulder arthroplasty (-23.1%), total hip arthroplasty (-39.2%), and total knee arthroplasty (-42.4%). By 2050, the number of single-level spinal instrumentation procedures performed yearly is projected to be 124,061 (95% FI, 87,027 to 142,907), with associated costs of $93,900,672 (95% FI, $80,281,788 to $108,220,932). CONCLUSIONS The number of single-level instrumentation procedures is projected to double by 2050, while the number of two-four level procedures will double by 2040. These projections offer a measurable basis for resource allocation and procedural distribution.
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Affiliation(s)
- Kyle Mani
- From the Albert Einstein College of Medicine, Bronx, NY (Mr. Mani, Ms. Kleinbart, Mr. Goldman, Ms. Golding); the Department of Neurological Surgery (Dr. Gelfand, Dr. Murthy, Dr. Yassari) and the Department of Orthopaedic Surgery (Dr. Eleswarapu, Dr. Fourman, Dr. Krystal), Montefiore Einstein, Bronx, NY
| | - Emily Kleinbart
- From the Albert Einstein College of Medicine, Bronx, NY (Mr. Mani, Ms. Kleinbart, Mr. Goldman, Ms. Golding); the Department of Neurological Surgery (Dr. Gelfand, Dr. Murthy, Dr. Yassari) and the Department of Orthopaedic Surgery (Dr. Eleswarapu, Dr. Fourman, Dr. Krystal), Montefiore Einstein, Bronx, NY
| | - Samuel N. Goldman
- From the Albert Einstein College of Medicine, Bronx, NY (Mr. Mani, Ms. Kleinbart, Mr. Goldman, Ms. Golding); the Department of Neurological Surgery (Dr. Gelfand, Dr. Murthy, Dr. Yassari) and the Department of Orthopaedic Surgery (Dr. Eleswarapu, Dr. Fourman, Dr. Krystal), Montefiore Einstein, Bronx, NY
| | - Regina Golding
- From the Albert Einstein College of Medicine, Bronx, NY (Mr. Mani, Ms. Kleinbart, Mr. Goldman, Ms. Golding); the Department of Neurological Surgery (Dr. Gelfand, Dr. Murthy, Dr. Yassari) and the Department of Orthopaedic Surgery (Dr. Eleswarapu, Dr. Fourman, Dr. Krystal), Montefiore Einstein, Bronx, NY
| | - Yaroslav Gelfand
- From the Albert Einstein College of Medicine, Bronx, NY (Mr. Mani, Ms. Kleinbart, Mr. Goldman, Ms. Golding); the Department of Neurological Surgery (Dr. Gelfand, Dr. Murthy, Dr. Yassari) and the Department of Orthopaedic Surgery (Dr. Eleswarapu, Dr. Fourman, Dr. Krystal), Montefiore Einstein, Bronx, NY
| | - Saikiran Murthy
- From the Albert Einstein College of Medicine, Bronx, NY (Mr. Mani, Ms. Kleinbart, Mr. Goldman, Ms. Golding); the Department of Neurological Surgery (Dr. Gelfand, Dr. Murthy, Dr. Yassari) and the Department of Orthopaedic Surgery (Dr. Eleswarapu, Dr. Fourman, Dr. Krystal), Montefiore Einstein, Bronx, NY
| | - Ananth Eleswarapu
- From the Albert Einstein College of Medicine, Bronx, NY (Mr. Mani, Ms. Kleinbart, Mr. Goldman, Ms. Golding); the Department of Neurological Surgery (Dr. Gelfand, Dr. Murthy, Dr. Yassari) and the Department of Orthopaedic Surgery (Dr. Eleswarapu, Dr. Fourman, Dr. Krystal), Montefiore Einstein, Bronx, NY
| | - Reza Yassari
- From the Albert Einstein College of Medicine, Bronx, NY (Mr. Mani, Ms. Kleinbart, Mr. Goldman, Ms. Golding); the Department of Neurological Surgery (Dr. Gelfand, Dr. Murthy, Dr. Yassari) and the Department of Orthopaedic Surgery (Dr. Eleswarapu, Dr. Fourman, Dr. Krystal), Montefiore Einstein, Bronx, NY
| | - Mitchell S. Fourman
- From the Albert Einstein College of Medicine, Bronx, NY (Mr. Mani, Ms. Kleinbart, Mr. Goldman, Ms. Golding); the Department of Neurological Surgery (Dr. Gelfand, Dr. Murthy, Dr. Yassari) and the Department of Orthopaedic Surgery (Dr. Eleswarapu, Dr. Fourman, Dr. Krystal), Montefiore Einstein, Bronx, NY
| | - Jonathan Krystal
- From the Albert Einstein College of Medicine, Bronx, NY (Mr. Mani, Ms. Kleinbart, Mr. Goldman, Ms. Golding); the Department of Neurological Surgery (Dr. Gelfand, Dr. Murthy, Dr. Yassari) and the Department of Orthopaedic Surgery (Dr. Eleswarapu, Dr. Fourman, Dr. Krystal), Montefiore Einstein, Bronx, NY
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Mani K, Kleinbart E, Schlumprecht A, Golding R, Akioyamen N, Song H, De La Garza Ramos R, Eleswarapu A, Yang R, Geller D, Hoang B, Fourman MS. Association of Socioeconomic Status With Worse Overall Survival in Patients With Bone and Joint Cancer. J Am Acad Orthop Surg 2024; 32:e346-e355. [PMID: 38354415 DOI: 10.5435/jaaos-d-23-00718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 12/25/2023] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND The effect of socioeconomic status (SES) on the outcomes of patients with metastatic cancer to bone has not been adequately studied. We analyzed the association between the Yost Index, a composite geocoded SES score, and overall survival among patients who underwent nonprimary surgical resection for bone metastases. METHODS This population-based study used data from the National Cancer Institute's Surveillance, Epidemiology, and End Results database (2010 to 2018). We categorized bone and joint sites using International Classification of Disease-O-3 recodes. The Yost Index was geocoded using a factor analysis and categorized into quintiles using census tract-level American Community Service 5-year estimates and seven measures: median household income, median house value, median rent, percent below 150% of the poverty line, education index, percent working class, and percent unemployed. Multivariate Cox regression models were used to calculate adjusted hazard ratios of overall survival and 95% confidence intervals. RESULTS A total of 138,158 patients were included. Patients with the lowest SES had 34% higher risk of mortality compared with those with the highest SES (adjusted hazard ratio of 1.34, 95% confidence interval: 1.32 to 1.37, P < 0.001). Among patients who underwent nonprimary surgery of the distant bone tumor (n = 11,984), the age-adjusted mortality rate was 31.3% higher in the lowest SES patients compared with the highest SES patients (9.9 versus 6.8 per 100,000, P < 0.001). Patients in the lowest SES group showed more racial heterogeneity (63.0% White, 33.5% Black, 3.1% AAPI) compared with the highest SES group (83.9% White, 4.0% Black, 11.8% AAPI, P < 0.001). Higher SES patients are more likely to be married (77.5% versus 59.0%, P < 0.0001) and to live in metropolitan areas (99.6% versus 73.6%, P < 0.0001) compared with lower SES patients. DISCUSSION Our results may have implications for developing interventions to improve access and quality of care for patients from lower SES backgrounds, ultimately reducing disparities in orthopaedic surgery.
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Affiliation(s)
- Kyle Mani
- From the Albert Einstein College of Medicine (Mani, Kleinbart, Golding, and Song), the Department of Neurological Surgery, Montefiore Einstein (Schlumprecht, and De La Garza Ramos), and the Department of Orthopaedic Surgery, Montefiore Einstein, Bronx, NY (Akioyamen, Eleswarapu, Yang, Geller, Hoang, and Fourman)
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Ryvlin J, Kim SW, Hamad MK, Fourman MS, Eleswarapu A, Murthy SG, Gelfand Y, De la Garza Ramos R, Yassari R. The prognostic role of neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and systemic immune-inflammation index on short- and long-term outcome following surgery for spinal metastases. J Neurosurg Spine 2024; 40:475-484. [PMID: 38157531 DOI: 10.3171/2023.10.spine23851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 10/25/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVE Inflammatory markers such as neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and systemic immune-inflammation index (SII) have shown promise in predicting mortality in various types of cancer. The purpose of this study was to assess NLR, PLR, and SII in predicting 30-day mortality and overall survival (OS) among surgically treated patients with spinal metastasis. METHODS This was a retrospective study including 153 patients who underwent surgery for spinal metastasis between 2012 and 2022. Electronic medical records were manually reviewed, and NLR, PLR, and SII were calculated from preoperative neutrophil, platelet, and lymphocyte counts. Receiver operating characteristic curves with areas under the curve were generated to determine cutoff values. Logistic regression was used to determine the odds ratios (ORs) for 30-day mortality. The Kaplan-Meier method and Cox regression were used to determine the hazard ratio (HR) for OS limited to 5 years postoperatively. RESULTS Preoperative cutoff values were as follows: NLR > 10.2, PLR > 260, and SII > 2900. Overall, 35.9% (55/153) of patients had elevated NLR, 45.7% (70/153) had elevated PLR, and 30.7% (47/153) had elevated SII. The overall 30-day mortality was 8.5% (13/153). After controlling for confounders such as performance status and primary tumor type, high NLR (OR 5.20, 95% CI 1.21-22.28; p = 0.026) and SII (OR 4.92, 95% CI 1.17-20.63; p = 0.029) were associated with increased odds of 30-day postoperative mortality. The median OS time in the study population was 26 months (95% CI 12-40 months). After controlling for confounders such as Eastern Cooperative Oncology Group status, primary tumor, and hypoalbuminemia, high NLR was associated with shorter OS (HR 2.23, 95% CI 1.48-3.97; p = 0.003). CONCLUSIONS High preoperative NLR and SII were independently associated with 30-day postoperative mortality in this study. Elevated NLR was also found to be associated with shorter OS. The prognostic role of these metrics warrants further investigation.
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Affiliation(s)
- Jessica Ryvlin
- 1Spine Research Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx
| | - Seung Woo Kim
- 1Spine Research Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx
| | - Mousa K Hamad
- 1Spine Research Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx
- 2Departments of Neurological Surgery and
| | - Mitchell S Fourman
- 1Spine Research Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx
- 3Orthopedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Ananth Eleswarapu
- 1Spine Research Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx
- 3Orthopedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Saikiran G Murthy
- 1Spine Research Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx
- 2Departments of Neurological Surgery and
| | - Yaroslav Gelfand
- 1Spine Research Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx
- 2Departments of Neurological Surgery and
| | - Rafael De la Garza Ramos
- 1Spine Research Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx
- 2Departments of Neurological Surgery and
| | - Reza Yassari
- 1Spine Research Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx
- 2Departments of Neurological Surgery and
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Werenski JO, Gonzalez MR, Fourman MS, Hung YP, Lozano-Calderon SA. ASO Visual Abstract: Does Wound VAC Temporization Offer Similar Patient-Reported Outcomes as Single-Stage Excision Reconstruction After Myxofibrosarcoma Resection? Ann Surg Oncol 2024; 31:2798. [PMID: 38253950 DOI: 10.1245/s10434-024-14922-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Affiliation(s)
- Joseph O Werenski
- Orthopaedic Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Marcos R Gonzalez
- Orthopaedic Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Mitchell S Fourman
- Department of Orthopaedic Surgery, Montefiore-Einstein, New York, NY, USA
| | - Yin P Hung
- Division of Bone and Soft Tissue Pathology, Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Santiago A Lozano-Calderon
- Orthopaedic Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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Werenski JO, Gonzalez MR, Fourman MS, Hung YP, Lozano-Calderón SA. Does Wound VAC Temporization Offer Patient-Reported Outcomes Similar to Single-Stage Excision Reconstruction After Myxofibrosarcoma Resection? Ann Surg Oncol 2024; 31:2757-2765. [PMID: 38197999 DOI: 10.1245/s10434-023-14839-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 12/12/2023] [Indexed: 01/11/2024]
Abstract
BACKGROUND Vacuum-assisted closure (VAC) temporization is a promising technique to achieve local control in aggressive soft tissue sarcomas. Despite its previously reported efficacy, adoption of VAC temporization remains limited, primarily due to the scarce literature on patient-reported outcomes (PROs) supporting its efficacy. This study compared the postoperative PROs after VAC temporization or single-stage (SS) excision and reconstruction for patients undergoing surgical resection for myxofibrosarcoma management. METHODS A retrospective analysis of myxofibrosarcoma patients who underwent surgical resections at our institution from 2016 to 2022 was performed. Postoperative PROs collected prospectively for those treated with VAC temporization or SS excision/reconstruction were compared using a visual analog scale (VAS) for pain and three Patient-Reported Outcomes Measurement Information System (PROMIS) questionnaires: Global Health Short-Form Mental (SF Mental), Global Health Short-Form Physical (SF Physical), and Physical Function Short-Form 10a (SF 10a). Absolute and differential (postoperative minus preoperative) scores at the 1-month, 3-month, 6-month, 1-year, and 2-year time points were compared. RESULTS The analysis included 79 patients (47 treated with VAC temporization and 32 treated with SS excision/reconstruction). All outcomes were similar between the groups except for physical function 1 year after surgery, in which the differential PROMIS SF 10a scores were higher in the SS group (p = 0.001). All the remaining absolute and differential PROMIS and VAS pain scores were similar between the groups at all time points. Postoperative complications did not differ between the groups. CONCLUSION The PROs for physical and mental health, physical function, and pain were similar between the myxofibrosarcoma patients who had VAC temporization and those who had SS excision/reconstruction after surgical resection.
