Long-term outcome after brace treatment of Scheuermann's kyphosis: an observational controlled cohort study.

BACKGROUND: In the literature, there are several papers on Scheuermann's kyphosis. It is a structural deformity of the spine that is characterized by anterior wedging of 5° or more of 3 adjacent thoracic vertebral bodies with kyphosis measuring greater than 45° between T5 and T12. Bracing treatment is able to obtain, during skeletal growth, remodeling of the deformed vertebrae. AIM: The aim of this study was to evaluate the effectiveness of conservative treatment in Scheuermann's kyphosis at a minimum follow-up of 10 years. DESIGN: This is an observational controlled cohort study nested in a prospective clinical on-going database in patients with Scheuermann kyphosis. SETTING: Inpatients and outpatients in Rome. METHODS: From a consecutive series of patients included in a prospective database, we selected 158 patients with thoracic Scheuermann's kyphosis who were treated using an anti-gravity brace: 93 males and 65 females. The mean age at the beginning of the treatment was 14 years. The time bracing prescribed was a max of 20 hours daily and a min of 16 hours daily. Weaning was started when a full recovery of vertebral geometry was seen on a lateral radiograph view or when growing was ended. Radiographical measurements were performed on radiographs from a lateral projection at baseline (t1), at the end of the treatment (t2) and at 10 years of minimum follow-up (t3). To avoid the great variance in the range of curve angles in thoracic kyphosis (TK) that rely on the radiological position, X-rays were performed observing the following position: standing with head straight, arms bent at 45° and hands lightly placed on a support. The anterior wedging angle (Alpha) of the apex vertebra and the degrees of the curve (Cobb methods) were analyzed using statistical analysis. RESULTS: The results from our study showed that in 158 patients with TK curves, the mean Cobb angle was 57.6±6.3 SD at baseline, 43.3±7.8 SD at the end of treatment and 44.49±7.4 SD at ten years of follow-up. The alpha angle was 14.43±2.535 SD at baseline and 8.571±3.589 SD at the end of treatment, and after ten years of follow-up, it was 8.654±3.57 SD. The mean duration of treatment was 28.42±12.07 months, and the mean follow-up was 128.3±11.07 months. The difference between baseline and end of treatment, tested with the one-way ANOVA comparisons test, was significant (P<0.0001) for both Cobb angle and alpha; instead, the difference between the end of treatment and follow-up was not significant (P=0.3277). CONCLUSIONS: The results confirm that conservative treatment in Scheuermann's kyphosis during skeletal growth is effective. Bracing treatment can remodel the deformed vertebrae. CLINICAL REHABILITATION IMPACT: At the 10-year follow-up after bracing, kyphosis curve correction was stable over time.

Is Surface Topography Useful in the Diagnosis of Scoliosis? Validation of the Biometrical Holistic of Human Body (BHOHB).

BACKGROUND: The concern around repeated exposure to X-rays has been motivating doctors involved in scoliosis to seek alternative solutions. Surface topography (ST) analysis is a modern system that has been shown to have good results. The purpose of the study is to validate the new BHOHB hardware for the investigation of scoliosis in adolescents by comparing it to X-ray examinations and to assess the reliability of intraoperator and interoperator tests. METHODS: Ninety-five patients were enrolled in our study. All the patients were analyzed via the BHOHB method 2 times by 2 independent physicians (t0) and for a second time 2 or 3 months later (t1). The Pearson correlation coefficient was used to evaluate the relationship between the measurements obtained by BHOHB and the gold standard. The intraclass correlation coefficient (ICC) was used to assess intra- and interoperator reliability. Statistical analysis was performed with the GraphPad Prism 8 software. RESULTS: The correlations between the first and second operators in the measurements and between the BHOHB method and X-ray showed a very good to excellent r for both. A very good correlation was also confirmed for prominence measured by operators and by the BHOHB machine. Intra- and interoperator reliability was found to be very positive for both the first and the second physicians. CONCLUSIONS: We can state that ST can be useful for diagnosing and treating scoliosis. The recommendation is to use it primarily to evaluate the evolution of the curve, as in this mode, you can reduce the patient's exposure to X-rays. The results indicate that BHOHB measures are comparable to radiographs and not influenced by the operator.

Superficial peroneal nerve entrapment in ankle sprain in childhood and adolescence.

Traumatic injuries of the ankle are the most common injuries in sports. Up to 40% of patients who have undergone inversion ankle sprain report residual symptoms. The primary purpose of the study is to evaluate the incidence of SPN entrapment as consequence of acute severe inversion ankle sprain in children and adolescents; the secondary is to report the diagnostic pathway and the results after surgical treatment. From 2000 to 2015 were reviewed to summarize patients under the age of 15 years treated for a first episode of severe inversion ankle sprain. Cases with persistent symptoms (more than 3 months) indicative for SPN neuropathy were then identified. Instrumental investigations were recovered and a pre-operative assessment of pain (VAS) was recorded. Patients were evaluated at minimum of 1-year post-operative follow-up. 981 acute ankle sprains have been evaluated. 122 were considered severe according to van Dijk criteria. 5 patients were considered affected by neuropathy of the SPN. All patients underwent surgery consisting in neurolysis and capsular retention and ligament reconstruction. At 25 months of follow-up AOFAS moved from 57.6 to 98.6. The study highlights a previously unreported condition of perineural fibrosis of the superficial peroneal nerve at the level of the ankle following first acute severe inversion ankle sprain in children.

