Publications by authors named "Ijezie Ikwuezunma"

8 Publications

  • Page 1 of 1

Surgical Evaluation and Management of Spinal Pathology in Patients with Connective Tissue Disorders.

Neurosurg Clin N Am 2022 Jan;33(1):49-59

Pediatric Orthopaedics, Johns Hopkins Medical Institutions, Baltimore, MD 21287, USA. Electronic address:

Connective tissue disorders represent a varied spectrum of syndromes that have important implications for the spine deformity surgeon. Spine surgeons must be aware of these diverse and global manifestations of disease because they have significant impact on perioperative and postoperative outcomes.
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http://dx.doi.org/10.1016/j.nec.2021.09.005DOI Listing
January 2022

Patient-reported outcomes after operative versus nonoperative treatment of pediatric lateral humeral condyle fractures.

Medicine (Baltimore) 2021 Oct;100(41):e27440

Department of Orthopaedic Surgery, The Johns Hopkins Hospital, 601 N. Caroline Street, Baltimore, MD.

Abstract: Lateral humeral condyle fractures in children are treated with several approaches, yet it is unclear which has the best treatment outcomes. We hypothesized that functional outcomes would be equivalent between treatment types, reduction approaches, and fixation types. Our purpose was to assess patient-reported outcomes and complications by treatment type (operative versus nonoperative), reduction approach (open versus percutaneous), and fixation type (cannulated screws versus Kirschner wires).We retrospectively reviewed data from acute lateral humeral condyle fractures treated at our level-1 pediatric trauma center from 2008 to 2017. Patients were included if they were 8 years or older and had completed clinical follow-up. Fractures were categorized by fracture severity as mild (<2-mm displacement), moderate (isolated, 2- to 5-mm displacement), or severe (isolated, >5-mm displacement or >2-mm displacement with concomitant elbow dislocation or other elbow fracture). We extracted data on patient age, sex, treatment type, reduction approach, fixation type, patient-reported outcomes (shortened Disabilities of the Arm, Shoulder, and Hand and Patient Reported Outcome Measurement Information System upper extremity), treatment complications, and follow-up duration. Patients in the operative versus nonoperative group and across fracture severity subgroups did not differ significantly by age, sex, or follow-up duration. Bivariate analysis was performed to determine whether outcomes differed by intervention. Alpha = 0.05.No differences were observed in patient-reported outcomes between operative versus nonoperative groups for the mild and severe fracture subgroups. No differences were observed between approach (open versus percutaneous) or instrumentation (cannulated screw versus Kirschner wire fixation) for any outcome measure within the operative group. Patients whose fractures were stabilized with screws versus wires had significantly higher rates of return to the operating room (94% versus 8.3%, P < .001). The overall complication rate for our cohort was low, with no differences by treatment type or fracture severity.In our cohort, patient-reported outcomes were similar across fracture severity categories, irrespective of treatment or fixation type. Patients who underwent internal fixation with cannulated screws experienced significantly higher rates of return to the operating room compared with those treated with Kirschner wires but otherwise had similar complication rates and patient-reported outcomes.Level of Evidence: 3.
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http://dx.doi.org/10.1097/MD.0000000000027440DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8519235PMC
October 2021

Spinal Fusion with Sacral Alar Iliac Pelvic Fixation in Severe Neuromuscular Scoliosis.

JBJS Essent Surg Tech 2021 Jul-Sep;11(3). Epub 2021 Aug 16.

Department of Pediatric Orthopaedics, Johns Hopkins University, Baltimore, Maryland.

Neuromuscular scoliosis is characterized by rapid progression of curvature during growth and may continue to progress following skeletal maturity. Posterior spinal fusion in patients with cerebral palsy and severe scoliosis results in substantial improvements in health-related quality of life. Correction of pelvic obliquity can greatly improve sitting balance, reduce pain, and decrease skin breakdown. The sacral alar iliac (SAI) technique has key advantages over prior techniques, including the Galveston and iliac-screw techniques. The SAI technique eliminates the need for subcutaneous muscle dissection over the iliac crest, does not require the use of connectors from the rod to the iliac screw, and decreases the risk of implant prominence.

