The Effect of Apical Vertebra Position on Growing Rod Treatment: A Clinical and Finite Element Study.

BACKGROUND: Growing rods (GRs) is a commonly utilized technique for the management of early-onset scoliosis. The significance of the position of the apical vertebrae relative to the rods is not known. The purpose of this study is to analyze the potential effects of the position of the apical vertebrae in relation to the GRs on deformity control through plain radiographs and finite element analysis (FEA) modeling. METHODS: We identified 140 patients treated with GR between 2000 and 2018. Patients who had a congenital vertebral anomaly or <2-year follow-up were excluded. Curve magnitude, traction radiograph under general anesthesia (TRUGA) flexibility, apical rotation, the lengths of T1-12, T1-S1, and the instrumented segments were recorded. Patients were divided into 3 groups according to the apical position on the postoperative radiographs: group 1 (both pedicles are between the rods), group 2 (convex rod is between the apical vertebra pedicles), group 3 (both pedicles are lateral to the convex rod). FEA models were created simulating the 3 groups. Both radiographic and FEA data were analyzed to compare the deformity control and growth in each group. RESULTS: Fifty-eight patients were included in the final analyses (mean age 84 mo; range: 38 to 148). Ten patients (17%) were in group 1, 34 (59%) in group 2, and 14 (24%) in group 3. Difference between TRUGA flexibilities was statistically insignificant. Group 3 was the least successful in terms of both height gain and rotational control. FEA showed a decrease in rotation and displacement for every group, however, the residual rotation and displacement was highest in group 3. CONCLUSIONS: Bringing the apex in line with the GR increases the capacity of growth preservation as it results in largest height gain and better deformity control. FEA model demonstrated that distraction alone is inadequate for controlling rotation, and with increasing apical translation, residual rotation after distraction also increases. LEVEL OF EVIDENCE: Level III.

Omitting the Early Postoperative Follow-up in Uncomplicated Operative Supracondylar Humerus Fractures in Children Does Not Negatively Affect Outcomes.

BACKGROUND: Supracondylar humerus (SCH) fractures are the most common surgically treated elbow injuries in children. There have been debates regarding if an early postoperative follow-up before pin removal is necessary to decrease the complications related to surgical fixation. To date, studies examining this topic have included smaller sample sizes, limiting the generalizability of their findings. METHODS: A retrospective chart review of outcomes after operative management of Gartland type II and III SCH fractures at a single level 1 pediatric trauma center between 2005 and 2015 was performed. Patient demographics, fracture characteristics, pin number and configuration, timing of initial follow-up, change in treatment plan after initial follow-up, time to pin removal, initial and final fracture radiographic parameters, and complications were observed via chart review. RESULTS: A total of 1518 SCH fractures underwent operative fixation: 755 Gartland type II and 765 type III. Of the 1518 SCH fractures identified, 1370 met inclusion criteria and were included for analysis. Of these, 1196 patients returned for initial follow-up within 1 to 2 weeks of surgery, and 174 patients had their initial follow-up 3 to 4 weeks postoperatively. There were 8 incidences where initial early follow-up resulted in a change of management; however, change in management was limited to cast alteration in 7 of these cases. CONCLUSIONS: Closed reduction and percutaneous pin fixation of otherwise uncomplicated closed SCH fractures have good outcomes and a very low complication rate at a level 1 pediatric trauma center. Early postoperative follow-up before the pin removal visit provides minimal utility in decreasing complications and may be safely omitted as long as the initial fracture fixation is deemed to be stable. LEVEL OF EVIDENCE: Level III.

Early Results of a Management Algorithm for Collapsing Spine Deformity in Young Children (Below 10-Year Old) With Spinal Muscular Atrophy Type II.

BACKGROUND: Progressive C-shaped scoliosis with marked pelvic obliquity is common to spinal muscular atrophy (SMA). Reducing the number of procedures with effective deformity control is critical to minimize the risk of pulmonary complications. This study reports the preliminary results of magnetically controlled growing rods (MCGR) in SMA-related collapsing spine deformity. METHODS: Inclusion criteria for this retrospective review were: (1) SMA type 2 patients, (2) early onset scoliosis (below 10 y), (3) collapsing spine deformity with pelvic obliquity, (4) growth-friendly scoliosis treatment with MCGR, (5) in between 2014 and 2017. Extracted data included demographic and clinical information, radiologic parameters, surgical details, and final status of the patients. RESULTS: A total of 11 patients (7 boys, 4 girls) were included. The average age at index surgery was 8.2 (6 to 10) years. Dual MCGR was implanted in 8 patients. In 3 patients, because of curve rigidity and inability of apex to be brought into the stable zone, apical fusion with gliding connectors (convexity) and a single MCGR (concavity) was preferred. Instrumentation included the pelvis in 9 and stopped at the lumbar spine (L3) in 2 patients at the index procedure. Average preoperative deformity of 81.8 degrees (66 to 115) decreased to 29 degrees (11 to 57) postoperatively and was 26 degrees at average 35 months (16 to 59). Pelvic obliquity of 20.9 degrees (11 to 30) decreased to 4.9 degrees (2 to 8) after index surgery and was 6.5 degrees (2 to 16) at the last follow-up. T1-S1 height of 329 mm (280 to 376) after index surgery increased to 356 mm (312 to 390) after 9.2 (4 to 20) outpatient lengthening. No neurologic, infectious, or implant-related complication was recorded. Distal adding-on deformity occurred in 2 patients without initial pelvic fixation.One patient deceased secondary to pneumonia at 16 months after surgery. CONCLUSIONS: Short-term results indicate that MCGR may be a good option in SMA-associated collapsing spine deformity to reduce the burden of repetitive lengthening procedures. The authors recommend apical deformity control in the convex side in case of curve rigidity. In addition, including the pelvis in the instrumentation at index surgery is critical to prevent distal adding-on. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Intermediate-term annualized curve progression of adolescent idiopathic scoliosis curves measuring 40° or greater.