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Affiliation(s)
- Joseph O Werenski
- Orthopaedic Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Marcos R Gonzalez
- Orthopaedic Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Mitchell S Fourman
- Department of Orthopaedic Surgery, Montefiore-Einstein, New York, NY, USA
| | - Yin P Hung
- Division of Bone and Soft Tissue Pathology, Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Santiago A Lozano-Calderón
- Orthopaedic Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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Akosman I, Kumar N, Mortenson R, Lans A, De La Garza Ramos R, Eleswarapu A, Yassari R, Fourman MS. Racial Differences in Perioperative Complications, Readmissions, and Mortalities After Elective Spine Surgery in the United States: A Systematic Review Using AI-Assisted Bibliometric Analysis. Global Spine J 2024; 14:750-766. [PMID: 37363960 PMCID: PMC10802512 DOI: 10.1177/21925682231186759] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/28/2023] Open
Abstract
STUDY DESIGN Systematic Review and Meta-analysis. OBJECTIVES To evaluate the impact of race on post-operative outcomes and complications following elective spine surgery in the United States. METHODS PUBMED, MEDLINE(R), ERIC, EMBASE, and SCOPUS were searched for studies documenting peri-operative events for White and African American (AA) patients following elective spine surgery. Pooled odds ratios were calculated for each 90-day outcome and meta-analyses were performed for 4 peri-operative events and 7 complication categories. Sub-analyses were performed for each outcome on single institution (SI) studies and works that included <100,000 patients. RESULTS 53 studies (5,589,069 patients, 9.8% AA) were included. Eleven included >100,000 patients. AA patients had increased rates of 90-day readmission (OR 1.33, P = .0001), non-routine discharge (OR 1.71, P = .0001), and mortality (OR 1.66, P = .0003), but not re-operation (OR 1.16, P = .1354). AA patients were more likely to have wound-related complications (OR 1.47, P = .0001) or medical complications (OR 1.35, P = .0006), specifically cardiovascular (OR 1.33, P = .0126), deep vein thrombosis/pulmonary embolism (DVT/PE) (OR 2.22, P = .0188) and genitourinary events (OR 1.17, P = .0343). SI studies could only detect racial differences in re-admissions and non-routine discharges. Studies with <100,000 patients replicated the above findings but found no differences in cardiovascular complications. Disparities in mortality were only detected when all studies were included. CONCLUSIONS AA patients faced a greater risk of morbidity across several distinct categories of peri-operative events. SI studies can be underpowered to detect more granular complication types (genitourinary, DVT/PE). Rare events, such as mortality, require larger sample sizes to identify significant racial disparities.
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Affiliation(s)
| | - Neerav Kumar
- Weill Cornell School of Medicine, New York, NY, USA
| | | | - Amanda Lans
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | | | - Ananth Eleswarapu
- Department of Orthopaedic Surgery, Montefiore Medical Center, Bronx, NY, USA
| | - Reza Yassari
- Department of Orthopaedic Surgery, Montefiore Medical Center, Bronx, NY, USA
| | - Mitchell S. Fourman
- Department of Orthopaedic Surgery, Montefiore Medical Center, Bronx, NY, USA
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9
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Kumar N, Akosman I, Mortenson R, Xu G, Kumar A, Mostafa E, Rivlin J, De La Garza Ramos R, Krystal J, Eleswarapu A, Yassari R, Fourman MS. Disparities in postoperative complications and perioperative events based on insurance status following elective spine surgery: A systematic review and meta-analysis. N Am Spine Soc J 2024; 17:100315. [PMID: 38533185 PMCID: PMC10964016 DOI: 10.1016/j.xnsj.2024.100315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 01/13/2024] [Accepted: 02/12/2024] [Indexed: 03/28/2024]
Abstract
Background Increasing evidence demonstrates disparities among patients with differing insurance statuses in the field of spine surgery. However, no pooled analyses have performed a robust review characterizing differences in postoperative outcomes among patients with varying insurance types. Methods A comprehensive literature search of the PUBMED, MEDLINE(R), ERIC, and EMBASE was performed for studies comparing postoperative outcomes in patients with private insurance versus government insurance. Pooled incidence rates and odds ratios were calculated for each outcome and meta-analyses were conducted for 3 perioperative events and 2 types of complications. In addition to pooled analysis, sub-analyses were performed for each outcome in specific government payer statuses. Results Thirty-eight studies (5,018,165 total patients) were included. Compared with patients with private insurance, patients with government insurance experienced greater risk of 90-day re-admission (OR 1.84, p<.0001), non-routine discharge (OR 4.40, p<.0001), extended LOS (OR 1.82, p<.0001), any postoperative complication (OR 1.61, p<.0001), and any medical complication (OR 1.93, p<.0001). These differences persisted across outcomes in sub-analyses comparing Medicare or Medicaid to private insurance. Similarly, across all examined outcomes, Medicare patients had a higher risk of experiencing an adverse event compared with non-Medicare patients. Compared with Medicaid patients, Medicare patients were only more likely to experience non-routine discharge (OR 2.68, p=.0007). Conclusions Patients with government insurance experience greater likelihood of morbidity across several perioperative outcomes. Additionally, Medicare patients fare worse than non-Medicare patients across outcomes, potentially due to age-based discrimination. Based on these results, it is clear that directed measures should be taken to ensure that underinsured patients receive equal access to resources and quality care.
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Affiliation(s)
- Neerav Kumar
- Weill Cornell School of Medicine, New York, NY,
USA
| | | | | | - Grace Xu
- Princeton University, Princeton, NJ, USA
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10
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De la Garza Ramos R, Ryvlin J, Hamad MK, Fourman MS, Eleswarapu A, Gelfand Y, Murthy SG, Shin JH, Yassari R. The prognostic nutritional index (PNI) is independently associated with 90-day and 12-month mortality after metastatic spinal tumor surgery. Eur Spine J 2023; 32:4328-4334. [PMID: 37700182 DOI: 10.1007/s00586-023-07930-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/25/2023] [Accepted: 08/28/2023] [Indexed: 09/14/2023]
Abstract
INTRODUCTION Estimated postoperative survival is an important consideration during the decision-making process for patients with spinal metastases. Nutritional status has been associated with poor outcomes and limited survival in the general cancer population. The objective of this study was to evaluate the predictive utility of the prognostic nutritional index (PNI) for postoperative mortality after spinal metastasis surgery. METHODS A total of 139 patients who underwent oncologic surgery for spinal metastases between April 2012 and August 2022 and had a minimum 90-day follow-up were included. PNI was calculated using preoperative serum albumin and total lymphocyte count, with PNI < 40 defined as low. The mean PNI of our cohort was 43 (standard deviation: 7.7). The primary endpoint was 90-day mortality, and the secondary endpoint was 12-month mortality. Multivariate logistic regression analyses were performed. RESULTS The 90-day mortality was 27% (37/139), and the 12-month mortality was 56% (51/91). After controlling for age, ECOG performance status, total psoas muscle cross-sectional area (TPA), and primary cancer site, the PNI was associated with 90-day mortality [odds ratio 0.86 (95% confidence interval 0.79-0.94); p = 0.001]. After controlling for ECOG performance status and primary cancer site, the PNI was associated with 12-month mortality [OR 0.89 (95% CI 0.82-0.97); p = 0.008]. Patients with a low PNI had a 50% mortality rate at 90 days and an 84% mortality rate at 12 months. CONCLUSION The PNI was independently associated with 90-day and 12-month mortality after metastatic spinal tumor surgery, independent of performance status, TPA, and primary cancer site.
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Affiliation(s)
- Rafael De la Garza Ramos
- Spine Research Group, Montefiore Medical Center, Albert Einstein College of Medicine, 3316 Rochambeau Avenue, 3rd Floor, Bronx, NY, 10467, USA.
- Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.
| | - Jessica Ryvlin
- Spine Research Group, Montefiore Medical Center, Albert Einstein College of Medicine, 3316 Rochambeau Avenue, 3rd Floor, Bronx, NY, 10467, USA
| | - Mousa K Hamad
- Spine Research Group, Montefiore Medical Center, Albert Einstein College of Medicine, 3316 Rochambeau Avenue, 3rd Floor, Bronx, NY, 10467, USA
- Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Mitchell S Fourman
- Spine Research Group, Montefiore Medical Center, Albert Einstein College of Medicine, 3316 Rochambeau Avenue, 3rd Floor, Bronx, NY, 10467, USA
- Department of Orthopedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ananth Eleswarapu
- Spine Research Group, Montefiore Medical Center, Albert Einstein College of Medicine, 3316 Rochambeau Avenue, 3rd Floor, Bronx, NY, 10467, USA
- Department of Orthopedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Yaroslav Gelfand
- Spine Research Group, Montefiore Medical Center, Albert Einstein College of Medicine, 3316 Rochambeau Avenue, 3rd Floor, Bronx, NY, 10467, USA
- Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Saikiran G Murthy
- Spine Research Group, Montefiore Medical Center, Albert Einstein College of Medicine, 3316 Rochambeau Avenue, 3rd Floor, Bronx, NY, 10467, USA
- Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - John H Shin
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Reza Yassari
- Spine Research Group, Montefiore Medical Center, Albert Einstein College of Medicine, 3316 Rochambeau Avenue, 3rd Floor, Bronx, NY, 10467, USA
- Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
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11
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Fourman MS, Alluri RK, Sarmiento JM, Lyons KW, Lovecchio FC, Araghi K, Dalal SS, Shinn DJ, Song J, Shahi P, Melissaridou D, Carrino JA, Sheha ED, Iyer S, Dowdell JE, Qureshi SS. Female Sex and Supine Proximal Lumbar Lordosis Are Associated With the Size of the LLIF "Safe Zone" at L4-L5. Spine (Phila Pa 1976) 2023; 48:1606-1610. [PMID: 36730683 DOI: 10.1097/brs.0000000000004541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 09/09/2022] [Indexed: 02/04/2023]
Abstract
STUDY DESIGN Retrospective chart review. OBJECTIVE Identify demographic and sagittal alignment parameters that are independently associated with femoral nerve position at the L4-L5 disk space. SUMMARY OF BACKGROUND DATA Iatrogenic femoral nerve or lumbar plexus injury during lateral lumbar interbody fusion (LLIF) can result in neurological complications. The LLIF "safe zone" is the anterior half to two third of the disk space. However, femoral nerve position varies and is inconsistently identifiable on magnetic resonance imaging. The safe zone is also narrowest at L4-L5. METHODS An analysis of patients with symptomatic lumbar spine pathology and magnetic resonance imaging with a visibly identifiable femoral nerve evaluated at a single large academic spine center from January 1, 2017, to January 8, 2020, was performed. Exclusion criteria were transitional anatomy, severe hip osteoarthritis, coronal deformity with cobb >10 degrees, > grade 1 spondylolisthesis at L4-L5 and anterior migration of the psoas.Standing and supine lumbar lordosis (LL) and its proximal (L1-L4) and distal (L4-S1) components were measured. Femoral nerve position on sagittal imaging was then measured as a percentage of the L4 inferior endplate. A stepwise multivariate linear regression of sagittal alignment and LL parameters was then performed. Data are written as estimate, 95% CI. RESULTS Mean patient age was 58.2±14.7 years, 25 (34.2%) were female and 26 (35.6%) had a grade 1 spondylolisthesis. Mean femoral nerve position was 26.6±10.3% from the posterior border of L4. Female sex (-6.6, -11.1 to -2.1) and supine proximal lumbar lordosis (0.4, 0.1-0.7) were independently associated with femoral nerve position. CONCLUSIONS Patient sex and proximal LL can serve as early indicators of the size of the femoral nerve safe zone during a transpsoas LLIF approach at L4-L5.
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Affiliation(s)
- Mitchell S Fourman
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Ram K Alluri
- Department of Orthopaedic Surgery, University of Southern California, Los Angeles, CA
| | - J Manuel Sarmiento
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Keith W Lyons
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Francis C Lovecchio
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Kasra Araghi
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Sidhant S Dalal
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Daniel J Shinn
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Junho Song
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Pratyush Shahi
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Dimitra Melissaridou
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - John A Carrino
- Department of Radiology, Hospital for Special Surgery, New York, NY
| | - Evan D Sheha
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Sravisht Iyer
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - James E Dowdell
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Sheeraz S Qureshi
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
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12
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De la Garza Ramos R, Ryvlin J, Hamad MK, Fourman MS, Gelfand Y, Murthy SG, Shin JH, Yassari R. Predictive value of six nutrition biomarkers in oncological spine surgery: a performance assessment for prediction of mortality and wound infection. J Neurosurg Spine 2023; 39:664-670. [PMID: 37542445 DOI: 10.3171/2023.5.spine23347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 05/24/2023] [Indexed: 08/07/2023]
Abstract
OBJECTIVE Assessment of nutritional status is fundamental in cancer patients. The objective of this study was to assess the predictive ability of 6 nutritional biomarkers for postoperative mortality and wound infection after metastatic spinal tumor surgery. METHODS A total of 139 patients who underwent oncological surgery for metastatic spine disease between April 2012 and August 2022 and had a minimum follow-up of 90 days were included. Six unique nutritional biomarkers were assessed: Prognostic Nutritional Index (PNI), Nutritional Risk Index (NRI), Controlling Nutritional Status Score (CONUT), total psoas cross-sectional area (TPA), body mass index (BMI), and body weight. Study endpoints were 90-day mortality rate, 12-month mortality rate, and wound infection. The discriminative ability of each of these markers was assessed with the c-statistic. A multivariate analysis was done for each of the biomarkers after a univariate analysis was first performed. RESULTS The 90-day mortality rate was 27% (37 of 139). The biomarkers and respective c-statistics were as follows: PNI (0.74), NRI (0.75), CONUT (0.71), TPA (0.64), BMI (0.59), and body weight (0.60). The 12-month mortality rate was 56% (51 of 91). The biomarkers and respective c-statistics were as follows: PNI (0.72), NRI (0.73), CONUT (0.70), TPA (0.63), BMI (0.59), and body weight (0.60). The wound infection rate was 8% (11 of 139). The biomarkers and respective c-statistics were as follows: PNI (0.57), NRI (0.53), CONUT (0.55), TPA (0.57), BMI (0.48), and body weight (0.52). The PNI, NRI, and CONUT all predicted 90-day and 12-month mortality after multivariate regression analysis. No association between nutrition and wound infection was found. CONCLUSIONS In this study, nutritional status was associated with postoperative mortality following oncological spine surgery. Three biomarkers predicted outcome independent of variables such as performance status or primary cancer. Future validation of these metrics is needed.