Long-term results after brace treatment with Progressive Action Short Brace in adolescent idiopathic scoliosis.

BACKGROUND: In the literature, there are few papers on long-term results after brace treatment and there is no consensus on whether scoliotic curves stop progressing at skeletal maturity. To date the factors that could influence curve behaviour following bracing have not been fully determined. AIM: The aim of this study was to evaluate the results and the loss of the scoliotic curve correction in a cohort of patients treated with Progressive Action Short Brace (PASB) brace during adolescence and to compare patient outcomes of under and over 30 Cobb degrees 10 years after brace removal. DESIGN: This is an observational controlled cohort study nested in a prospective clinical on-going database including 1536 patients with idiopathic scoliosis. SETTING: Inpatients and outpatients in Rome. POPULATION: The study enrolled 163 patients with idiopathic adolescent scoliosis who had been treated with the PASB brace at a 10 years minimum long-term follow-up examination. METHODS: One hundred sixty-three (female) patients with adolescent idiopathic scoliosis (AIS) treated with the Progressive Action Short Brace (PASB) at a mean age of 13.4 years (range 10-34) had accepted to undergo long-term follow-up examination. All patients had clinical and radiological examinations, but only 62 replied to some simple questions (including work status, pregnancy and pain) the population was divided into two groups based on Cobb degrees (< 30° and ≥ 30°). Statistical analysis was applied to test the efficacy of our hypothesis. RESULTS: The patients underwent a long-term follow-up after brace removal at a mean age of 13.46 years (±3.4). The prebrace mean curve was 28.98° (±7.918); after treatment, the mean was 13.88° and increased to a minimum of 15.35° in the 10 years following brace removal. However, there was no significant difference between the mean Cobb angle at the end of weaning and the mean Cobb angle at long-term follow-up. The curve angle at baseline of patients who were treated with a brace was reduced by 15° during the treatment, but at follow-up the curve size was found to have lost 2°. The over 30° group showed a prebrace scoliotic mean curve of 37.26°; at the end of weaning, the mean curve angle was 22.98° which increased to a mean of 25.07° at follow-up. The <30° group showed a prebrace scoliotic mean curve of 24.40° which, at the end of weaning, had reduced to a mean of 8.69°, increasing to 9.98° at follow-up. There was no significant difference in the mean progression of curve magnitude between the ˂ 30° and ≥ 30° groups at the long-term follow-up. Work status was 62% full-time and 11% part-time. 24% had given birth. Three percent presented back pain related to instability of the spine. No patients underwent surgery after maturity but one patient had indication to surgical treatment. CONCLUSIONS: The PASB brace is effective for the treatment of lumbar and thoracolumbar scoliosis and is characterized by positive long-term outcomes, including in patients demonstrating moderate curves. In both groups, at 10-years minimum follow-up after bracing, scoliotic curves did not deteriorate beyond their original curve size after bracing in both groups at the 10-years minimum follow-ups. CLINICAL REHABILITATION IMPACT: At 10 years follow-up after bracing, scoliotic curves had not deteriorated beyond their original curve size.

Bifocal Avulsion of the Patellar Tendon From the Distal Patella and Tibial Tuberosity in a Skeletally Immature Patient: A Case Report.

CASE: A 13-year-old boy suffered a sports injury of the right knee. The clinical examination showed swelling, inability to bear weight, and pain involving the inferior apex of the patella and the anterior tibial tuberosity. Imaging studies showed an avulsion fracture, sleeve-like, from the patella apex and avulsion of the tibial tuberosity. The patient underwent open reduction and internal fixation. At the 24-month follow-up, no pain, limitation, or complication was reported. CONCLUSIONS: Bifocal patellar tendon avulsion in a skeletally immature patient is an extremely rare injury, and to our knowledge, only one case is reported.

Effectiveness of school scoliosis screening and the importance of this method in measures to reduce morbidity in an Italian territory.