Description: We demonstrate how to perform posterior spinal fusion with SAI pelvic fixation in a patient with cerebral palsy. In correcting the scoliosis, we utilize the segmental 3-dimensional technique, which includes compression, distraction, transverse approximation to 1 rod at a time, and derotation around 2 rods. We also demonstrate SAI pelvic fixation with identification of the screw starting point on the lateral-caudal border of the first sacral foramen and trajectory toward the anterior inferior iliac spine.

Alternatives: Nonoperative alternatives include bracing, trunk support, contouring of sitting surfaces (such as wheelchairs), and physical therapy to slow curve progression during growth periods and delay the need for surgical treatment. Decision-making is shared with the family following education about the risks and benefits. Families who are satisfied with the function of the child at baseline should not be persuaded into pursuing surgical treatment.

Rationale: Neuromuscular scoliosis can include difficulty sitting secondary to increased pelvic obliquity, along with poor trunk control and balance. Surgical intervention is considered in patients with curves exceeding approximately 50°, as these curves will often continue to progress even after maturity. In patients with neuromuscular scoliosis, indications for pelvic fixation include pelvic obliquity of >15°, poor control of the trunk as indicated by lack of independent sitting or standing, and location of the apex of the curve in the lumbar spine. SAI screws are utilized as a low-profile option for pelvic fixation to avoid implant prominence and an increased risk of skin breakdown and infection, which are associated with traditional sacroiliac screws.

Expected Outcomes: Miyanji et al. reported quality outcomes in patients with cerebral palsy and Gross Motor Function Classification Scores of ≥4. In that study, caregivers completed a validated disease-specific questionnaire grading the health-related quality of life of the patient preoperatively and at 1, 2, and 5 years postoperatively. Complication data were prospectively collected for each patient and preoperative outcome scores were compared at each of the postoperative time points. Survey scores at 1, 2, and 5 years postoperatively were significantly higher compared with baseline preoperative values.Sponseller et al. compared the 2-year postoperative radiographic parameters of 32 pediatric patients who underwent SAI fixation and 27 patients who underwent pelvic fixation with the sacroiliac technique. Among patients who underwent SAI fixation, the mean correction of pelvic obliquity was 20° ± 11° (70% correction) and the mean Cobb angle 42° ± 25° (67%). Among patients who underwent pelvic fixation with the sacroiliac technique, those values were 10° ± 9° (50%) and 46° ± 16° (60%), respectively. SAI screws provided significantly better pelvic obliquity correction (p = 0.002) but no difference in Cobb correction or complications compared with other traditional techniques.

Important Tips: Family discussion prior to surgical treatment is paramount.Perform preoperative neurologic examination.Examine the cranium carefully for a ventriculoperitoneal shunt or prior cranial reconstruction prior to cranial traction.Transcranial neuromonitoring may be useful. Use descending neural motor evoked potentials when no signals from transcranial monitoring are obtained.Sink the SAI screw until it lines up with the S1 screw. Bury the SAI screw so it is not prominent.Measure rods longer in order to ensure adequate length for compression and distraction in correction of the pelvic obliquity.Use a T-square to verify adequate spinopelvic alignment.Postoperatively, the use of incisional vacuum-assisted closure can decrease soiling in these patients.

Acronyms And Abbreviations: SAI = Sacral alar iliacCP = Cerebral palsyAIS = Adolescent idiopathic scoliosisSMA = Spinal muscular atrophyIONM = Intraoperative neuromonitoringGMFCS = Gross Motor Functional Classification SystemDNMEP = Descending neural motor evoked potentialTXA = Tranexamic acidFFP = Fresh frozen plasmaASIS = Anterior superior iliac spineAIIS = Anterior inferior iliac spinePJK = Proximal junctional kyphosis.
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http://dx.doi.org/10.2106/JBJS.ST.20.00060DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8505341PMC
August 2021

Tranexamic acid use is associated with reduced intraoperative blood loss during spine surgery for Marfan syndrome.