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Affiliation(s)
- Rafael De la Garza Ramos
- 1Spine Research Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
- Departments of2Neurological Surgery and
| | - Jessica Ryvlin
- 1Spine Research Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Mousa K Hamad
- 1Spine Research Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
- Departments of2Neurological Surgery and
| | - Mitchell S Fourman
- 1Spine Research Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
- 3Orthopedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York; and
| | - Yaroslav Gelfand
- 1Spine Research Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
- Departments of2Neurological Surgery and
| | - Saikiran G Murthy
- 1Spine Research Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
- Departments of2Neurological Surgery and
| | - John H Shin
- 4Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Reza Yassari
- 1Spine Research Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
- Departments of2Neurological Surgery and
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Setliff J, Dalton J, Sadhwani S, Tang MY, Mirvish A, Adida S, Wawrose R, Lee JY, Fourman MS, Shaw JD. Examining the safety profile of a standard dose tranexamic acid regimen in spine surgery. Neurosurg Focus 2023; 55:E16. [PMID: 37778044 DOI: 10.3171/2023.7.focus23384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 07/26/2023] [Indexed: 10/03/2023]
Abstract
OBJECTIVE Perioperative blood loss during spinal surgery is associated with complications and in-hospital mortality. Weight-based administration of tranexamic acid (TXA) has the potential to reduce blood loss and related complications in spinal surgery; however, evidence for standardized dosing is lacking. The purpose of this study was to evaluate the impact of a standardized preoperative 2 g bolus TXA dosing regimen on perioperative transfusion, blood loss, thromboembolic events, and postoperative outcomes in spine surgery patients. METHODS An institutional review board approved this retrospective review of prospectively enrolled adult spine patients (> 18 years of age). Patients were included who underwent elective and emergency spine surgery between September 2018 and July 2021. Patients who received a standardized 2 g dose of TXA were compared to patients who did not receive TXA. The primary outcome measure was perioperative transfusion. Secondary outcomes included estimated blood loss and thromboembolic or other perioperative complications. Descriptive statistics were calculated, and continuous variables were analyzed with the two-tailed independent t-test, while categorical variables were analyzed with the Fisher's exact test or chi-square test. Stepwise multivariate regression analysis was performed to examine independent risk factors for perioperative outcomes. RESULTS TXA was administered to 353 of 453 (78%) patients, and there were no demographic differences between groups. Although the TXA group had more operative levels and a longer operative time, the transfusion rate was not different between the TXA and no-TXA groups (7.4% vs 8%, p = 0.83). Stepwise multivariate regression found that the number of operative levels was an independent predictor of perioperative transfusion and that both operative levels and operative time were correlated with estimated blood loss. TXA was not identified as an independent predictor of any postoperative complication. CONCLUSIONS A standardized preoperative 2 g bolus TXA dosing regimen was associated with an excellent safety profile, and despite increased case complexity in terms of number of operative levels and operative time, patients treated with TXA did not require more blood transfusions than patients not treated with TXA.
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Affiliation(s)
- Joshua Setliff
- 1Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- 3Pittsburgh Orthopaedic Spine Research Group, Pittsburgh, Pennsylvania
| | - Jonathan Dalton
- 1Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- 3Pittsburgh Orthopaedic Spine Research Group, Pittsburgh, Pennsylvania
| | - Shaan Sadhwani
- 1Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Melissa Yunting Tang
- 1Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- 3Pittsburgh Orthopaedic Spine Research Group, Pittsburgh, Pennsylvania
| | - Asher Mirvish
- 1Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- 3Pittsburgh Orthopaedic Spine Research Group, Pittsburgh, Pennsylvania
| | - Samuel Adida
- 1Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- 3Pittsburgh Orthopaedic Spine Research Group, Pittsburgh, Pennsylvania
| | - Richard Wawrose
- 1Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- 3Pittsburgh Orthopaedic Spine Research Group, Pittsburgh, Pennsylvania
| | - Joon Y Lee
- 1Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- 3Pittsburgh Orthopaedic Spine Research Group, Pittsburgh, Pennsylvania
| | - Mitchell S Fourman
- 2Department of Orthopaedic Surgery, Montefiore Medical Center, New York, New York; and
- 3Pittsburgh Orthopaedic Spine Research Group, Pittsburgh, Pennsylvania
| | - Jeremy D Shaw
- 1Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- 3Pittsburgh Orthopaedic Spine Research Group, Pittsburgh, Pennsylvania
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Fourman MS, Lafage R, Lovecchio F, Sheikh Alshabab B, Shah S, Punyala A, Ang B, Elysee J, Lenke LG, Kim HJ, Schwab F, Lafage V. How Does Gravity Influence the Distribution of Lordosis in Patients With Sagittal Malalignment? Global Spine J 2023; 13:2446-2453. [PMID: 35352585 PMCID: PMC10538318 DOI: 10.1177/21925682221087467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE Compare the supine vs standing radiographs of patients with adult spinal deformity against ideals defined by healthy standing alignment. METHODS 56 patients with primary sagittal ASD (SRS-Schwab Type N) and 119 asymptomatic volunteers were included. Standing alignment of asymptomatic volunteers was used to calculate PI-based formulas for normative age-adjusted standing PI-LL, L4-S1, and L1-L4. These formulas were applied to the supine and standing alignment of ASD cohort. Analyses were repeated on a cohort of 25 patients with at least 5 degrees of lumbar flexibility (difference between supine and standing lordosis). RESULTS The asymptomatic cohort yielded the following PI-based formulas: PI-LL = -38.3 + .41*PI + .21*Age, L4-S1 = 45.3-.18*Age, L1-L4 = -3 + .48*PI). PI-LL improved with supine positioning (mean 8.9 ± 18.7°, P < .001), though not enough to correct to age-matched norms (mean offset 12.2 ± 16.9°). Compared with mean normative alignment at L1-L4 (22.1 ± 6.2°), L1-L4 was flatter on standing (7.2 ± 17.0°, P < .001) and supine imaging (8.5 ± 15.0°, P < .001). L4-S1 lordosis of subjects with L1-S1 flexibility >5° corrected on supine imaging (33.9 ± 11.1°, P = 1.000), but L1-L4 did not (23.0 ± 6.2° norm vs 2.2 ± 14.4° standing, P < .001; vs 7.3 ± 12.9° supine, P < .001). CONCLUSIONS When the effects of gravity are removed, the distal portion of the lumbar spine (i.e., below the apex of lordosis) corrects, suggesting that structural lumbar deformity is primarily proximal.
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Affiliation(s)
- Mitchell S. Fourman
- Spine Surgery Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, USA
| | - Renaud Lafage
- Spine Surgery Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, USA
| | - Francis Lovecchio
- Spine Surgery Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, USA
| | - Basel Sheikh Alshabab
- Spine Surgery Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, USA
| | - Sachiin Shah
- Spine Surgery Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, USA
| | - Ananth Punyala
- Spine Surgery Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, USA
| | - Bryan Ang
- Spine Surgery Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, USA
| | - Jonathan Elysee
- Spine Surgery Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, USA
| | - Lawrence G Lenke
- Spine Service, Department of Orthopaedic Surgery, Columbia University Medical Center, New York, USA
| | - Han Jo Kim
- Spine Surgery Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, USA
| | - Frank Schwab
- Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, USA
| | - Virginie Lafage
- Spine Surgery Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, USA
- Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, USA
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15
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Fourman MS, Vaynrub M. Identifying the ideal trajectory for prone trephine iliac crest bone graft harvesting. Spine J 2023; 23:1571-1573. [PMID: 37402430 PMCID: PMC10538411 DOI: 10.1016/j.spinee.2023.06.402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/29/2023] [Accepted: 06/29/2023] [Indexed: 07/06/2023]
Affiliation(s)
- Mitchell S Fourman
- Orthopaedic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, H-1011, New York, NY, 10065, USA
| | - Max Vaynrub
- Orthopaedic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, H-1011, New York, NY, 10065, USA.
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16
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Araghi K, Fourman MS, Merrill RK, Maayan O, Zhao E, Pajak A, Subramanian T, Kim DN, Kamil R, Shahi P, Sheha ED, Dowdell JE, Iyer S, Qureshi SA. Postoperative Radiculitis After L5-S1 Anterior Lumbar Interbody Fusion. Spine (Phila Pa 1976) 2023; 48:1317-1325. [PMID: 37259185 DOI: 10.1097/brs.0000000000004740] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 05/24/2023] [Indexed: 06/02/2023]
Abstract
STUDY DESIGN Retrospective chart review. OBJECTIVE This study aimed to examine postoperative radiculitis after isolated L5-S1 anterior lumbar interbody fusion (ALIF), determine which factors contribute to its development, and investigate the comparative outcomes of patients with versus without postoperative radiculitis. SUMMARY OF BACKGROUND DATA Both standalone and traditionalALIF are common and safe lumbar spine fusion techniques. Although optimal safety and effectiveness are achieved through appropriate patient selection, postoperative radiculitis after L5-S1 ALIF is a potential complication that seems to be the least predictable in the absence of iatrogenic injury. PATIENTS AND METHODS All adult patients (18-80 yr) with preoperative radiculopathies who underwent L5-S1 ALIF by 9 board-certified spine surgeons at a single academic institution from January 2016 to December 2021 with a minimum of 3 months follow-up were included. Patient records were assessed for data on clinical characteristics and patient-reported outcome scores (patient-reported outcome measures). All patient records were evaluated to determine whether postoperative radiculitis developed. Radiographic measurements using x-rays were completed using all available pre and postoperative imaging. Multivariable logistic regressions were performed utilizing radiculitis as the dependent variable and various independent predictor variables. RESULTS One hundred forty patients were included, 48 (34%) patients developed postoperative radiculitis, with symptom onset and resolution occurring at 14.5 and 83 days, respectively. The two groups had no differences in preoperative or postoperative radiographic parameters. Multivariable regression showed 3 independent predictors of postoperative radiculitis: methylprednisolone use [OR: 6.032; (95% CI: 1.670-25.568)], increased implant height [OR: 1.509; (95% CI: 1.189-1.960)], and no posterior fixation [OR: 2.973; (95% CI: 1.353-0.806)]. CONCLUSIONS Of the 34% of patients who developed postoperative radiculitis after L5-S1 ALIF, it resolved on average within 3 months of surgery. These findings may help reduce the risk of undue short-term morbidity after isolated L5-S1 ALIF by informing preoperative counseling and intraoperative decision-making.
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Affiliation(s)
- Kasra Araghi
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Mitchell S Fourman
- Department of Orthopaedic Surgery, Orthopaedic Spine Service, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Robert K Merrill
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Omri Maayan
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Eric Zhao
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Anthony Pajak
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Tejas Subramanian
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - David N Kim
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Robert Kamil
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Pratyush Shahi
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Evan D Sheha
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - James E Dowdell
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Sravisht Iyer
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Sheeraz A Qureshi
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
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Ramsey DC, Fourman MS, Berner EA, Werenski J, Sodhi A, Heng M, Newman ET, Raskin KA, Valerio I, Eberlin KR, Lozano-Calderon S. What Are the Functional and Surgical Outcomes of Tibial Turnup-plasty for Salvage in Patients With Chronic Lower Extremity Infection? Clin Orthop Relat Res 2023; 481:1196-1205. [PMID: 36716090 PMCID: PMC10194532 DOI: 10.1097/corr.0000000000002536] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 11/29/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Tibial turnup-plasty is a rarely performed surgical option for large bone defects of the distal or entire femur and can serve as an alternative to hip disarticulation or high above-knee amputation. It entails pedicled transport of the ipsilateral tibia with or without the proximal hindfoot for use as a vascularized autograft. It is rotated 180° in the coronal or sagittal plane to the remaining proximal femur or pelvis, augmenting the functional length of the thigh. Prior reports consist of small case series with heterogeneous surgical techniques. Patient-reported outcome measures after the procedure have not been reported, and ambulatory status after the procedure is also unknown. QUESTIONS/PURPOSES (1) What proportion of patients underwent reoperation after tibial turnup-plasty? (2) What is the ambulatory status and what proportion of patients used a prosthesis after tibial turnup-plasty? (3) What are the Patient-Reported Outcome Measurement Information System (PROMIS) Global-10 mental and physical function scores after tibial turnup-plasty? METHODS A retrospective analysis was performed of 11 patients who underwent tibial turnup-plasty between 2003 and 2021 by a single orthopaedic oncology division in collaboration with a reconstructive plastic surgery team. Nine patients were men, with a median age of 55 years (range 34 to 75 years). All had chronic infections after arthroplasty or oncologic reconstructions, with a median number of 13 surgeries before turnup-plasty. All were considered to have no other surgical options other than hip disarticulation or high transfemoral amputation. All patients who were offered this possibility accepted it. Data of interest included patient demographics and comorbidities, surgical history that led to limb compromise, medical and surgical perioperative complications, date of prosthesis fitting, and functional capacity at the most recent follow-up interval based on ambulatory status and PROMIS Global-10 mental and physical function scores. The statistical analysis was descriptive. RESULTS The median number of reoperations after turnup-plasty was one (range 0 to 11). Of the six patients who underwent at least one reoperation, indications for surgery included wound infection (four patients), nonunion of the osteosynthesis site (two), heterotopic ossification (one), tumor recurrence (one), and flap hypoperfusion treated with local tissue revision (one). One patient underwent conversion to external hemipelvectomy for tumor recurrence. Ten of the 11 patients were ambulatory at the final follow-up interval with standard above-knee amputation prostheses. Two ambulated unassisted, four used a single crutch or cane, and four used two crutches or a walker. Of the nine patients for whom scores were available, the median PROMIS Global-10 physical and mental health scores were 48 (range 30 to 68) and 53 (range 41 to 68), both within the standard deviation of the population mean of 50. CONCLUSION The tibial turnup-plasty is a complex surgical option for patients with large bone defects of the femur for whom there are no alternative surgeries capable of producing residual extremities with acceptable functional length. This should be viewed as a procedure of last resort to avoid a hip disarticulation or a high transfemoral amputation in patients who have typically undergone numerous prior operations. Although ambulation with a prosthesis within 1 year can be expected, almost all patients will require an assistive device to do so, and reoperations are frequent. LEVEL OF EVIDENCE Level IV, therapeutic study.