Although several procedures for treating scoliosis have been developed, the most effective treatment is still based on early detection. For early diagnosis of idiopathic scoliosis, many authors have proposed methods of school screening; however, there is still no standardized screening program. The aim of this study was to evaluate a school screening method and the prevalence and distribution of scoliosis in Italian school children, aged 9-14 years, and to determine if the screening method can reduce morbidity in an Italian territory. The screening program consisted of three steps: the first step was a clinical examination carried out by the school physician and two specialists. In the second step, doubtful cases (presence of a hump between the two sides of the torso, in the thoracic or thoracolumbar region, measured using a hump meter) were evaluated by an orthopedic specialist and subsequently controlled every 6 months either clinically or by radiographic examination. The third step was the classification of the scoliosis and procedures for treatment. All patients were scheduled for a follow-up program and were evaluated during the subsequent 3 years. Statistical analyses were performed with GraphPad Prism 6. A total of 8995 children were screened for scoliosis. Of these, 487 showed clinical signs of scoliosis, and 181 were referred for anteroposterior radiographs because of a positive result on the forward-bending test (hump>5 mm). No significant statistical difference was observed by the three clinical examiners. Of the 181 patients who were referred, 69 were radiographed, and the clinical diagnosis was confirmed in 94.2% of the cases. The prevalence of scoliosis (defined as a curve of ≥10°) was 0.76% (65 of 8995 children), and most of the curves (44; prevalence 67.69%) were small (<20°). The overall ratio of boys to girls was 1 : 3.3, but varied according to the magnitude of the curve (1 : 3 for curves of <20°, 1 : 3.25 for curves of 20-29°, and 1 : 4 for curves of ≥30°). Double curves were the most common type identified, followed by thoracolumbar curves; specifically, of the 65 children who had a curve, 21 (32.30%) had a double curve, 18 (27.6%) had a thoracolumbar curve, 17 (26.1%) had a lumbar curve, and nine (13.84%) had a thoracic curve. In the following 3 years, only four patients were found to have curves more than 20° and none more than 30°. Our results show that the school screening program was accurate and repeatable. Moreover, screening children for scoliosis using a simple test appears to be an effective means of early detection. Above all, the screening process effectively decreased morbidity in the territory at a negligible cost.

Brace treatment of Idiopathic Scoliosis is effective for a curve over 40 degrees, but is the evaluation of Cobb angle the only parameter for the indication of treatment?

BACKGROUND: The recent literature showed positive results for bracing of patients with idiopathic scoliosis above 45° who refused surgery. However, no one has investigated whether other parameters can affect the results. AIM: The aim of this study was to evaluate the effectiveness of bracing in idiopathic scoliosis with curves above 40° and to verify the mechanical and biological parameters which go beyond the simple bend value expressed in Cobb degrees. DESIGN: This is an observational controlled cohort study nested in a prospective clinical on-going database including 1,238 patients with idiopathic scoliosis. SETTING: Inpatients and outpatients in Rome. POPULATION: The study enrolled 160 patients with idiopathic scoliosis with curves above 40°. METHODS: This is a prospective study based on an ongoing database including 1,238 patients with idiopathic scoliosis. The patients studied had idiopathic scoliosis with curves of 40° or more, Risser grade 0-4, and had refused any surgical treatment. 160 patients met the inclusion criteria. Of these, 104 patients had a definite outcome, 28 abandoned treatment and 28 are currently under treatment. The minimum duration of follow-up was 24 months. X-rays were used to obtain Cobb degrees and torsion of the apical vertebrae (Perdriolle's method). Three outcomes were distinguished according to SRS-SOSORT criteria: correction, stabilization and progression. To achieve the second aim, we divided the sample into subgroups according to Cobb degrees (<45°; ≥45°), Risser (0-2; 3-4) and rotation (<20; ≥20). Furthermore, logistic regression was applied by Stepwise Regression. RESULTS: The results of our study showed that in 104 patients with a definite outcome the Cobb mean value was initially 47±5.25 SD and 34.19 ±8.45 SD at follow-up. Perdriolle was initially 20.04±5.53 SD and 16.76±7.04 at follow-up. Overall, 81 patients (78%) obtained a curve correction, and stabilization was achieved in 14 cases (13%). Nine patients experienced curve progression (9%), 16 patients were recommended for surgery because the curve at follow up was over 45°. The analysis of subgroups shows that with Cobb <45° at baseline, the average reduction was 11.46° Cobb, while in cases with Cobb ≥45 at baseline, the mean correction was 13.74° Cobb. In subgroups with Perdriolle <20° at baseline, the average reduction was 16.02° Cobb, while in cases with Perdriolle ≥20° at baseline, the mean correction was 8.4° Cobb. In subgroups with Risser 0-2 at baseline, the average reduction was 14.7° Cobb, while in cases with Risser 3-4 at baseline, the mean correction was 6.7° Cobb. The logistic regression model shows significance for the initial value of Perdriolle and Risser. CONCLUSIONS: Our results indicate that an adequate conservative treatment must definitely be considered for patients with scoliotic curves who refuse surgery; the results will be better particularly if the rotation is lower than 20 and Risser is between 0-2. CLINICAL REHABILITATION IMPACT: With the simultaneous evaluation of the Cobb angle, the vertebral rotation and the potential vertebral growth, it was possible to predict the final results at the start of treatment.

Fixation in slipped capital femoral epiphysis avoiding femoral-acetabular impingement.

