Pediatric fellow Chad Crigger details what we have learned from looking back on pelvic osteotomy in classic bladder exstrophy and cloacal exstrophy as well as the impact for care. This is based on research from the Brady Urological Institute’s Division of Pediatric Urology at the Johns Hopkins Children’s Center. To refer a patient, please visit
hopkinsmedicine.org/urology or call 410-955-6108.
Sholklapper TN, Crigger C, Haney N, Khandge P, Wu W, Sponseller PD, Gearhart JP. Orthopedic complications after osteotomy in patients with classic bladder exstrophy and cloacal exstrophy: a comparative study. J Pediatr Urol. 2022 Sep 15:S1477-5131(22)00369-2. doi: 10.1016/j.jpurol.2022.09.005. Epub ahead of print. PMID: 36216696.
Haney NM, Crigger CB, Sholklapper T, Mudalegundi S, Griggs-Demmin A, Nasr IW, Sponseller PD, Gearhart JP. Pelvic osteotomy in cloacal exstrophy: A changing perspective. J Pediatr Surg. 2022 Jul 7:S0022-3468(22)00446-8. doi: 10.1016/j.jpedsurg.2022.06.020. Epub ahead of print. PMID: 35906108. I want to take this opportunity and review some of what we have learned regarding Osteo to me and the classic bladder actually as well as the clinical actually patients. Uh this work is based on two recent publications from our lab and since 1958, we know that public cost economy has played an important role in changing how we approach the closure of actually surgically. We now know that public osteo to me is particularly after three days of life or with wider puke die. Stasi's really helped bring the pelvis together and that takes undue tension off of our abdominal wall and soft tissue closure and allows these patients to heal in a way that will increase the rate of success. Now, initially the first Vietnamese were done from a post your approach. So the baby prone um face down and the pelvis access via that route. And we have come a long way from that. You know, since really the mid 19 nineties, the spawn seller or the combined approach using bilateral poster Elliott cost economies with bilateral anterior nominate Osti. Autumn has become the gold standard for Ostuni closure uh with regard to the bony pelvis. And key to this is application of the external fixation device after surgery, as well as keeping our patients legs and mobile afterwards so that there's as minimal um sheer force and moving of the pelvis as possible. Now, looking at our large database, we were able to identify 122 patients, 47 of whom were closed here at Johns Hopkins. And we found that the use of Ost Iata me nationally increased over time from 1960 up through 19 through 2020. Excuse me. And that beginning really in the 1990s that sponsor approach that combined aussie artemis approaches in the poster and interior aspects of the pelvis at the same time really began to take off. And we found that really the reason for this was a success rate. Using the combined approach compared to the posterior or anterior approach alone uh increases your success by about 30%. Which is really significant as our success rates are now approaching the upper 90% title. And additionally, we have found that the trend for localization of the lower extremities has gone from spica and mummy wraps too. More definitive management such as bucks traction Brian's traction and combination with the external fixation for 4-6 weeks after closure. Now finding that the use of Osteo to me has increased um nationally. We wanted to identify if there was a increase risk in the complications seen as well, particularly between classic ladder extra fee and clinical extra fee. And to do this, we found back in our database 144 patients um and compared their average time closure and found that In the classic bladder execute patients, they were closed at a median of 68 days, whereas the clinical expertise were closed at 597 days um typically and Well, this is not surprising what we did find was that the complication rate was higher than previously reported. Looking at complication rates overall. We found that the complication rate in classic biography was 38% and approached 57% in our clinical patients. And the good news is the most for the most part of these complication rates are grade three or less on the Canadian classification. So they're minor. But it does shed light on the fact that perhaps we're capturing more just because our database goes back uh so long and also captures more data. Uh Looking at orthopedic specific complications when we look at classic versus cortical. Overall there was a 7.5% complication rate but 4% of classic water activities experience in orthopedic complications versus 16% of cool vehicles. And by and large the the majority of these were pinsight infections. So thankfully none of our hardware had to be explained to. None of our hardware itself was infected. But these pin sites did require treatment either with greater um antibiotic use or debridement in the operative theater. And thankfully none of these patients developed osteomyelitis which is a comfort. So really kind of what does this mean? And how can this be used? Looking at this? We think clinically this information is important and helpful to help guide pediatric urologists, not just stateside but internationally um to really push for that combined approach to sponsor Osti Autumn E. As well as immobilization to give your surgical repair the best chances of healing um and being successful, but also when consulting with parents and comforting them. You can, you know, quote the complication rates, but also give them some comfort that by by and large, these complications are gonna be rather minor and can be expected but managed um in a safe way. So thank you for your time.