Spine Deform 2021 Oct 5. Epub 2021 Oct 5.

Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N. Caroline Street, JHOC 5223, Baltimore, MD, 21287, USA.

Purpose: The utility of tranexamic acid (TXA) in patients with Marfan syndrome (MFS) is uncertain given associated aberrations within the vasculature and clotting cascade. Therefore, this study aimed to assess the association of TXA use with intraoperative blood loss and allogeneic blood transfusions in patients with MFS who underwent spinal arthrodesis.

Methods: We queried our institutional database for MFS patients who underwent spinal arthrodesis for scoliosis between 2000 and 2020 by one surgeon. We excluded procedures spanning < 4 vertebral levels, those using anterior or combined anterior/posterior approaches, and those involving growing rods, postoperative infection, or spondylolisthesis. Fifty-two patients met our criteria, of whom 22 were treated with TXA and 30 were not. Mean differences in blood loss, transfusion volume, and proportions receiving transfusion were compared between TXA and the control groups using Student t, chi-squared, or Fisher exact tests. Alpha = 0.05.

Results: MFS patients treated with TXA experienced less mean (± standard deviation) intraoperative blood loss (1023 ± 534 mL) compared to the control group (1436 ± 1022 mL) (p = 0.01). The TXA group had estimated blood volume loss of 27% ± 16% compared to 36% ± 21% for controls (p = 0.05). No differences were found in allogeneic transfusion rate (p = 0.66) or transfusion volume (p = 0.15).

Conclusions: We found an association between TXA use and reduced blood loss during surgical treatment of MFS-associated scoliosis, suggesting that the connective tissue deficiency in MFS does not interfere with TXA's mechanism of action.

Level Of Evidence: III.
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http://dx.doi.org/10.1007/s43390-021-00416-1DOI Listing
October 2021

Arthroscopic Posterior Capsulotomy for Knee Flexion Contracture Using a Spinal Needle.

Arthrosc Tech 2021 Aug 13;10(8):e1903-e1907. Epub 2021 Jul 13.

Department of Orthopaedic Surgery, Johns Hopkins University Hospital, Baltimore, Maryland, U.S.A.

Knee flexion contractures can arise from posterior capsule arthrofibrosis secondary to trauma, surgery, or chronic degenerative disease. This leads to limited knee extension and increased mechanical stress on the contralateral joint. Depending on the severity of the contracture, a treatment option may include surgical release of the posterior capsule. Arthroscopic posterior capsular release has been reported previously to have excellent resolution of extension deficits with minimal risk of postoperative complications. These techniques typically use an array of instruments, including shavers, biters, or scissors to perform arthrolysis of the posteromedial and posterolateral capsules. Our primary objective is to present a modified arthroscopic surgical technique for percutaneous treatment of knee flexion contracture using a spinal needle to perform a posterior capsule release.
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http://dx.doi.org/10.1016/j.eats.2021.04.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8355179PMC
August 2021

Cost-utility Analysis Comparing Bracing Versus Observation for Skeletally Immature Patients with Thoracic Scoliosis.

Spine (Phila Pa 1976) 2021 Dec;46(23):1653-1659

Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.

Study Design: Cost-utility analysis.

Objective: This study aimed to investigate the cost-utility of bracing versus observation in patients with thoracic scoliosis who would be indicated for bracing.

Summary Of Background Data: There is high-quality evidence that bracing can prevent radiographic progression of spinal curvature in adolescent idiopathic scoliosis (AIS) patients with curves between 25° and 40° and Risser 0 to 2 skeletal maturity index. However, to our knowledge, the cost-utility of bracing in AIS has not been established.

Methods: A decision-analysis model comparing bracing versus observation was developed for a hypothetical 10-year old girl (Risser 0, Sanders 3) with a 35° main thoracic curve. We estimated the probability, cost, and quality-adjusted life years (QALY) for each node based on comprehensive review of the literature. Costs were adjusted for inflation based on Consumer Price Index and reported in terms of 2020 real dollars. Incremental net monetary benefit (INMB) was calculated based on a probabilistic sensitivity analysis using Monte Carlo simulations of 1000 hypothetical patients. One-way sensitivity analyses were performed by varying cost, probability, and QALY estimates.