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Affiliation(s)
- Duncan C. Ramsey
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School. Boston, MA, USA
| | - Mitchell S. Fourman
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School. Boston, MA, USA
| | - Emily A. Berner
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School. Boston, MA, USA
| | - Joseph Werenski
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School. Boston, MA, USA
| | - Alisha Sodhi
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School. Boston, MA, USA
| | - Marilyn Heng
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School. Boston, MA, USA
| | - Erik T. Newman
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School. Boston, MA, USA
| | - Kevin A. Raskin
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School. Boston, MA, USA
| | - Ian Valerio
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School. Boston, MA, USA
| | - Kyle R. Eberlin
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School. Boston, MA, USA
| | - Santiago Lozano-Calderon
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School. Boston, MA, USA
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18
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Fourman MS, Siraj L, Duvall J, Ramsey DC, De La Garza Ramos R, Hadzipasic M, Connolly I, Williamson T, Shankar GM, Schoenfeld A, Yassari R, Massaad E, Shin JH. Can We Use Artificial Intelligence Cluster Analysis to Identify Patients with Metastatic Breast Cancer to the Spine at Highest Risk of Postoperative Adverse Events? World Neurosurg 2023; 174:e26-e34. [PMID: 36805503 DOI: 10.1016/j.wneu.2023.02.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 02/12/2023] [Accepted: 02/13/2023] [Indexed: 02/22/2023]
Abstract
OBJECTIVE Group patients who required open surgery for metastatic breast cancer to the spine by functional level and metastatic disease characteristics to identify factors that predispose to poor outcomes. METHODS A retrospective analysis included patients managed at 2 tertiary referral centers from 2008 to 2020. The primary outcome was a 90-day adverse event. A 2-step unsupervised cluster analysis stratified patients into cohorts using function at presentation, preoperative spine radiation, structural instability, epidural spinal cord compression (ESCC), neural deficits, and tumor location/hormone status. Comparisons were performed using χ2 test and one-way analysis of variance. RESULTS Five patient "clusters" were identified. High function (HIGH) had thoracic metastases and an Eastern Cooperative Oncology Group (ECOG) score of 1.0 ± 0.8. Low function/irradiated (LOW + RADS) had preoperative radiation and the lowest Karnofsky scores (56.0 ± 10.6). Estrogen receptor or progesterone receptor (ER/PR) positive patients had >90% estrogen/progesterone positivity and moderate Karnofsky scores (74.0 ± 11.5). Lumbar/noncompressive (NON-COMP) had the fewest patients with ESCC grade 2 or 3 epidural disease (42.1%, P < 0.001). Low function/neurologic deficits (LOW + NEURO) had ESCC grade 2 or 3 disease and neurologic deficits. Adverse event rates were 25.0% in the HIGH group, 73.3% in LOW + RADS, 24.0% in ER/PR, 31.6% in NON-COMP, and 60.0% in LOW + NEURO (P = 0.003). CONCLUSIONS Function at presentation, tumor hormone signature, radiation history, and epidural compression delineated postoperative trajectory. We believe our results can aid in expectation management and the identification of at-risk patients who may merit closer surveillance following surgical intervention.
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Affiliation(s)
- Mitchell S Fourman
- Departments of Orthopaedic Surgery and Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Orthopaedic Surgery, Montefiore Medical Center, Bronx, New York, USA
| | - Layla Siraj
- Departments of Orthopaedic Surgery and Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Julia Duvall
- Departments of Orthopaedic Surgery and Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Duncan C Ramsey
- Departments of Orthopaedic Surgery and Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Muhamed Hadzipasic
- Departments of Orthopaedic Surgery and Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ian Connolly
- Departments of Orthopaedic Surgery and Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Theresa Williamson
- Departments of Orthopaedic Surgery and Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ganesh M Shankar
- Departments of Orthopaedic Surgery and Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Andrew Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Reza Yassari
- Department of Neurological Surgery, Montefiore Medical Center, Bronx, New York, USA
| | - Elie Massaad
- Departments of Orthopaedic Surgery and Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - John H Shin
- Departments of Orthopaedic Surgery and Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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19
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Dupont MM, Fourman MS, Iyer S, Qureshi SA, Sheha ED, Rhie-Lee J, Dowdell J. Impact of Lumbar Disk Herniation on Performance Outcomes and New Contracts in the National Football League. Clin Spine Surg 2023; 36:E139-E144. [PMID: 36127776 DOI: 10.1097/bsd.0000000000001389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 08/17/2022] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN This was a retrospective cohort study. OBJECTIVE To determine performance outcomes and the contract-signing ability for the most recent cohort of professional football players treated for lumbar disk herniation (LDH). SUMMARY OF BACKGROUND DATA LDH can have a significant impact on the career of a National Football League (NFL) player. Previous studies have found favorable return to play (RTP) and performance outcomes for players with LDH, but the impact on the ability to sign new contracts (an important surrogate to assess continued success) has not previously been studied. MATERIALS AND METHODS NFL players treated for LDH from 2000 to 2020 were identified from a public records search. Age, position, type of treatment, and RTP measures were collected. Pro Football Focus (PFF) performance grade and contract values were compared before the injury and after treatment. Multivariable logistic regression was used to identify independent risk factors associated with the ability to RTP and sign high-value contracts. RESULTS One hundred one players were treated for an LDH, of which 75 returned to play. Posttreatment performance as measured by PFF was similar to preinjury levels ( P =0.2). However, both total and guaranteed contract values were significantly reduced ( P <0.01). In multivariable analysis, both lower age and higher preinjury PFF grade were independent predictors of RTP and ability to sign a new contract. A preinjury contract that contained a high proportion of guaranteed money was found to be an independent predictor of the ability to sign a contract that was >20% guaranteed. CONCLUSION Although the majority of players were able to RTP at preserved performance levels following LDH treatment, their contract values were significantly reduced. RTP and contract-signing ability were not associated with the type of treatment, but rather baseline factors such as the player's age, performance, and preinjury compensation. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
| | | | - Sravisht Iyer
- Hospital for Special Surgery
- Weill Cornell Medical College, New York, NY
| | - Sheeraz A Qureshi
- Hospital for Special Surgery
- Weill Cornell Medical College, New York, NY
| | - Evan D Sheha
- Hospital for Special Surgery
- Weill Cornell Medical College, New York, NY
| | | | - James Dowdell
- Hospital for Special Surgery
- Weill Cornell Medical College, New York, NY
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20
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Sarmiento JM, Fourman MS, Kim HJ. Construct-to-construct biplanar cantilever technique for spinal deformity correction: illustrative case. J Neurosurg Case Lessons 2023; 5:CASE22527. [PMID: 37039296 PMCID: PMC10550534 DOI: 10.3171/case22527] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 02/14/2023] [Indexed: 04/12/2023]
Abstract
BACKGROUND There is a continued trend toward posterior-only approaches for achieving spinal deformity correction of idiopathic scoliosis. We present a posteriorly based correction technique and en bloc translation reduction maneuver that can be useful in the management of kyphoscoliosis. OBSERVATIONS A 50-year-old female with a past medical history of untreated adolescent idiopathic scoliosis since she was 12 years old presented to the clinic for evaluation of progressive thoracolumbar spinal deformity and worsening mid-to-low back pain. Standing scoliosis radiographs shows an 85° left lumbar curve with an apex at the L1-2 disk. There was a compensatory 58° right thoracic curve with an apex at T9, a -1.4 cm central vertical axis, and a focal kyphotic deformity of 86° from T11-L3 with a corresponding apex at the L1-2 disk. She was diagnosed with adult idiopathic scoliosis and indicated for a T9-L4 posterior spinal fusion with T11-L4 Smith-Peterson osteotomies. A simple en bloc reduction maneuver was used to translate the apex of the coronal deformity toward the midline and simultaneously correct the patient's focal kyphosis. LESSONS A construct-to-construct biplanar cantilever technique is ideal for the treatment of kyphoscoliosis and can provide effective deformity correction in both the sagittal and coronal planes.
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21
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Oyekan AA, Lee JY, Hodges JC, Chen SR, Wilson AE, Fourman MS, Clayton EO, Njoku-Austin C, Crasto JA, Wisniewski MK, Bilderback A, Gunn SR, Levin WI, Arnold RM, Hinrichsen KL, Mensah C, Hogan MV, Hall DE. Increasing Quality and Frequency of Goals-of-Care Documentation in the Highest-Risk Surgical Candidates: One-Year Results of the Surgical Pause Program. JB JS Open Access 2023; 8:JBJSOA-D-22-00107. [PMID: 37101601 PMCID: PMC10125643 DOI: 10.2106/jbjs.oa.22.00107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/28/2023] Open
Abstract
Patient values may be obscured when decisions are made under the circumstances of constrained time and limited counseling. The objective of this study was to determine if a multidisciplinary review aimed at ensuring goal-concordant treatment and perioperative risk assessment in high-risk orthopaedic trauma patients would increase the quality and frequency of goals-of-care documentation without increasing the rate of adverse events. Methods We prospectively analyzed a longitudinal cohort of adult patients treated for traumatic orthopaedic injuries that were neither life- nor limb-threatening between January 1, 2020, and July 1, 2021. A rapid multidisciplinary review termed a "surgical pause" (SP) was available to those who were ≥80 years old, were nonambulatory or had minimal ambulation at baseline, and/or resided in a skilled nursing facility, as well as upon clinician request. Metrics analyzed include the proportion and quality of goals-of-care documentation, rate of return to the hospital, complications, length of stay, and mortality. Statistical analysis utilized the Kruskal-Wallis rank and Wilcoxon rank-sum tests for continuous variables and the likelihood-ratio chi-square test for categorical variables. Results A total of 133 patients were either eligible for the SP or referred by a clinician. Compared with SP-eligible patients who did not undergo an SP, patients who underwent an SP more frequently had goals-of-care notes identified (92.4% versus 75.0%, p = 0.014) and recorded in the appropriate location (71.2% versus 27.5%, p < 0.001), and the notes were more often of high quality (77.3% versus 45.0%, p < 0.001). Mortality rates were nominally higher among SP patients, but these differences were not significant (10.6% versus 5.0%, 5.1% versus 0.0%, and 14.3% versus 7.9% for in-hospital, 30-day, and 90-day mortality, respectively; p > 0.08 for all). Conclusions The pilot program indicated that an SP is a feasible and effective means of increasing the quality and frequency of goals-of-care documentation in high-risk operative candidates whose traumatic orthopaedic injuries are neither life- nor limb-threatening. This multidisciplinary program aims for goal-concordant treatment plans that minimize modifiable perioperative risks. Level of Evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Anthony A. Oyekan
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Pittsburgh Ortho Spine Research (POSR) Group, University of Pittsburgh, Pittsburgh, Pennsylvania
- Email for corresponding author:
| | - Joon Y. Lee
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Pittsburgh Ortho Spine Research (POSR) Group, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jacob C. Hodges
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Stephen R. Chen
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Pittsburgh Ortho Spine Research (POSR) Group, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Alan E. Wilson
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mitchell S. Fourman
- Pittsburgh Ortho Spine Research (POSR) Group, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Elizabeth O. Clayton
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Jared A. Crasto
- Department of Orthopaedic Surgery, The Spine Institute of Arizona, Scottsdale, Arizona
| | - Mary Kay Wisniewski
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Andrew Bilderback
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Scott R. Gunn
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - William I. Levin
- Department of Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Robert M. Arnold
- Department of Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Section of Palliative Care and Medical Ethics, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Katie L. Hinrichsen
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Christopher Mensah
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - MaCalus V. Hogan
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Daniel E. Hall
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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22
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Dalton JF, Fourman MS, Rynearson B, Wawrose R, Cluts L, Shaw JD, Lee JY. The L3 Flexion Angle Predicts Failure of Non-Operative Management in Patients with Tandem Spondylolithesis. Global Spine J 2023:21925682231161305. [PMID: 36881755 DOI: 10.1177/21925682231161305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE Determine impact of standard/novel spinopelvic parameters on global sagittal imbalance, health-related quality of life (HRQoL) scores, and clinical outcomes in patients with multi-level, tandem degenerative spondylolisthesis (TDS). METHODS Single institution analysis; 49 patients with TDS. Demographics, PROMIS and ODI scores collected. Radiographic measurements-sagittal vertical axis (SVA), pelvic incidence (PI), lumbar lordosis (LL), PI-LL mismatch, sagittal L3 flexion angle (L3FA) and L3 sagittal distance (L3SD). Stepwise linear multivariate regression performed using full length cassettes to identify demographic and radiographic factors predictive of aberrant SVA (≥5 cm). Receiver operative curve (ROC) analysis used to identify cutoffs for lumbar radiographic values independently predictive of SVA ≥5 cm. Univariate comparisons of patient demographics, (HRQoL) scores and surgical indication were performed around this cutoff using two-way Student's t-tests and Fisher's exact test for continuous and categorical variables, respectively. RESULTS Patients with increased L3FA had worse ODI (P = .006) and increased rate of failing non-operative management (P = .02). L3FA (OR 1.4, 95% CI) independently predicted of SVA ≥5 cm (sensitivity and specifity of 93% and 92%). Patients with SVA ≥5 cm had lower LL (48.7 ± 19.5 vs 63.3 ± 6.9 mm, P < .021), higher L3SD (49.3 ± 12.9 vs 28.8 ± 9.2, P < .001) and L3FA (11.6 ± 7.9 vs -3.2 ± 6.1, P < .001) compared to patients with SVA ≤5 cm. CONCLUSIONS Increased flexion of L3, which is easily measured by the novel lumbar parameter L3FA, predicts global sagittal imbalance in TDS patients. Increased L3FA is associated with worse performance on ODI, and failure of non-operative management in patients with TDS.