BACKGROUND: The appropriate treatment in mild slipped capital femoral epiphysis (SCFE) should not only prevent further slipping of the epiphysis but also address potential femoroacetabular impingement by restoring the anatomy of the proximal femur. The aim of this study was to quantify length of the remodeling phase mediated by growth of the femoral neck, after treatment of SCFE with a screw designed to prevent premature closure of the physis and provide stability. METHODS: Between 2001 and 2011, 38 patients with unilateral mild SCFE were treated by fixation in situ using a modified screw which does not cause premature physeal arrest. Twenty-four patients were investigated for clinical and radiological evidence of femoroacetabular impingement immediately after surgery, at 6- and 12-month follow-ups. Statistical analysis was performed comparing measurements of neck length and the α angle of the affected and contralateral side. RESULTS: Mean α angle immediately after pinning was 56.2 ± 10.6° on the anteroposterior view and 91.4 ± 8.2° on the lateral view. These measurements significantly improved at 6 months post-op to 48.9 ± 5.4° on the anteroposterior view and 51.2 ± 6.5° on the lateral view (p < 0.0001). At 12 months from surgery, AP view α angle was 43.0 ± 2.8° (p < 0.0001) and lateral view was 44.2 ± 4.1° (p < 0.0001). We observed a similar growth rate and speed of the femoral neck of both the affected and unaffected sides during the first year of treatment. The clinical results in all patients were rated as excellent. CONCLUSION: Our data supports the use of a surgical technique that allows residual growth of the femoral neck following mild SCFE and permits restoration of the anatomy of the proximal femur while avoiding development of femoroacetabular impingement following mild SCFE.

Curve progression after long-term brace treatment in adolescent idiopathic scoliosis: comparative results between over and under 30 Cobb degrees - SOSORT 2017 award winner.

BACKGROUND: The factors influencing curve behavior following bracing are incompletely understood and there is no agreement if scoliotic curves stop progressing with skeletal maturity. The aim of this study was to evaluate the loss of the scoliotic curve correction in patients treated with bracing during adolescence and to compare patient outcomes of under and over 30 Cobb degrees, 10 years after brace removal. METHODS: We reviewed 93 (87 female) of 200 and nine patients with adolescent idiopathic scoliosis (AIS) who were treated with the Lyon or PASB brace at a mean of 15 years (range 10-35). All patients answered a simple questionnaire (including work status, pregnancy, and pain) and underwent clinical and radiological examination. The population was divided into two groups based on Cobb degrees (< 30° and > 30°). Statistical analysis was performed to test the efficacy of our hypothesis. RESULTS: The patients underwent a long-term follow-up at a mean age of 184.1 months (±72.60) after brace removal. The pre-brace scoliotic mean curve was 32.28° (± 9.4°); after treatment, the mean was 19.35° and increased to a minimum of 22.12° in the 10 years following brace removal. However, there was no significant difference in the mean Cobb angle between the end of weaning and long term follow-up period (p = 0.105). The curve angle of patients who were treated with a brace from the beginning was reduced by 13° during the treatment, but the curve size lost 3° at the follow-up period.The groups over 30° showed a pre-brace scoliotic mean curve of 41.15°; at the end of weaning, the mean curve angle was 25.85° and increased to a mean of 29.73° at follow-up; instead, the groups measuring ≤ 30° showed a pre-brace scoliotic mean curve of 25.58°; at the end of weaning, it was reduced to a mean of 14.24° and it increased to 16.38° at follow-up.There was no significant difference in the mean progression of curve magnitude between the ≤ 30° and > 30° groups at the long-term follow-up. CONCLUSIONS: Scoliotic curves did not deteriorate beyond their original curve size after bracing in both groups at the 15-year follow-ups. These results are in contrast with the history of this pathology that normally shows a progressive and lowly increment of the curve at skeletal maturity. Bracing is an effective treatment method characterized by positive long-term outcomes, including for patients demonstrating moderate curves.

Conservative treatment in Scheuermann's kyphosis: comparison between lateral curve and variation of the vertebral geometry.

BACKGROUND: Conservative treatment in the Scheuermann's kyphosis obtain, during skeletal growth, remodelling of the deformed vertebras. In a previous paper on Scheuermann's kyphosis, we have studied the geometry variations of all vertebrae included in the curve, before and after the treatment. The purpose of this study was to confirm the effectiveness of conservative treatment in Scheuermann's kyphosis and was to evaluate and compare the variation of the vertebral geometry with the curve trend in Cobb degrees, before and after conservative treatment. METHODS: From a consecutive series of patients, we selected 90 patients with thoracic Scheuermann's kyphosis, treated using anti-gravity brace: 59 male, 31 female. The mean age at the beginning of the treatment was 14 years. Radiographical measurements were performed on radiographs from a lateral projection, at the beginning (t1) and at the end of the treatment (t5). Vertebral geometry modifications at t1 and t5 were analysed according to the following parameters and evaluated by three independent observers: Anterior wedging angle (ALFA) of the apex vertebra and Posterior wall inclination (APOS) of the limiting lower vertebra. The curve was measured in Cobb degrees. RESULTS: The results from our study showed that of the 90 patients with a thoracic curve mean value of Cobb degrees was 57.8 ± 6.0 SD at t1 and 41.3 ± 5.6 SD at t5. The differences between t1(angle at baseline) and t5 (end of treatment) were calculated for Cobb, ALFA and APOS angle and were respectively -16.4 ± 4.5, -6.4 ± 1.4 and -2.7 ± 1.2; tested with paired t-test were significative (p < 0.01). The results of the regression analysis to test the relationship between the three measures for the kyphosis (Cobb degree, ALFA and APOS) showed that the best association was between Cobb t5 and ALFA t5 (p < 0.01) and Cobb t1 and APOS t1 (p < 0.01). No significative association was found between the difference between ALFA and APOS. CONCLUSION: We sustain that using new parameters to study vertebral remodelling allows us to reach a better comprehension of Scheuermann spine response to anti-gravity brace treatment. Furthermore, the evaluation of the ALFA angle of the apex vertebra confirms to be more reliable than Cobb's angle because it cannot be affected by the radiological position.