Results: Our decision-analysis model revealed that bracing was the dominant treatment choice over observation at $50,000/QALY willingness to pay threshold. In simulation analysis of a hypothetical patient cohort, bracing was associated with lower net lifetime costs ($60,377 ± $5,340 with bracing vs. $85,279 ± $4543 with observation) and higher net lifetime QALYs (24.1 ± 2.0 with bracing vs. 23.9 ± 1.8 with observation). Bracing was associated with an INMB of $36,093 (95% confidence interval $18,894-$55,963) over observation over the patient's lifetime. The model was most sensitive to the impact of bracing versus observation on altering the probability of requiring surgery, either as an adolescent or an adult.

Conclusion: Cost-utility analysis supports scoliosis bracing as the preferred choice in management of appropriately indicated AIS patients with thoracic scoliosis.Level of Evidence: 5.
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http://dx.doi.org/10.1097/BRS.0000000000004189DOI Listing
December 2021

Case of the Missing Vertebra: A Report of a Radiographic Stitching Error in a Scoliosis Patient.

JBJS Case Connect 2021 07 6;11(3). Epub 2021 Jul 6.

Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland.

Case: A 14-year-old girl with adolescent idiopathic scoliosis underwent imaging in preparation for scoliosis surgery. Posteroanterior traction radiographs showed 4 lumbar vertebrae, while the standing film showed 5. Reconciliation with the component radiographs used for the traction showed the discrepancy was caused by a software error. She underwent surgical correction, and her recovery has been uncomplicated.

Conclusion: Image stitching errors can lead to false depiction of structural abnormalities. Radiology technicians and clinicians should be cautious when reviewing digitally stitched images. We recommend that technicians label stitched images and indicate the overlapping region to assist with radiographic assessment.
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http://dx.doi.org/10.2106/JBJS.CC.21.00295DOI Listing
July 2021

Using Predictive Modeling and Supervised Machine Learning to Identify Patients at Risk for Venous Thromboembolism Following Posterior Lumbar Fusion.

Global Spine J 2021 May 26:21925682211019361. Epub 2021 May 26.

Department of Orthopaedic Surgery, 1501The Johns Hopkins Hospital, Baltimore, MD, USA.

Study Design: Retrospective review.

Objective: To use predictive modeling and machine learning to identify patients at risk for venous thromboembolism (VTE) following posterior lumbar fusion (PLF) for degenerative spinal pathology.

Methods: Patients undergoing single-level PLF in the inpatient setting were identified in the National Surgical Quality Improvement Program database. Our outcome measure of VTE included all patients who experienced a pulmonary embolism and/or deep venous thrombosis within 30-days of surgery. Two different methodologies were used to identify VTE risk: 1) a novel predictive model derived from multivariable logistic regression of significant risk factors, and 2) a tree-based extreme gradient boosting (XGBoost) algorithm using preoperative variables. The methods were compared against legacy risk-stratification measures: ASA and Charlson Comorbidity Index (CCI) using area-under-the-curve (AUC) statistic.

Results: 13, 500 patients who underwent single-level PLF met the study criteria. Of these, 0.95% had a VTE within 30-days of surgery. The 5 clinical variables found to be significant in the multivariable predictive model were: age > 65, obesity grade II or above, coronary artery disease, functional status, and prolonged operative time. The predictive model exhibited an AUC of 0.716, which was significantly higher than the AUCs of ASA and CCI (all, < 0.001), and comparable to that of the XGBoost algorithm ( > 0.05).

Conclusion: Predictive analytics and machine learning can be leveraged to aid in identification of patients at risk of VTE following PLF. Surgeons and perioperative teams may find these tools useful to augment clinical decision making risk stratification tool.
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http://dx.doi.org/10.1177/21925682211019361DOI Listing
May 2021
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