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Affiliation(s)
- Jonathan F Dalton
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Pittsburgh Orthopaedic Spine Research Group (POSR), University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Mitchell S Fourman
- Pittsburgh Orthopaedic Spine Research Group (POSR), University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Bronx, NY, USA
| | - Bryan Rynearson
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Pittsburgh Orthopaedic Spine Research Group (POSR), University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Rick Wawrose
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Pittsburgh Orthopaedic Spine Research Group (POSR), University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Landon Cluts
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Pittsburgh Orthopaedic Spine Research Group (POSR), University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jeremy D Shaw
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Pittsburgh Orthopaedic Spine Research Group (POSR), University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Joon Y Lee
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Pittsburgh Orthopaedic Spine Research Group (POSR), University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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23
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Lafage R, Fourman MS, Smith JS, Bess S, Shaffrey CI, Kim HJ, Kebaish KM, Burton DC, Hostin R, Passias PG, Protopsaltis TS, Daniels AH, Klineberg EO, Gupta MC, Kelly MP, Lenke LG, Schwab FJ, Lafage V. Can unsupervised cluster analysis identify patterns of complex adult spinal deformity with distinct perioperative outcomes? J Neurosurg Spine 2023; 38:547-557. [PMID: 36806173 DOI: 10.3171/2023.1.spine221095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 01/04/2023] [Indexed: 02/23/2023]
Abstract
OBJECTIVE The objective of this study was to use an unsupervised cluster approach to identify patterns of operative adult spinal deformity (ASD) and compare the perioperative outcomes of these groups. METHODS A multicenter data set included patients with complex surgical ASD, including those with severe deformities, significant surgical complexity, or advanced age who underwent a multilevel fusion. An unsupervised cluster analysis allowing for 10% outliers was used to identify different deformity patterns. The perioperative outcomes of these clusters were then compared using ANOVA, Kruskal-Wallis, and chi-square tests, with p values < 0.05 considered significant. RESULTS Two hundred eighty-six patients were classified into four clusters of deformity patterns: hyper-thoracic kyphosis (hyper-TK), severe coronal, severe sagittal, and moderate sagittal. Hyper-TK patients had the lowest disability (mean Oswestry Disability Index [ODI] 32.9 ± 17.1) and pain scores (median numeric rating scale [NRS] back score 6, leg score 1). The severe coronal cluster had moderate functional impairment (mean physical component score 34.4 ± 12.3) and pain (median NRS back score 7, leg score 4) scores. The severe sagittal cluster had the highest levels of disability (mean ODI 49.3 ± 15.6) and low appearance scores (mean 2.3 ± 0.7). The moderate cluster (mean 68.8 ± 7.8 years) had the highest pain interference subscores on the Patient-Reported Outcomes Measurement Information System (mean 65.2 ± 5.8). Overall 30-day adverse events were equivalent among the four groups. Fusion to the pelvis was most common in the moderate sagittal (89.4%) and severe sagittal (97.5%) clusters. The severe coronal cluster had more osteotomies per case (median 11, IQR 6.5-14) and a higher rate of 30-day implant-related complications (5.5%). The severe sagittal and hyper-TK clusters had more three-column osteotomies (43% and 32.3%, respectively). Hyper-TK patients had shorter hospital stays. CONCLUSIONS This cohort of patients with complex ASD surgeries contained four natural clusters of deformity, each with distinct perioperative outcomes.
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Affiliation(s)
- Renaud Lafage
- 1Department of Orthopedic Surgery, Lenox Hill Hospital, New York, New York
| | - Mitchell S Fourman
- 2Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Justin S Smith
- 3Department of Neurosurgery, UVA Health, Charlottesville, Virginia
| | - Shay Bess
- 4Department of Orthopedic Surgery, NYU Langone Medical Center, New York, New York
| | | | - Han Jo Kim
- 2Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Khaled M Kebaish
- 6Department of Orthopedic Surgery, Johns Hopkins Medicine, Baltimore, Maryland
| | - Douglas C Burton
- 7Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Richard Hostin
- 8Department of Orthopedic Surgery, Medical City Scoliosis & Advanced Spine Center, Plano, Texas
| | - Peter G Passias
- 4Department of Orthopedic Surgery, NYU Langone Medical Center, New York, New York
| | | | - Alan H Daniels
- 9Department of Orthopedic Surgery, Brown University, Providence, Rhode Island
| | - Eric O Klineberg
- 10Department of Orthopedic Surgery, UC Davis Health, Sacramento, California
| | - Munish C Gupta
- 11Department of Orthopedic Surgery, Washington University Orthopedics, St. Louis, Missouri; and
| | - Michael P Kelly
- 11Department of Orthopedic Surgery, Washington University Orthopedics, St. Louis, Missouri; and
| | - Lawrence G Lenke
- 12Department of Orthopedic Surgery, Columbia Orthopedic Surgery, New York, New York
| | - Frank J Schwab
- 1Department of Orthopedic Surgery, Lenox Hill Hospital, New York, New York
| | - Virginie Lafage
- 1Department of Orthopedic Surgery, Lenox Hill Hospital, New York, New York
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24
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Lans A, Bales JR, Fourman MS, Borkhetaria PP, Verlaan JJ, Schwab JH. Health Literacy in Orthopedic Surgery: A Systematic Review. HSS J 2023; 19:120-127. [PMID: 36776507 PMCID: PMC9837407 DOI: 10.1177/15563316221110536] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 05/20/2022] [Indexed: 02/14/2023]
Abstract
Background: Limited health literacy has been associated with adverse health outcomes. Undergoing orthopedic surgery often requires patients to make complex decisions and adhere to complicated instructions, suggesting that health literacy skills might have a profound impact on orthopedic surgery outcomes. Purpose: We sought to review the literature for studies investigating the level of health literacy in patients undergoing orthopedic surgery and also to assess how those studies report factors affecting health equity. Methods: We conducted a systematic search of PubMed, Embase, and Cochrane Library for all health literacy studies published in the orthopedic surgery literature up to February 8, 2022. Search terms included synonyms for health literacy and for all orthopedic surgery subspecialties. Two reviewers independently extracted study data in addition to indicators of equity reporting using the PROGRESS+ checklist (Place of Residence, Race/Ethnicity, Occupation, Gender/sex, Religion, Education, Social capital, Socioeconomic status, plus age, disability, and sexual orientation). Results: The search resulted in 616 studies; 9 studies remained after exclusion criteria were applied. Most studies were of arthroplasty (4/9; 44%) or trauma (3/9; 33%) patients. Validated health literacy assessments were used in 4 of the included studies, and only 3 studies reported the rate of limited health literacy in the patients studied, which ranged between 34% and 38.5%. At least one PROGRESS+ item was reported in 88% (8/9) of the studies. Conclusions: We found a paucity of appropriately designed studies that used validated measures of health literacy in the field of orthopedic surgery. The potential impact of health literacy on orthopedic patients and their outcomes has yet to be elucidated. Thoughtful, high-quality trials across diverse demographics and geographies are warranted.
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Affiliation(s)
- Amanda Lans
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Orthopaedic Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - John R. Bales
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Mitchell S. Fourman
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Pranati P. Borkhetaria
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jorrit-Jan Verlaan
- Department of Orthopaedic Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Joseph H. Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Fourman MS. CORR Insights®: Are There Racial or Socioeconomic Disparities in Ambulatory Outcome or Survival After Oncologic Spine Surgery for Metastatic Cancer? Results From a Medically Underserved Center. Clin Orthop Relat Res 2023; 481:308-311. [PMID: 36580477 PMCID: PMC9831162 DOI: 10.1097/corr.0000000000002510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 11/08/2022] [Indexed: 12/30/2022]
Affiliation(s)
- Mitchell S Fourman
- Assistant Professor of Orthopaedic Spine Surgery, Department of Orthopaedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA
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Fourman MS, Yates AJ, Kim HJ. Clinical Faceoff: Hip Osteoarthritis in the Setting of Adult Spinal Deformity. Clin Orthop Relat Res 2023; 481:32-38. [PMID: 36410010 PMCID: PMC9750692 DOI: 10.1097/corr.0000000000002485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 10/17/2022] [Indexed: 11/22/2022]
Affiliation(s)
- Mitchell S. Fourman
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Adolph J. Yates
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Han Jo Kim
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
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Sarmiento JM, Shahi P, Melissaridou D, Fourman MS, Araghi K, Qureshi SA. Step-by-step guide to robotic-guided minimally invasive transforaminal lumbar interbody fusion (MI-TLIF). Ann Transl Med 2023; 11:221. [PMID: 37007570 PMCID: PMC10061490 DOI: 10.21037/atm-22-3273] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 12/03/2022] [Indexed: 01/12/2023]
Abstract
Robotics in spinal surgery offers a promising potential to refine and improve the minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) technique. Suitable surgeons for this technique include those who are already familiar with robotic-guided lumbar pedicle screw placement and want to advance their skillset by incorporating posterior-based interbody fusion. We provide a step-by-step guide for robotic-guided MI-TLIF. The procedure is divided into 7 practical and detailed techniques. The steps in sequential order include: (I) planning trajectories for pedicle screws and the tubular retractor; (II) robotic-guided pedicle screw placement; (III) placement of tubular retractor; (IV) unilateral facetectomy using the surgical microscope; (V) discectomy & disc preparation; (VI) interbody implant insertion; and (VII) percutaneous rod placement. We standardize surgeon training in robotic MI-TLIF by teaching our spine surgery fellows these 7 key technical steps highlighted in this guide. Current-generation robotics offers integrated navigation capability, K-wireless placement of pedicle screws through a rigid robotic arm, compatibility with tubular retractor systems to perform facetectomy, and allows for placement of interbody devices. We have found robotic-guided MI-TLIF to be a safe procedure that allows for accurate and reliable pedicle screw placement, less collateral damage to the soft tissues of the low back, and decreased radiation exposure.
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Affiliation(s)
- J Manuel Sarmiento
- Spine and Scoliosis Service, Hospital for Special Surgery, New York, NY, USA
| | - Pratyush Shahi
- Spine and Scoliosis Service, Hospital for Special Surgery, New York, NY, USA
| | | | - Mitchell S Fourman
- Spine and Scoliosis Service, Hospital for Special Surgery, New York, NY, USA
| | - Kasra Araghi
- Spine and Scoliosis Service, Hospital for Special Surgery, New York, NY, USA
| | - Sheeraz A Qureshi
- Spine and Scoliosis Service, Hospital for Special Surgery, New York, NY, USA
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Duvall JB, Massaad E, Siraj L, Kiapour A, Connolly I, Hadzipasic M, Elsamadicy AA, Williamson T, Shankar GM, Schoenfeld AJ, Fourman MS, Shin JH. Assessment of Spinal Metastases Surgery Risk Stratification Tools in Breast Cancer by Molecular Subtype. Neurosurgery 2023; 92:83-91. [PMID: 36305664 PMCID: PMC10158884 DOI: 10.1227/neu.0000000000002180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 08/06/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Breast cancer molecular features and modern therapies are not included in spine metastasis prediction algorithms. OBJECTIVE To examine molecular differences and the impact of postoperative systemic therapy to improve prognosis prediction for spinal metastases surgery and aid surgical decision making. METHODS This is a retrospective multi-institutional study of patients who underwent spine surgery for symptomatic breast cancer spine metastases from 2008 to 2021 at the Massachusetts General Hospital and Brigham and Women's Hospital. We studied overall survival, stratified by breast cancer molecular subtype, and calculated hazard ratios (HRs) adjusting for demographics, tumor characteristics, treatments, and laboratory values. We tested the performance of established models (Tokuhashi, Bauer, Skeletal Oncology Research Group, New England Spinal Metastases Score) to predict and compare all-cause. RESULTS A total of 98 patients surgically treated for breast cancer spine metastases were identified (100% female sex; median age, 56 years [IQR, 36-84 years]). The 1-year probabilities of survival for hormone receptor positive, hormone receptor positive/human epidermal growth factor receptor 2+, human epidermal growth factor receptor 2+, and triple-negative breast cancer were 63% (45 of 71), 83% (10 of 12), 0% (0 of 3), and 12% (1 of 8), respectively ( P < .001). Patients with triple-negative breast cancer had a higher proportion of visceral metastases, brain metastases, and poor physical activity at baseline. Postoperative chemotherapy and endocrine therapy were associated with prolonged survival. The Skeletal Oncology Research Group prognostic model had the highest discrimination (area under the receiver operating characteristic, 0.77 [95% CI, 0.73-0.81]). The performance of all prognostic scores improved when preoperative molecular data and postoperative systemic treatment plans was considered. CONCLUSION Spine metastases risk tools were able to predict prognosis at a significantly higher degree after accounting for molecular features which guide treatment response.
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Affiliation(s)
- Julia B. Duvall
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Elie Massaad
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Layla Siraj
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Program in Health Sciences & Technology, Harvard Medical School & Massachusetts Institute of Technology, Boston, Massachusetts, USA
| | - Ali Kiapour
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ian Connolly
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Muhamed Hadzipasic
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Aladine A. Elsamadicy
- Program in Health Sciences & Technology, Harvard Medical School & Massachusetts Institute of Technology, Boston, Massachusetts, USA
| | - Theresa Williamson
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ganesh M. Shankar
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Andrew J. Schoenfeld
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Mitchell S. Fourman
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - John H. Shin
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Oyekan A, Dalton J, Fourman MS, Ridolfi D, Cluts L, Couch B, Shaw JD, Donaldson W, Lee JY. Multilevel tandem spondylolisthesis associated with a reduced "safe zone" for a transpsoas lateral lumbar interbody fusion at L4-5. Neurosurg Focus 2023; 54:E5. [PMID: 36587399 DOI: 10.3171/2022.10.focus22605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 10/18/2022] [Indexed: 01/02/2023]
Abstract
OBJECTIVE The aim of this study was to investigate the effect of degenerative spondylolisthesis (DS) on psoas anatomy and the L4-5 safe zone during lateral lumbar interbody fusion (LLIF). METHODS In this retrospective, single-institution analysis, patients managed for low-back pain between 2016 and 2021 were identified. Inclusion criteria were adequate lumbar MR images and radiographs. Exclusion criteria were spine trauma, infection, metastases, transitional anatomy, or prior surgery. There were three age and sex propensity-matched cohorts: 1) controls without DS; 2) patients with single-level DS (SLDS); and 3) patients with multilevel, tandem DS (TDS). Axial T2-weighted MRI was used to measure the apical (ventral) and central positions of the psoas relative to the posterior tangent line at the L4-5 disc. Lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), and PI-LL mismatch were measured on lumbar radiographs. The primary outcomes were apical and central psoas positions at L4-5, which were calculated using stepwise multivariate linear regression including demographics, spinopelvic parameters, and degree of DS. Secondary outcomes were associations between single- and multilevel DS and spinopelvic parameters, which were calculated using one-way ANOVA with Bonferroni correction for between-group comparisons. RESULTS A total of 230 patients (92 without DS, 92 with SLDS, and 46 with TDS) were included. The mean age was 68.0 ± 8.9 years, and 185 patients (80.4%) were female. The mean BMI was 31.0 ± 7.1, and the mean age-adjusted Charlson Comorbidity Index (aCCI) was 4.2 ± 1.8. Age, BMI, sex, and aCCI were similar between the groups. Each increased grade of DS (no DS to SLDS to TDS) was associated with significantly increased PI (p < 0.05 for all relationships). PT, PI-LL mismatch, center psoas, and apical position were all significantly greater in the TDS group than in the no-DS and SLDS groups (p < 0.05). DS severity was independently associated with 2.4-mm (95% CI 1.1-3.8 mm) center and 2.6-mm (95% CI 1.2-3.9 mm) apical psoas anterior displacement per increased grade (increasing from no DS to SLDS to TDS). CONCLUSIONS TDS represents more severe sagittal malalignment (PI-LL mismatch), pelvic compensation (PT), and changes in the psoas major muscle compared with no DS, and SLDS and is a risk factor for lumbar plexus injury during L4-5 LLIF due to a smaller safe zone.