Lyon bracing in adolescent females with thoracic idiopathic scoliosis: a prospective study based on SRS and SOSORT criteria.

BACKGROUND: The Lyon brace is commonly prescribed in many European countries to patients with thoracic curves and is based on the three-point pressure system. The purpose of this study was to evaluate the efficacy of Lyon bracing for the conservative treatment of adolescent females with idiopathic thoracic curves in a case series selected on the basis of the Scoliosis Research Society (SRS) Committee on Bracing and Nonoperative Management Standardization Criteria and followed the guidelines on management of idiopathic scoliosis with corrective braces, proposed by the International Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT). METHODS: Prospective study based on an ongoing database. From 1297 patients treated for idiopathic scoliosis between 1995 and 2014 fulfill the inclusion criteria 102 patients treated with Lyon brace. Of these, 69 patients had a definite outcome, 17 have abandoned treatment e 16 are still in treatment. The 104 patients were adolescent females with curvatures in the thoracic spine and a pre-treatment Risser score ranging from 0 to 2. All patients were prescribed with full-time Lyon bracing. The minimum duration of follow-up was 24 months after the end of weaning (mean: 41.64 ± 31.45 months). Anteroposterior radiographs were used to estimate the curve magnitude (CM) at 5 time points: beginning of treatment (t1), one year after the beginning of treatment (t2), intermediate time between t1 and t4 (t3), end of weaning (t4), 2-year minimum follow-up from t4 (t5). Three outcomes were distinguished: curve correction, curve stabilization and curve progression. RESULTS: The results from our study showed that of the 69 patients with a definite outcome the CM mean value was 31.51° ± 4.34 SD at t1 and 20° ± 7.6 SD at t5. Curve correction was accomplished in 85.5 % of patients, curve stabilization was obtained in 13 % of patients and curve progression was evident in only 1.5 %. None of the patients were recommended surgery post-bracing. Of 17 patients who abandoned the treatment, at the time of abandonment (14.4 age) have achieved curve correction in 13 cases (77 %), stabilization in 53 cases (18 %) and progression in 1 case (5 %). CONCLUSION: The Lyon brace, through its biomechanical action on vertebral modeling, is highly effective in correcting thoracic curves in particularly when the SOSORT guidelines were adopted in addition to the SRS criteria.

Radial neck fractures in children: results when open reduction is indicated.

BACKGROUND: Radial neck fractures in children are rare, representing 5% of all elbow pediatric fractures. Most are minimally displaced or nondisplaced. Severely displaced or angulated radial neck fractures often have poor outcomes, even after open reduction, and case series reported in literature are limited. The aim of the study is to analyze the outcomes of patients with a completely displaced and angulated fracture who underwent open reduction when closed reduction failed. METHODS: Between 2000 and 2009, 195 patients with radial neck fractures were treated in our institute. Twenty-four cases satisfied all the inclusion criteria and were evaluated clinically and radiologically at a mean follow-up of 7 years. At follow-up, the carrying angle in full elbow extension and the range of motion of the elbow and forearm were measured bilaterally. We recorded clinical results as good, fair, or poor according to the range of movement and the presence of pain. Radiographic evaluation documented the size of the radial head, the presence of avascular necrosis, premature physeal closure, and cubitus valgus. RESULTS: Statistical analysis showed that fair and poor results are directly correlated with loss of pronation-supination (P = 0.001), reduction of elbow flexion-extension (P = 0.001), increase of elbow valgus angle (P = 0.002), necrosis of the radial head (P = 0.001), premature physeal closure (P = 0.01), and associated lesions (olecranon fracture with or without dislocation of the elbow) (P = 0.002). DISCUSSION: In our cases, residual radial head deformity due to premature closure of the growth plate and avascular necrosis were correlated with a functional deficit. Associated elbow injury was coupled with a negative prognosis. In our series, about 25% of patients had fair and 20% had poor results. Outcomes were good in 55% and felt to represent a better outcome than if the fracture remained nonanatomically reduced with residual angulation and/or displacement of the radial head. This study reports the largest series of these fractures with a combination of significant angulation and displacement of the fracture requiring open reduction. We feel that open reduction is indicated when the head of the radius is completely displaced and without contact with the rim of the metaphysis.

Correlation between compliance and brace treatment in juvenile and adolescent idiopathic scoliosis: SOSORT 2014 award winner.

BACKGROUND: Over the last years, evidence has accumulated in support of bracing as an effective treatment option in patients with idiopathic scoliosis. Yet, little information is available on the impact of compliance on the outcome of conservative treatment in scoliotic subjects. The aim of the present study was to prospectively evaluate the association between compliance to brace treatment and the progression of scoliotic curve in patients with idiopathic adolescent (AIS) or juvenile scoliosis (JIS). METHODS: Among 1.424 patients treated for idiopathic scoliosis, 645 were eligible for inclusion criteria. Three outcomes were distinguished in agreement with the SRS criteria: curve correction, curve stabilization and curve progression. Brace wearing was assessed by one orthopaedic surgeon (LA) and scored on a standardized form. Compliance to treatment was categorized as complete (brace worn as prescribed), incomplete A (brace removed for 1 month), incomplete B (brace removed for 2 months), incomplete C (brace removed during school hours), and incomplete D (brace worn overnight only). Chi square test, T test or ANOVA and ANOVA for repeated measures tests were used as statistical tests. RESULTS: The results from our study showed that at follow-up the compliance was: Complete 61.1%; Incomplete A 5.2%; Incomplete B 10.7%; Incomplete C 14.2%; Incomplete D 8.8%. Curve correction was accomplished in 301/319 of Complete, 19/27 Incomplete A, 25/56 Incomplete B, 52/74 Incomplete C, 27/46 Incomplete D. Cobb mean value was 29.8 ± 7.5 SD at beginning and 17.1 ± 10.9 SD at follow-up. Both Cobb and Perdriolle degree amelioration was significantly higher in patients with complete compliance over all other groups, both in juvenile, both in adolescent scoliosis. In the intention-to-treat analysis, the rate of surgical treatment was 2.1% among patients with definite outcome and 12.1% among those with drop-out. Treatment compliance showed significant interactions with time. CONCLUSION: Curve progression and referral to surgery are lower in patients with high brace compliance. Bracing discontinuation up to 1 month does not impact on the treatment outcome. Conversely, wearing the brace only overnight is associated with a high rate of curve progression.

Brace treatment in juvenile idiopathic scoliosis: a prospective study in accordance with the SRS criteria for bracing studies - SOSORT award 2013 winner.

BACKGROUND: The Juvenile idiopathic scoliosis by age of onset, severity and evolutivity is source of great doubts concerning the purpose and use of conservative treatment. The different clinical experiences leave unsolved the question that arises in applying a conservative treatment when the patients are effectively forward a long growing period, in scoliosis characterized by inevitable evolutivity. The purpose of the present prospective study was to determine the effectiveness of conservative treatment in Juvenile idiopathic scoliosis. METHODS: From 1238 patients treated for idiopathic scoliosis between 1995 and 2012 fulfill the inclusion criteria 163 patients treated with PASB, Lyon brace and Milwaukee. Of these, 113 patients had a definite outcome, 27 have abandoned treatment e 23 are still in treatment. The minimum follow-up was 24 months. Radiographs were used to estimate the curve magnitude (CM) and the torsion of the apical vertebra (TA) at 5 time points: beginning (t1), 6 months after the beginning (t2), intermediate time between t1 and t4 (t3), end of weaning (t4), 2-years minimum follow-up (t5). Three outcomes were distinguished in agreement with SRS criteria: correction, stabilization and progression. RESULTS: The results from our study showed that of the 113 patients with a definite outcome CM mean value was 29.6 ± 7.5 SD at t1 and 16.9 ± 11.1 SD at t5. TA was 13.5 ± 5.4 SD at t1 and 8.5 ± 5.6 at t5. The variations between CM t5-t1 and TA t5-t1 were statistically significantly different. Curve correction was accomplished in 88 patients (77.8%), stabilization was obtained in 18 patients (15.9%). 7 patients (6.19%) have a progression and 4 of these were recommended for surgery. Of 26 patients who abandoned the treatment, at the time of abandonment (12.5 age) have achieved curve correction in 19 cases (70.0%), stabilization in 5 cases (19%) and progression in 3 cases (11%). Of these patients, reviewed at the end of growing, four have been operated on. CONCLUSIONS: Our study confirmed that conservative treatment with brace is highly effective in treating juvenile idiopathic scoliosis, in particular most patients reaching a complete curve correction and only 4.9% of patients need surgery.

Validation of Italian version of Brace Questionnaire (BrQ).