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Affiliation(s)
- Anthony Oyekan
- 1Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh.,2Pittsburgh Orthopaedic Spine Research Group, Pittsburgh
| | - Jonathan Dalton
- 1Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh.,2Pittsburgh Orthopaedic Spine Research Group, Pittsburgh
| | - Mitchell S Fourman
- 2Pittsburgh Orthopaedic Spine Research Group, Pittsburgh.,4Department of Orthopaedic Surgery, Montefiore Medical Center, Bronx, New York
| | - Dominic Ridolfi
- 2Pittsburgh Orthopaedic Spine Research Group, Pittsburgh.,3University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
| | - Landon Cluts
- 2Pittsburgh Orthopaedic Spine Research Group, Pittsburgh.,3University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
| | - Brandon Couch
- 1Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh.,2Pittsburgh Orthopaedic Spine Research Group, Pittsburgh
| | - Jeremy D Shaw
- 1Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh.,2Pittsburgh Orthopaedic Spine Research Group, Pittsburgh
| | - William Donaldson
- 1Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh.,2Pittsburgh Orthopaedic Spine Research Group, Pittsburgh
| | - Joon Y Lee
- 1Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh.,2Pittsburgh Orthopaedic Spine Research Group, Pittsburgh
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Lans A, Bales JR, Fourman MS, Tobert DG, Verlaan JJ, Schwab JH. Reliability of self-reported health literacy screening in spine patients. Spine J 2022; 23:715-722. [PMID: 36565954 DOI: 10.1016/j.spinee.2022.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/28/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND CONTEXT Limited health literacy has previously been associated with increased health care utilization, worse general health status and self-reported health, and increased mortality. Identifying and accommodating patients with limited health literacy may offer an avenue towards mitigating adverse health outcomes and reduce unnecessary health care expenditure. Due to the challenges associated with implementation of lengthy health literacy assessments, the Brief Health Literacy Screening Instrument was developed. However, to our knowledge, there are no reports on the accuracy of this screening questionnaire, with or without the inclusion of sociodemographic characteristics, when predicting limited health literacy in orthopaedic spine patients. PURPOSE To evaluate the reliability and predictive accuracy of self-reported health literacy screening questions with and without the inclusion of sociodemographic variables in orthopaedic spine patients. STUDY DESIGN Cross-sectional. PATIENT SAMPLE Patients seen at a tertiary urban academic hospital-based multi-surgeon spine center OUTCOME MEASURES: Brief Health Literacy Screening Instrument (BRIEF), and the Newest Vital Sign (NVS) health literacy assessment tool. METHODS Between December 2021 and February 2022, consecutive English-speaking patients over the age of 18 presenting as new patients to an urban, hospital-based outpatient spine clinic were approached for participation. A sociodemographic survey, the BRIEF, and the NVS Health Literacy Assessment Tool were administered verbally. Simple and multivariable logistic regression was utilized to assess the accuracy of each BRIEF question individually, and collectively, at predicting limited health literacy as defined by the NVS. Further regression analysis included sociodemographic variables (age, body mass index, race, ethnicity, highest educational degree, employment status, marital status, annual household income, insurance status, and self-reported health. RESULTS A total of 262 patients [mean age (years), 57 ± 17] were included in this study. One hundred thirty-four (51%) were male, 223 (85%) were White, and 151 (58%) were married. Patient BRIEF scores were as follows: 23 (9%) limited, 43 (16%) marginal, and 196 (75%) adequate. NVS scores identified 87 (33%) patients with possible limited health literacy. BRIEF items collectively demonstrated fair accuracy in the prediction of limited health literacy (area under the receiver operating characteristic curve, 0.76; 95% CI, 0.70-0.82). Individually, the fourth BRIEF item ("How confident are you in filling out medical forms by yourself?") was the best predictor of limited health literacy (area under the receiver operating characteristic curve, 0.67; 95% CI, 0.60-0.73). The predictive accuracy of the BRIEF items, both individually and collectively, increased with the inclusion of sociodemographic variables within the logistic regression. Specific characteristics independently associated with limited health literacy were self-identified Black race, retired or disabled employment status, single or divorced marital status, high school education or below, and self-reported "poor" health. CONCLUSIONS Limited health literacy has implications for patient outcomes and health care costs. Our results show that the BRIEF questionnaire is a low-cost screening tool that demonstrates fair predictability in determining limited health literacy within a population of spine patients. Self-reported health literacy assessments may be more feasible in daily practice and easier to implement into clinical workflow.
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Affiliation(s)
- Amanda Lans
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114 USA; Department of Orthopaedic Surgery, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, 3584 CX, the Netherlands.
| | - John R Bales
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114 USA
| | - Mitchell S Fourman
- Department of Orthopaedic Surgery, Orthopaedic Spine Service, Montefiore Medical School - Albert Einstein School of Medicine, 1250 Waters Pl, Tower 1, 11(th) Floor, Bronx, NY 10461 USA
| | - Daniel G Tobert
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114 USA
| | - Jorrit-Jan Verlaan
- Department of Orthopaedic Surgery, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, 3584 CX, the Netherlands
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114 USA
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Heng M, Fourman MS, Mitrevski A, Berner E, Lozano-Calderon SA. Augmenting Pathologic Acetabular Bone Loss With Photodynamic Nails to Support Primary Total Hip Arthroplasty. Arthroplast Today 2022; 18:1-6. [PMID: 36267396 PMCID: PMC9576482 DOI: 10.1016/j.artd.2022.08.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 07/27/2022] [Accepted: 08/29/2022] [Indexed: 11/07/2022] Open
Abstract
Background Pathologic acetabular defects can undermine the stability and osseointegration of a primary total hip arthroplasty (THA) acetabular component. Our service has used photodynamic nails (PDNs) in a modified Harrington technique to provide space-filling stability to a primary acetabular implant without impeding local osseointegration. Here we describe our experience with PDN-augmented THAs. Methods An institutional review board-approved retrospective analysis of all patients who underwent PDN-augmented THA in the management of severe (Harrington class II or III) acetabular defects from September 1, 2020 to May 1, 2021 with at least 6 months of follow-up was performed. The primary outcome was implant survivorship. Comparisons between preoperative and 6-week postoperative visual analogue pain scores were made using the Mann-Whitney U test. Results Six patients were included in this case series, 5 with metastatic cancer and 1 with pelvic discontinuity and avascular necrosis following failed attempted acetabular fixation. The mean follow-up duration was 10.3 ± 4.3 months. The mean age was 75.5 ± 4.7 years, mean body mass index 27.3 ± 5.6, and 5 patients were female. All but 1 patient was American Society of Anesthesiologists (ASA) class III. Two patients required acetabular revisions, one for aseptic loosening and a second for a pathologic fracture secondary to disease progression. One patient passed away 90 days after the procedure. The mean visual analogue pain score significantly improved from 7.8 ± 1.6 to 2.0 ± 1.4 six weeks after surgery (P = .008). Conclusions PDN augmentation of the periacetabular bone of patients with large pelvic defects yields durable pain relief and function in vulnerable hosts. PDN should be considered a part of the reconstructive surgeon’s armamentarium.
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Affiliation(s)
- Marilyn Heng
- Orthopaedic Trauma Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Mitchell S. Fourman
- Orthopaedic Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Aiden Mitrevski
- Orthopaedic Trauma Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Emily Berner
- Orthopaedic Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Santiago A. Lozano-Calderon
- Orthopaedic Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA,Corresponding author. Orthopaedic Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA. Tel.: +1 617 643 3653.
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Massaad E, Bridge CP, Kiapour A, Fourman MS, Duvall JB, Connolly ID, Hadzipasic M, Shankar GM, Andriole KP, Rosenthal M, Schoenfeld AJ, Bilsky MH, Shin JH. Evaluating frailty, mortality, and complications associated with metastatic spine tumor surgery using machine learning-derived body composition analysis. J Neurosurg Spine 2022; 37:263-273. [PMID: 35213829 DOI: 10.3171/2022.1.spine211284] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 01/05/2022] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Cancer patients with spinal metastases may undergo surgery without clear assessments of prognosis, thereby impacting the optimal palliative strategy. Because the morbidity of surgery may adversely impact recovery and initiation of adjuvant therapies, evaluation of risk factors associated with mortality risk and complications is critical. Evaluation of body composition of cancer patients as a surrogate for frailty is an emerging area of study for improving preoperative risk stratification. METHODS To examine the associations of muscle characteristics and adiposity with postoperative complications, length of stay, and mortality in patients with spinal metastases, the authors designed an observational study of 484 cancer patients who received surgical treatment for spinal metastases between 2010 and 2019. Sarcopenia, muscle radiodensity, visceral adiposity, and subcutaneous adiposity were assessed on routinely available 3-month preoperative CT images by using a validated deep learning methodology. The authors used k-means clustering analysis to identify patients with similar body composition characteristics. Regression models were used to examine the associations of sarcopenia, frailty, and clusters with the outcomes of interest. RESULTS Of 484 patients enrolled, 303 had evaluable CT data on muscle and adiposity (mean age 62.00 ± 11.91 years; 57.8% male). The authors identified 2 clusters with significantly different body composition characteristics and mortality risks after spine metastases surgery. Patients in cluster 2 (high-risk cluster) had lower muscle mass index (mean ± SD 41.16 ± 7.99 vs 50.13 ± 10.45 cm2/m2), lower subcutaneous fat area (147.62 ± 57.80 vs 289.83 ± 109.31 cm2), lower visceral fat area (82.28 ± 48.96 vs 239.26 ± 98.40 cm2), higher muscle radiodensity (35.67 ± 9.94 vs 31.13 ± 9.07 Hounsfield units [HU]), and significantly higher risk of 1-year mortality (adjusted HR 1.45, 95% CI 1.05-2.01, p = 0.02) than individuals in cluster 1 (low-risk cluster). Decreased muscle mass, muscle radiodensity, and adiposity were not associated with a higher rate of complications after surgery. Prolonged length of stay (> 7 days) was associated with low muscle radiodensity (mean 30.87 vs 35.23 HU, 95% CI 1.98-6.73, p < 0.001). CONCLUSIONS Body composition analysis shows promise for better risk stratification of patients with spinal metastases under consideration for surgery. Those with lower muscle mass and subcutaneous and visceral adiposity are at greater risk for inferior outcomes.
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Affiliation(s)
- Elie Massaad
- 1Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Christopher P Bridge
- 2Massachusetts General Hospital and Brigham and Women's Hospital Center for Clinical Data Science, Harvard Medical School, Boston
- 4Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston
| | - Ali Kiapour
- 1Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Mitchell S Fourman
- 3Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Julia B Duvall
- 1Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Ian D Connolly
- 1Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Muhamed Hadzipasic
- 1Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Ganesh M Shankar
- 1Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Katherine P Andriole
- 2Massachusetts General Hospital and Brigham and Women's Hospital Center for Clinical Data Science, Harvard Medical School, Boston
- 4Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston
| | - Michael Rosenthal
- 4Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston
- 5Department of Radiology, Dana Farber Cancer Institute, Boston
| | - Andrew J Schoenfeld
- 6Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - Mark H Bilsky
- 7Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - John H Shin
- 1Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston
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Feroe AG, Hassan MM, Fourman MS, Anderson ME, Kim YJ. Surgical Hip Dislocation for a Diagnostic Dilemma: Differentiating Synovial Chondromatosis and Pigmented Villonodular Synovitis. Iowa Orthop J 2022; 42:263-265. [PMID: 35821952 PMCID: PMC9210434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Pigmented villonodular synovitis (PVNS) and synovial chondromatosis (SC) of the hip are rare synovial diseases that can induce joint destruction without early diagnosis and treatment. The extent of surgical excision is critical given the high rates of recurrence. In the presented case, a 19-year-old female was referred to our institution with progressive left hip pain and radiologic evidence of an intra-articular mass that was consistent with PVNS versus SC. Her medical history was notable for a prior excision of a fibrous lesion at an outside hospital at age 13 with persistent pain. The patient underwent a surgical hip dislocation approach to obtain near-complete visualization of the femoroacetabular joint, ensuring complete evaluation and excision. The tumor was intraoperatively diagnosed as SC and excised accordingly, during an uneventful operation. Pathology confirmed the diagnosis. The essential diagnostic and surgical steps for the management of this pelvic tumor diagnostic dilemma are described. Level of Evidence: V.