BACKGROUND: Brace questionnaire (BrQ) is a tool used to evaluate Health Quality of Life (HRQoL) in patients with Adolescent Idiopathic Scoliosis (AIS) that undergo bracing treatment. The BrQ has not been translated and validated for Italian-speaking patients with AIS. The aim of the study was to perform a trans-cultural validation of BrQ to be used in an Italian speaking population. METHODS: Translation into Italian (I-BrQ) and back translation to the original Greek (G-BrQ) was performed. The final I-BrQ was then analyzed for Italian cultural characteristics and no inconsistencies were found. After that, construct validity was measured analyzing the I-BrQ relationship with 1) Scoliosis Research Society-22 patient Questionnaire (SRS-22), in order to evaluate the relationship with another patient-oriented questionnaire not focused on brace therapy; 2) Cobb degree scale, in order to evaluate the relationship with the magnitude of the curve. Reproducibility was also tested. RESULTS: Translation of the G-BrQ into Italian was successful and back-translation to Greek corresponded well with the original Greek version.Global I-BrQ correlated strongly with SRS-22 (r = 0.826; p < 0.001). Almost all sub scores from each I-BrQ domain strongly correlated with the single domain scores of SRS-22. Only two I-BrQ sub scores weakly inversely correlated with Cobb degree value.Reproducibility was good (Spearman-Brown coefficient value was 0.943; p < 0.05). CONCLUSIONS: Trans-cultural validation in Italian language showed the validity and reliability of the I-BrQ.

Joint line tenderness and McMurray tests for the detection of meniscal lesions: what is their real diagnostic value?

OBJECTIVES: To assess the interobserver concordance of the joint line tenderness (JLT) and McMurray tests, and to determine their diagnostic efficiency for the detection of meniscal lesions. DESIGN: Prospective observational study. SETTING: Orthopedics outpatient clinic, university hospital. PARTICIPANTS: Patients (N=60) with suspected nonacute meniscal lesions who underwent knee arthroscopy. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Patients were examined by 3 independent observers with graded levels of experience (>10y, 3y, and 4mo of practice). The interobserver concordance was assessed by Cohen-Fleiss κ statistics. Accuracy, negative and positive predictive values for prevalence 10% to 90%, positive (LR+) and negative (LR-) likelihood ratios, and the Bayesian posttest probability with a positive or negative result were also determined. The diagnostic value of the 2 tests combined was assessed by logistic regression. Arthroscopy was used as the reference test. RESULTS: No interobserver concordance was determined for the JLT. The McMurray test showed higher interobserver concordance, which improved when judgments by the less experienced examiner were discarded. The whole series studied by the "best" examiner (experienced orthopedist) provided the following values: (1) JLT: sensitivity, 62.9%; specificity, 50%; LR+, 1.26; LR-, .74; (2) McMurray: sensitivity, 34.3%; specificity, 86.4%; LR+, 2.52; LR-, .76. The combination of the 2 tests did not offer advantages over the McMurray alone. CONCLUSIONS: The JLT alone is of little clinical usefulness. A negative McMurray test does not modify the pretest probability of a meniscal lesion, while a positive result has a fair predictive value. Hence, in a patient with a suspected meniscal lesion, a positive McMurray test indicates that arthroscopy should be performed. In case of a negative result, further examinations, including imaging, are needed.

Brace technology thematic series: the progressive action short brace (PASB).

BACKGROUND: The Progressive Action Short Brace (PASB) is a custom-made thoraco-lumbar-sacral orthosis (TLSO), devised in 1976 by Dr. Lorenzo Aulisa (Institute of Orthopedics at the Catholic University of the Sacred Heart, Rome, Italy). The PASB was designed to overcome the limits imposed by the trunk anatomy. Indeed, the particular geometry of the brace is able to generate internal forces that modify the elastic reaction of the spine. The PASB is indicated for the conservative treatment of lumbar and thoraco-lumbar scoliosis. The aim of this article is to explain the biomechanic principles of the PASB and the rationale underlying its design. Recently published studies reporting the results of PASB-based treatment of adolescent scoliotic patients are also discussed. DESCRIPTION AND PRINCIPLES: On the coronal plane, the upper margin of the PASB, at the side of the curve concavity, prevents the homolateral bending of the scoliotic curve. The opposite upper margin ends just beneath the apical vertebra. The principle underlying such configuration is that the deflection of the inferior tract of a curved elastic structure, fixed at the bottom end, causes straightening of its upper tract. Therefore, whenever the patient bends towards the convexity of the scoliotic curve, the spine is deflected. On the sagittal plane, the inferior margins of the PASB reach the pelvitrochanteric region, in order to stabilize the brace on the pelvis. The transverse section of the brace above the pelvic grip consists of asymmetrical ellipses. This allows the spine to rotate towards the concave side only, leading to the continuous generation of derotating moments. On the sagittal plane, the brace is contoured so as to reduce the lumbar lordosis. The PASB, by allowing only those movements counteracting the progression of the curve, is able to produce corrective forces that are not dissipated. Therefore, the brace is based on the principle that a constrained spine dynamics can achieve the correction of a curve by inverting the abnormal load distribution during skeletal growth. RESULTS: Since its introduction in 1976, several studies have been published supporting the validity of the biomechanical principles to which the brace is inspired. In this article, we present the outcome of a case series comprising 110 patients with lumbar and thoraco-lumbar curves treated with PASB brace. Antero-posterior radiographs were used to estimate the curve magnitude (CM) and the torsion of the apical vertebra (TA) at 5 time points: beginning of treatment (t1), one year after the beginning of treatment (t2), intermediate time between t1 and t4 (t3), end of weaning (t4), 2-year minimum follow-up from t4 (t5). The average CM value was 29.3°Cobb at t1 and 13.0°Cobb at t5. TA was 15.8° Perdroille at t1 and 5.0° Perdriolle at t5. These results support the efficacy of the PASB in the management of scoliotic patients with lumbar and thoraco-lumbar curves. CONCLUSION: The results obtained in patients treated with the PASB confirm the validity of our original biomechanical approach. The efficacy of the PASB derives not only from its unique biomechanical features but also from the simplicity of its design, construction and management.

2011 SOSORT guidelines: Orthopaedic and Rehabilitation treatment of idiopathic scoliosis during growth.

BACKGROUND: The International Scientific Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT), that produced its first Guidelines in 2005, felt the need to revise them and increase their scientific quality. The aim is to offer to all professionals and their patients an evidence-based updated review of the actual evidence on conservative treatment of idiopathic scoliosis (CTIS). METHODS: All types of professionals (specialty physicians, and allied health professionals) engaged in CTIS have been involved together with a methodologist and a patient representative. A review of all the relevant literature and of the existing Guidelines have been performed. Documents, recommendations, and practical approach flow charts have been developed according to a Delphi procedure. A methodological and practical review has been made, and a final Consensus Session was held during the 2011 Barcelona SOSORT Meeting. RESULTS: The contents of the document are: methodology; generalities on idiopathic scoliosis; approach to CTIS in different patients, with practical flow-charts; literature review and recommendations on assessment, bracing, physiotherapy, Physiotherapeutic Specific Exercises (PSE) and other CTIS. Sixty-five recommendations have been given, divided in the following topics: Bracing (20 recommendations), PSE to prevent scoliosis progression during growth (8), PSE during brace treatment and surgical therapy (5), Other conservative treatments (3), Respiratory function and exercises (3), Sports activities (6), Assessment (20). No recommendations reached a Strength of Evidence level I; 2 were level II; 7 level III; and 20 level IV; through the Consensus procedure 26 reached level V and 10 level VI. The Strength of Recommendations was Grade A for 13, B for 49 and C for 3; none had grade D. CONCLUSION: These Guidelines have been a big effort of SOSORT to paint the actual situation of CTIS, starting from the evidence, and filling all the gray areas using a scientific method. According to results, it is possible to understand the lack of research in general on CTIS. SOSORT invites researchers to join, and clinicians to develop good research strategies to allow in the future to support or refute these recommendations according to new and stronger evidence.

Determination of quality of life in adolescents with idiopathic scoliosis subjected to conservative treatment.

INTRODUCTION AND OBJECTIVES: Physical deformities caused by adolescent idiopathic scoliosis (AIS) coupled with conservative treatment of AIS with orthesis unavoidably impacts on patients' quality of life (QoL). The present study aimed at evaluating the QoL in patients affected by AIS treated with brace. The study also sought to determine the ability of different QoL questionnaires to monitor QoL over the course of treatment. MATERIALS AND METHODS: Data were collected in 108 consecutive patients (96 females, 16 males) affected by AIS admitted to the outpatient orthopaedic clinic of the Catholic University of the Sacred Heart in Rome (Italy). Patients were subjected to full-time (i.e., 22 hrs per day) conservative treatment with the progressive action short brace (PASB), the Lyon brace or a combination of PASB + Lyon brace. Three instruments were used for QoL determination: the Scoliosis Research Society 22 (SRS-22), Bad Sobernheim Stress Questionnaire (BSSQ) and the Brace Questionnaire (BrQ). RESULTS: A significant correlation was detected among the 3 scores (p < 0.001). The BrQ possesses a higher capacity to detect changes in QoL in relation to the patient gender, type of brace, curve severity at baseline and at the completion of treatment, and curve type. Overall, boys displayed a higher QoL than girls. In all 3 questionnaires, higher QoL scores were determined in patients treated with the PASB compared with those using the Lyon brace. QoL scores were significantly correlated with the curve severity. Higher QoL scores were obtained by participants with thoraco-lumbar curves as compared with those with other curves. CONCLUSIONS: The 3 questionnaires are effective in capturing changes in QoL in AIS patients subjected to conservative treatment. However, the BrQ possesses a higher discriminatory capacity compared with the other questionnaires tested. PASB-based treatment is associated with better QoL than the Lyon bracing.

Calorie restriction for optimal cardiovascular aging: the weight of evidence.

The epidemic of obesity and overweight is spreading worldwide. Excessive adiposity is associated with a myriad of adverse health outcomes, leading to increased healthcare expenditures and shortened life expectancy. In contrast to overeating, calorie restriction (CR), defined as a reduction in food intake without malnutrition, increases both mean and maximum lifespan in a variety of species by reducing the incidence of several chronic degenerative diseases, including cardiovascular disease. The constellation of health benefits brought about by CR results from biological and physiological changes affecting fundamental processes underlying aging and age-related pathologies. Despite the beneficial properties of CR, it is likely that most people will not engage in such a dietary regimen for the long-term. Supplementation with specific compounds mimicking CR may represent a more feasible means to improve health and prolong life. However, evidence on long-term effectiveness and safety of these compounds is not yet available in humans.