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Affiliation(s)
- Aliya G. Feroe
- Department of Orthopaedic Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Mahad M. Hassan
- Department of Orthopaedic Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Mitchell S. Fourman
- Department of Orthopaedic Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Megan E. Anderson
- Department of Orthopaedic Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Young-Jo Kim
- Department of Orthopaedic Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
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Sarmiento JM, Fourman MS, Lovecchio F, Lyons KW, Farmer JC. Acute development of spinal lumbar synovial facet cyst within 1 week after lumbar decompression: illustrative case. J Neurosurg Case Lessons 2022; 3:CASE2226. [PMID: 36303504 PMCID: PMC9379693 DOI: 10.3171/case2226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 02/18/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Synovial facet cysts can sometimes develop in patients with lumbar spinal stenosis after decompressive laminectomy. The etiology of spinal lumbar synovial cysts is still unclear, but their formation is associated with underlying spinal instability, facet joint arthropathy, and degenerative spondylolisthesis. OBSERVATIONS A 61-year-old-male patient presented with neurogenic claudication due to lumbar spinal stenosis. Radiographic studies showed grade I spondylolisthesis and radiological predictors of delayed spinal instability. He underwent lumbar decompression and shortly thereafter developed spinal instability and recurrent symptoms, with formation of a new spinal lumbar synovial facet cyst. He required revisional decompression, cyst excision, and posterolateral spinal fusion for definitive treatment. LESSONS The literature reports postoperative spinal instability in up to one-third of patients with lumbar spinal stenosis and stable degenerative spondylolisthesis who undergo decompressive laminectomy. Close radiographic monitoring and early advanced imaging may be prudent in this patient population if they develop new postoperative neurological symptoms and show radiographic predictors of instability on preoperative imaging. Posterolateral spinal fusion with instrumentation should be considered in addition to lumbar decompression in this select group of patients who demonstrate radiographic predictors of delayed spinal instability if they are medically capable of tolerating a spinal fusion procedure.
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Fourman MS, Adjei J, Wawrose R, Moloney G, Siska PA, Tarkin IS. Male sex, Gustillo-Anderson type III open fracture and definitive external fixation are risk factors for a return to the or following the surgical management of geriatric low energy open ankle fractures. Injury 2022; 53:746-751. [PMID: 34815056 PMCID: PMC8957801 DOI: 10.1016/j.injury.2021.11.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 10/15/2021] [Accepted: 11/09/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Open ankle fractures in geriatric (age > 60 years) patients are a source of significant morbidity and mortality. Surgical management includes plate and screw fixation (ORIF), retrograde hindfoot nail (HFN), definitive external fixation (ex-fix) and below knee amputation. However, each modality poses unique challenges for this population. We sought to identify predictors of unplanned OR and short-term mortality after geriatric open ankle fractures managed by our service. MATERIALS AND METHODS In an IRB-approved protocol, we evaluated patients over 60 years of age managed for a low energy open ankle/distal tibia pilon fracture by trauma fellowship-trained surgeons from a single academic department that covers two level I trauma centers. Our primary outcome was an unplanned return to the OR. Secondary outcomes were a 90-day "event", defined as an all-cause hospital readmission or mortality, and 1-year mortality. Differences with a p-value < 0.1 measured on univariate analysis were evaluated using a multivariable logistic regression to identify independent outcome predictors. RESULTS A total of 113 (60 ORIF, 36 HFN, 11 ex-fix, 6 amputations) were performed. Cohort mean age was 75.2 ± 9.8 years, and 31 patients (27.4%) were male. Mean age-adjusted charlson comorbidity index was 5.5 ± 2.0. Significant independent predictors of an unplanned return to the OR were male sex (OR 4.4, 95% CI 1.3 to 15.4), Gustilo Type III open fracture (OR 4.9, 95% CI 1.5 to 17.5) and ex-fix (OR 15.6, 95% CI 2.7 to 126.3). Independent predictors of a 90-day "event" were walker/minimal ambulation (OR 3.5, 95% CI 1.3 to 10.4), surgical site infection (OR 4.8, 95% CI 1.8 to 13.8) and reduced BMI (OR 0.9, 95% CI 0.9 - 0.99), while independent predictors of 1-year mortality were age (OR 1.1, 95% CI 1.003 to 1.2), ACCI (OR 1.4, 95% CI 1.02 to 2.0) and walker/minimal ambulator (OR 7.5, 95% CI 1.7 to 53) CONCLUSIONS: Host factors, particularly pre-operative mobility, were most predictive of 90-day event and 1-year mortality. Only definitive external fixation was found to influence patient morbidity as a significant predictor of unplanned OR. However, no surgical modality had any influence on short-term readmission or survival.
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Affiliation(s)
- Mitchell S. Fourman
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Joshua Adjei
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Richard Wawrose
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Gele Moloney
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Peter A. Siska
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ivan S. Tarkin
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Fourman MS, Ramsey DC, Newman ET, Heng M, Raskin KA, Lozano-Calderon SA. Tubercle-Sparing Proximal Tibial Reconstruction in Patients with Primary and Metastatic Bone Disease: A Case Report. JBJS Case Connect 2022; 12:01709767-202203000-00012. [PMID: 35020626 DOI: 10.2106/jbjs.cc.21.00483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
CASE Two patients with cancer involving their proximal tibia required proximal tibial replacement (PTR). One had a soft-tissue sarcoma that involved her posterior cortex, and the other had extensive metaphyseal destruction from metastatic breast cancer. Their anterolateral cortex and tibial tubercle were uninvolved, permitting tubercle-sparing PTR. A plate was applied to the bone bridge in the latter patient in anticipation of radiotherapy. Both healed uneventfully and had minimal extensor lag 2 weeks postoperatively. CONCLUSION Tubercle-sparing PTR preserves extensor mechanism function with minimal lag. It should be considered in patients with cancer when sparing the anterolateral cortex is oncologically safe.
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Affiliation(s)
- Mitchell S Fourman
- Orthopaedic Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston Massachusetts
| | - Duncan C Ramsey
- Orthopaedic Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston Massachusetts
| | - Erik T Newman
- Orthopaedic Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston Massachusetts
| | - Marilyn Heng
- Orthopaedic Trauma Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston Massachusetts
| | - Kevin A Raskin
- Orthopaedic Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston Massachusetts
| | - Santiago A Lozano-Calderon
- Orthopaedic Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston Massachusetts
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Fourman MS, Ramsey DC, Newman ET, Schwab JH, Chen YL, Hung YP, Chebib I, Deshpande V, Petur Nielsen G, DeLaney TF, Mullen JT, Raskin KA, Lozano-Calderon S. ASO Visual Abstract: Assessing the Safety and Utility of Wound VAC Temporization of the Sarcoma or Benign Aggressive Tumor Bed Until Final Margins are Achieved. Ann Surg Oncol 2022. [DOI: 10.1245/s10434-021-11268-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Fourman MS, Ramsey DC, Newman ET, Schwab JH, Chen YL, Hung YP, Chebib I, Deshpande V, Nielsen GP, DeLaney TF, Mullen JT, Raskin KA, Lozano Calderón SA. Assessing the Safety and Utility of Wound VAC Temporization of the Sarcoma or Benign Aggressive Tumor Bed Until Final Margins Are Achieved. Ann Surg Oncol 2021; 29:2290-2298. [PMID: 34751874 DOI: 10.1245/s10434-021-11023-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 10/13/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Local recurrence of microinvasive sarcoma or benign aggressive pathologies can be limb- and life-threatening. Although frozen pathology is reliable, tumor microinvasion can be subtle or missed, having an impact on surgical margins and postoperative radiation planning. The authors' service has begun to temporize the tumor bed after primary tumor excision with a wound vacuum-assisted closure (VAC) pending formal margin analysis, with coverage performed in the setting of final negative margins. METHODS This retrospective analysis included all patients managed at a tertiary referral cancer center with VAC temporization after soft tissue sarcoma or benign aggressive tumor excision from 1 January 2000 to 1 January 2019 and at least 2 years of oncologic follow-up evaluation. The primary outcome was local recurrence. The secondary outcomes were distant recurrence, unplanned return to the operating room for wound/infectious indications, thromboembolic events, and tumor-related deaths. RESULTS For 62 patients, VAC temporization was performed. The mean age of the patients was 62.2 ± 22.3 years (median 66.5 years; 95% confidence interval [CI] 61.7-72.5 years), and the mean age-adjusted Charlson Comorbidity Index was 5.3 ± 1.9. The most common tumor histology was myxofibrosarcoma (51.6%, 32/62). The mean volume was 124.8 ± 324.1 cm3, and 35.5% (22/62) of the cases were subfascial. Local recurrences occurred for 8.1% (5/62) of the patients. Three of these five patients had planned positive margins, and 17.7% (11/62) of the patients had an unplanned return to the operating room. No demographic or tumor factors were associated with unplanned surgery. CONCLUSIONS The findings showed that VAC-temporized management of microinvasive sarcoma and benign aggressive pathologies yields favorable local recurrence and unplanned operating room rates suggestive of oncologic and technical safety. These findings will need validation in a future randomized controlled trial.
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Affiliation(s)
- Mitchell S Fourman
- Orthopaedic Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Duncan C Ramsey
- Orthopaedic Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Erik T Newman
- Orthopaedic Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Joseph H Schwab
- Spine Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Yen-Lin Chen
- Department of Radiation Oncology, Massachusetts General Hospital Cancer Center, Boston, MA, USA
| | - Yin P Hung
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Ivan Chebib
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Vikram Deshpande
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - G Petur Nielsen
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Thomas F DeLaney
- Department of Radiation Oncology, Massachusetts General Hospital Cancer Center, Boston, MA, USA
| | - John T Mullen
- Surgical Oncology Service, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Kevin A Raskin
- Orthopaedic Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Santiago A Lozano Calderón
- Orthopaedic Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA.
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Yang JJ, Chen CW, Fourman MS, Bongers MER, Karhade AV, Groot OQ, Lin WH, Yen HK, Huang PH, Yang SH, Schwab JH, Hu MH. International external validation of the SORG machine learning algorithms for predicting 90-day and one-year survival of patients with spine metastases using a Taiwanese cohort. Spine J 2021; 21:1670-1678. [PMID: 33545371 DOI: 10.1016/j.spinee.2021.01.027] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 01/26/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Accurately predicting the survival of patients with spinal metastases is important for guiding surgical intervention. The SORG machine-learning (ML) algorithm for the 90-day and one-year mortality of patients with metastatic cancer to the spine has been multiply validated, with a high degree of accuracy in both internal and external validation studies. However, prior external validations were conducted using patient groups located on the east coast of the United States, representing a generally homogeneous population. The aim of this study was to externally validate the SORG algorithms with a Taiwanese population. STUDY DESIGN/SETTING Retrospective study at a single tertiary care center in Taiwan PATIENT SAMPLE: Four hundred and twenty-seven patients who underwent surgery for metastatic spine disease from November 1, 2010 to December 31, 2018 OUTCOME MEASURES: 90-day and one-year mortality METHODS: The baseline characteristics of our validation cohort were compared with those of the previously published developmental and external validation cohorts. Discrimination (c-statistic and receiver operating curve), calibration (calibration plot, intercept, and slope), overall performance (Brier score), and decision curve analysis were used to assess the performance of the SORG ML algorithms in this cohort. RESULTS Ninety-day and one-year mortality rates were 110 of 427 (26%) and 256 of 427 (60%), respectively. The external validation cohort and the developmental cohort differed in body mass index (BMI), preoperative performance status, American Spinal Injury Association impairment scale, primary tumor histology and in several laboratory measurements. The SORG ML algorithm for 90-day and 1-year mortality demonstrated a high level of discriminative ability (c-statistics of 0.73 [95% confidence interval [CI], 0.67-0.78] and 0.74 [95% CI, 0.69-0.79]), overall performance, and had a positive net benefit throughout the range of threshold probabilities in decision curve analysis. The algorithm for 1-year mortality had a calibration intercept of 0.08, representing a good calibration. However, the 90-day mortality algorithm underestimated mortality for the lowest predicted probabilities, with an overall intercept of 0.81. CONCLUSIONS The SORG algorithms for predicting 90-day and 1-year mortality in patients with spinal metastatic disease generally performed well on international external validation in a predominately Taiwanese population. However, 90-day mortality was underestimated in this group. Whether this inconsistency was due to different primary tumor characteristics, body mass index, selection bias or other factors remains unclear, and may be better understood with further validative works that utilize international and/or diverse populations.
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Affiliation(s)
- Jiun-Jen Yang
- Department of Orthopedics, National Taiwan University College of Medicine and National Taiwan University Hospital, Taipei, Taiwan; School of Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chih-Wei Chen
- Department of Orthopedics, National Taiwan University College of Medicine and National Taiwan University Hospital, Taipei, Taiwan
| | - Mitchell S Fourman
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Michiel E R Bongers
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Aditya V Karhade
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Olivier Q Groot
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Wei-Hsin Lin
- Department of Orthopedics, National Taiwan University College of Medicine and National Taiwan University Hospital, Taipei, Taiwan
| | - Hung-Kuan Yen
- School of Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Po-Hao Huang
- Department of Orthopedics, National Taiwan University College of Medicine and National Taiwan University Hospital, Taipei, Taiwan
| | - Shu-Hua Yang
- Department of Orthopedics, National Taiwan University College of Medicine and National Taiwan University Hospital, Taipei, Taiwan
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Ming-Hsiao Hu
- Department of Orthopedics, National Taiwan University College of Medicine and National Taiwan University Hospital, Taipei, Taiwan.
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Fourman MS. CORR Insights®: What Is the Implant Survivorship and Functional Outcome After Total Humeral Replacement in Patients with Primary Bone Tumors? Clin Orthop Relat Res 2021; 479:1765-1767. [PMID: 33739330 PMCID: PMC8277275 DOI: 10.1097/corr.0000000000001732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 02/18/2021] [Indexed: 01/31/2023]
Affiliation(s)
- Mitchell S Fourman
- Orthopaedic Oncology Service, Massachusetts General Hospital / Harvard Medical School, Boston, MA, USA
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Fourman MS, Ramsey DC, Newman ET, Raskin KA, Tobert DG, Lozano-Calderon S. How I do it: Percutaneous stabilization of symptomatic sacral and periacetabular metastatic lesions with photodynamic nails. J Surg Oncol 2021; 124:1192-1199. [PMID: 34291827 DOI: 10.1002/jso.26617] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/25/2021] [Accepted: 07/12/2021] [Indexed: 01/23/2023]
Affiliation(s)
- Mitchell S Fourman
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Duncan C Ramsey
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Erik T Newman
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kevin A Raskin
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Daniel G Tobert
- Department of Orthopaedic Surgery, Orthopaedic Spine Service, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Santiago Lozano-Calderon
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital, Boston, Massachusetts, USA
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Fourman MS, Ramsey DC, Kleiner J, Daud A, Newman ET, Schwab JH, Chen YL, DeLaney TF, Mullen JT, Raskin KA, Lozano-Calderón SA. Temporizing Wound VAC Dressing Until Final Negative Margins are Achieved Reduces Myxofibrosarcoma Local Recurrence. Ann Surg Oncol 2021; 28:9171-9176. [PMID: 34143336 DOI: 10.1245/s10434-021-10242-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 05/17/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND The microinvasive nature of suprafascial myxofibrosarcoma reduces the accuracy of intraoperative margin assessment, and tumor bed resections after soft-tissue reconstruction are unreliable. In 2017, we began temporizing the excised tumor bed with a wound VAC, delaying soft-tissue coverage until final negative margins were achieved. We compare the oncologic/surgical outcomes of suprafascial myxofibrosarcomas managed with VAC temporization (VT) with single-stage excision/reconstruction (SS). METHODS We retrospectively studied suprafascial myxofibrosarcomas managed from January 1, 2000 to January 1, 2019 for patients who received neoadjuvant or adjuvant radiation and had at least 2 years of oncologic follow-up at a tertiary referral cancer center. Our primary outcome was local recurrence. Comparisons were performed by using Fisher's exact test or Student's t test. A p value < 0.05 was considered significant. RESULTS Fifty-three patients (18 VAC temporized, 35 single stage) were included. While VT patients were older (74.9 ± 10.2 vs. 63.9 ± 13.6, p = 0.003), treatment groups did not significantly differ with respect to comorbidity, tumor volume, stage and grade. VT patients had significantly fewer local recurrences (5.6% vs. 28.6% after SS, p = 0.048) and R1 resections that required an unplanned readmission for tumor bed reexcision (0% vs. 37.1% after SS, p = 0.002). VT required more total surgeries (2.8 ± 0.9 vs. 1.8 ± 0.9 for SS, p = 0.0002). Postoperative infectious and wound complications were equivalent. CONCLUSIONS Our VAC temporization strategy had a significantly lower LR than SS treatment. While high quality multi-institutional validation is required, VT may represent a paradigm shift in the management of myxofibrosarcoma.
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Affiliation(s)
- Mitchell S Fourman
- Orthopaedic Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Duncan C Ramsey
- Orthopaedic Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Justin Kleiner
- Department of Orthopaedic Surgery, Boston Medical Center, Boston, MA, USA
| | - Anser Daud
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Erik T Newman
- Orthopaedic Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Joseph H Schwab
- Spine Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Yen-Lin Chen
- Department of Radiation Oncology, Massachusetts General Hospital Cancer Center, Boston, MA, USA
| | - Thomas F DeLaney
- Department of Radiation Oncology, Massachusetts General Hospital Cancer Center, Boston, MA, USA
| | - John T Mullen
- Surgical Oncology Service, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Kevin A Raskin
- Orthopaedic Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Santiago A Lozano-Calderón
- Orthopaedic Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA.
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Fourman MS, Ramsey DC, Kleiner J, Daud A, Newman ET, Schwab JH, Chen YL, DeLaney TF, Mullen JT, Raskin KA, Lozano-Calderon S. ASO Visual Abstract: Temporizing Wound VAC Dressing Until Final Negative Margins are Achieved Reduces Myxofibrosarcoma Local Recurrence. Ann Surg Oncol 2021. [PMID: 34117576 DOI: 10.1245/s10434-021-10302-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Mitchell S Fourman
- Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Duncan C Ramsey
- Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Justin Kleiner
- Department of Orthopaedic Surgery, Boston Medical Center, Boston, MA, USA
| | - Anser Daud
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Erik T Newman
- Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Yen-Lin Chen
- Department of Radiation Oncology, Massachusetts General Hospital Cancer Center, Boston, MA, USA
| | - Thomas F DeLaney
- Department of Radiation Oncology, Massachusetts General Hospital Cancer Center, Boston, MA, USA
| | - John T Mullen
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Kevin A Raskin
- Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Santiago Lozano-Calderon
- Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
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Williams BA, Kennedy PJ, Ritter ME, Fourman MS, Nettrour JF. Pain and Rehabilitation Parameters after Hip Replacement using differing Multimodal Perineural Analgesia Strategies: A Quality Improvement Series. Pain Med 2021; 22:1455-1458. [PMID: 33155045 DOI: 10.1093/pm/pnaa384] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Brian A Williams
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh and VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | | | - Marsha E Ritter
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh and VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Mitchell S Fourman
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Current Position: Orthopaedic Oncology Fellow, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - John F Nettrour
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Massaad E, Williams N, Hadzipasic M, Patel SS, Fourman MS, Kiapour A, Schoenfeld AJ, Shankar GM, Shin JH. Performance assessment of the metastatic spinal tumor frailty index using machine learning algorithms: limitations and future directions. Neurosurg Focus 2021; 50:E5. [PMID: 33932935 DOI: 10.3171/2021.2.focus201113] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 02/23/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Frailty is recognized as an important consideration in patients with cancer who are undergoing therapies, including spine surgery. The definition of frailty in the context of spinal metastases is unclear, and few have studied such markers and their association with postoperative outcomes and survival. Using national databases, the metastatic spinal tumor frailty index (MSTFI) was developed as a tool to predict outcomes in this specific patient population and has not been tested with external data. The purpose of this study was to test the performance of the MSTFI with institutional data and determine whether machine learning methods could better identify measures of frailty as predictors of outcomes. METHODS Electronic health record data from 479 adult patients admitted to the Massachusetts General Hospital for metastatic spinal tumor surgery from 2010 to 2019 formed a validation cohort for the MSTFI to predict major complications, in-hospital mortality, and length of stay (LOS). The 9 parameters of the MSTFI were modeled in 3 machine learning algorithms (lasso regularization logistic regression, random forest, and gradient-boosted decision tree) to assess clinical outcome prediction and determine variable importance. Prediction performance of the models was measured by computing areas under the receiver operating characteristic curve (AUROCs), calibration, and confusion matrix metrics (positive predictive value, sensitivity, and specificity) and was subjected to internal bootstrap validation. RESULTS Of 479 patients (median age 64 years [IQR 55-71 years]; 58.7% male), 28.4% had complications after spine surgery. The in-hospital mortality rate was 1.9%, and the mean LOS was 7.8 days. The MSTFI demonstrated poor discrimination for predicting complications (AUROC 0.56, 95% CI 0.50-0.62) and in-hospital mortality (AUROC 0.69, 95% CI 0.54-0.85) in the validation cohort. For postoperative complications, machine learning approaches showed a greater advantage over the logistic regression model used to develop the MSTFI (AUROC 0.62, 95% CI 0.56-0.68 for random forest vs AUROC 0.56, 95% CI 0.50-0.62 for logistic regression). The random forest model had the highest positive predictive value (0.53, 95% CI 0.43-0.64) and the highest negative predictive value (0.77, 95% CI 0.72-0.81), with chronic lung disease, coagulopathy, anemia, and malnutrition identified as the most important predictors of postoperative complications. CONCLUSIONS This study highlights the challenges of defining and quantifying frailty in the metastatic spine tumor population. Further study is required to improve the determination of surgical frailty in this specific cohort.
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Affiliation(s)
| | | | | | - Shalin S Patel
- 2Orthopedic Surgery, Massachusetts General Hospital; and
| | | | | | - Andrew J Schoenfeld
- 3Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Couch BK, Fourman MS, Shaw JD, Wawrose RA, Talentino SE, Boakye LAT, Donaldson WF, Lee JY. Pre-Operative Bariatric Surgery Imparts An Increased Risk of Infection, Re-Admission and Operative Intervention Following Elective Instrumented Lumbar Fusion. Global Spine J 2021; 13:977-983. [PMID: 33906460 DOI: 10.1177/21925682211011601] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES To evaluate the impact of bariatric surgery on patient outcomes following elective instrumented lumbar fusion. METHODS A retrospective review of a prospectively collected database was performed. Patients who underwent a bariatric procedure prior to an elective instrumented lumbar fusion were evaluated. Lumbar procedures were performed at a large academic medical center from 1/1/2012 to 1/1/2018. The primary outcome was surgical site infection (SSI) requiring surgical debridement. Secondary outcomes were prolonged wound drainage requiring treatment, implant failure requiring revision, revision secondary to adjacent segment disease (ASD), and chronic pain states. A randomly selected, surgeon and comorbidity-matched group of 59 patients that underwent an elective lumbar fusion during that period was used as a control. Statistical analysis was performed using Student's two-way t-tests for continuous data, with significance defined as P < .05. RESULTS Twenty-five patients were identified who underwent bariatric surgery prior to elective lumbar fusion. Mean follow-up was 2.4 ± 1.9 years in the bariatric group vs. 1.5 ± 1.3 years in the control group. Patients with a history of bariatric surgery had an increased incidence of SSI that required operative debridement, revision surgery due to ASD, and a higher incidence of chronic pain. Prolonged wound drainage and implant failure were equivalent between groups. CONCLUSION In the present study, bariatric surgery prior to elective instrumented lumbar fusion was associated increased risk of surgical site infection, adjacent segment disease and chronic pain when compared to non-bariatric patients.
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Affiliation(s)
- Brandon K Couch
- Department of Orthopaedic Surgery, 6595University of Pittsburgh Medical Center, PA, USA
| | - Mitchell S Fourman
- Department of Orthopaedic Surgery, 6595University of Pittsburgh Medical Center, PA, USA
| | - Jeremy D Shaw
- Department of Orthopaedic Surgery, 6595University of Pittsburgh Medical Center, PA, USA
| | - Richard A Wawrose
- Department of Orthopaedic Surgery, 6595University of Pittsburgh Medical Center, PA, USA
| | | | - Lorraine A T Boakye
- Department of Orthopaedic Surgery, 6595University of Pittsburgh Medical Center, PA, USA
| | - William F Donaldson
- Department of Orthopaedic Surgery, 6595University of Pittsburgh Medical Center, PA, USA
| | - Joon Y Lee
- Department of Orthopaedic Surgery, 6595University of Pittsburgh Medical Center, PA, USA
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Abstract
PURPOSE OF REVIEW Osteosarcoma (OSA) is the most common primary tumor of bone, mainly affecting children and adolescents. Here we discuss recent advances in surgical and systemic therapies, and highlight potentially new modalities in preclinical evaluation and prognostication. RECENT FINDINGS The advent of neoadjuvant and adjuvant chemotherapy has markedly improved the disease-free recurrence and overall survival of OSA. However, treatment efficacy has been stagnant since the 1980s. This plateau has prompted preclinical and clinical research into in precision surgery, inhaled chemotherapy to increase pulmonary drug concentration without systemic side effects, and novel immunomodulators intended to block molecular pathways associated with OSA proliferation and metastasis. With the advent of novel surgical techniques and new forms and vectors for chemotherapy, it is hoped that OSA treatment outcomes will exceed their currently sustained plateau in the near future.
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Affiliation(s)
- Rebekah Belayneh
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Mitchell S Fourman
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Sumail Bhogal
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kurt R Weiss
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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Weiss KR, Fourman MS. Editor’s Preface to Osteosarcoma Edition. Ann Joint 2021. [DOI: 10.21037/aoj-2019-os-08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Fourman MS. CORR Insights®: Minimal Pain Decrease Between 2 and 4 Weeks after Nonoperative Management of a Displaced Midshaft Clavicle Fracture Is Associated with a High Risk of Symptomatic Nonunion. Clin Orthop Relat Res 2021; 479:139-141. [PMID: 33298742 PMCID: PMC7899724 DOI: 10.1097/corr.0000000000001606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 07/23/2020] [Indexed: 01/31/2023]
Affiliation(s)
- Mitchell S Fourman
- M. S. Fourman, Orthopaedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Couch BK, Maher PL, Fourman MS, Moloney GB, Siska PA, Tarkin IS. Increased Medial Displacement of the Humeral Shaft of at Least 40% Correlates With an Increased Incidence of Nerve Injury in Proximal Humerus Fractures. Iowa Orthop J 2021; 41:163-166. [PMID: 34552419 PMCID: PMC8259169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND Peripheral nerve and infraclavicular brachial plexus injury following proximal humerus fractures are commonplace, but diagnosing a concomitant nerve injury in the acute setting is challenging. Fracture displacement has been identified as a qualitative risk factor for nerve injury, and additional attention should be paid to the neurologic exams of patients with proximal humerus fractures with significant medial shaft displacement. However, a quantitative relationship between the risk of nerve injury and medialization of the humeral shaft has not been shown, and additional risk factors for this complication have not been assessed. The aim of this study was to identify the risk factors for a neurologic deficit following a proximal humerus fracture, with particular interest in the utility of the magnitude of medial shaft displacement as a predictor of neurologic dysfunction. METHODS A retrospective chart review was performed on all proximal humerus fractures in a 3-year period (2012-2015) at a level one trauma center. Isolated greater tuberosity fractures (OTA 11-A1) were excluded. Fracture displacement was measured on initial injury AP shoulder radiograph and expressed as a percentage of humeral diaphyseal width. All orthopedic inpatient documentation was assessed to identify clinical neurologic deficits. RESULTS We identified 139 patients for inclusion. There were 22 patients (16%) with new neurologic deficits at presentation (8 axillary nerve, 2 radial nerve, 12 infraclavicular brachial plexus or multiple nerve injuries). The average shaft medial displacement in patients with neurologic injuries was 59% vs. 21% without nerve deficits (p=0.03). Using a 40% medial displacement threshold, the odds ratio for a nerve injury was 5.24 (95% CI 1.54 - 17.77, p=.008). CONCLUSION Increased medial displacement of the humeral shaft following proximal humerus fracture is associated with an increased incidence of nerve injury at the time of initial presentation. This finding is not meant to be a surrogate for a high-quality neurologic exam in all patients with proximal humerus fractures. However, improved knowledge of the specific risk factors for an occult neurologic injury will improve the clinician's ability to accurately diagnose and properly treat proximal humerus fractures and their sequelae.Level of Evidence: III.
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Affiliation(s)
- Brandon K. Couch
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Patrick L. Maher
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Mitchell S. Fourman
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Gele B. Moloney
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Peter A. Siska
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ivan S. Tarkin
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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