STUDY DESIGN: Prospective cohort study. OBJECTIVES: The objective of this study was to examine intermediate-term progression for a large series of patients with adolescent idiopathic scoliosis (AIS) with curves 40° or greater. BACKGROUND: Curve progression in AIS has been well documented for smaller curves in adolescence up to skeletal maturity; however, the data on curve progression past 40° or into adulthood are limited. With many surgeons recommending surgical correction when patients reach this threshold, it is important to understand the radiographic progression of curves into adulthood. METHODS: A database of all patients seen by a single surgeon from 1984 through 2018 with AIS curves progressing to at least 40° entered prospectively was utilized for this study. This included a total of 738 patients. Curve progression was analyzed overall and stratified by length of follow-up, curve location, and Risser stage at the time of presentation among other variables. Curve magnitude and Risser stage designations in this study were validated by performing a separate inter- and intrarater agreement study using four independent reviewers reading 50 patients' Cobb angle and Risser stage blinded in triplicate to examine the reliability of the study measurements. RESULTS: Annualized curve progression (ACP) averaged 6.3 ± 10.4°. ACP varied with length of follow-up: patients with up to 1 year of follow-up had an average ACP of 11.5 ± 17.0°, while those with 1-2 years had 8.2 ± 8.8°, and 2-5 years had 3.7 ± 4.1°, tapering off further from there. Risser stage 0 or 1 was associated with the highest ACP as compared to Risser stage 2-3 or 4-5. Intraclass correlation (ICC) values for Cobb angle measurement and Risser stage designations from four raters measuring 50 patients' measures, blinded and in triplicate, were all > 0.80, signifying a high degree of reliability within and between readers. CONCLUSIONS: Annualized curve progression for 40° and greater curves was not linear over time; it was greatest immediately after a curve reaches 40° and tapered off over the next decade. Immature Risser stage at presentation was strongly associated with increasing ACP at all time frames. LEVEL OF EVIDENCE: Prognostic Level I.

Restoring sagittal and frontal balance following posterior instrumented fusion.

Correction techniques for adolescent idiopathic scoliosis have evolved over the years as the understanding of the disease and the implant technology advanced. Utilization of the modern implant systems, along with the appropriate corrective maneuvers and selection of the appropriate levels of instrumentation, improves the outcomes after surgical treatment of adolescent idiopathic scoliosis. Coronal and sagittal balance are important predictors for successful posterior spine fusion. Many corrective methods have been developed to address the multiple facets of the spinal deformity and curve types. Treating surgeons should familiarize themselves with all of the techniques, their utility, and appropriate usage in different deformity settings. A literature review is provided with the best evidence available to achieve optimal deformity correction to help guide treating physicians.

Spinal Instrumentation in Growing Children Retards the Natural Development of Pelvic Incidence.

BACKGROUND: Pelvic incidence increases gradually throughout growth until skeletal maturity. Growing rod instrumentation has been suggested to have a stabilizing effect on the development of the normal sagittal spinal alignment. The purpose of this study is to determine the effect of fixed sagittal plane caused by dual growing rod instrumentation on the natural progression of sagittal spinopelvic parameters in children with idiopathic or idiopathic-like early onset scoliosis. METHODS: Hospital records of children with growing rod instrumentation from 4 separate institutions were reviewed retrospectively. Inclusion criteria were idiopathic or idiopathic-like early onset scoliosis, treatment with dual growing rods with lower instrumented vertebra L4 or upper and more than 2 years of follow-up. Instrumentation levels, magnitudes of major curve, thoracic kyphosis (T2-T12), lumbar lordosis (L1-S1) and pelvic incidence were recorded from preoperative and postoperative standing whole-spine radiographs. Estimated pelvic incidence was also calculated for each patient as if their spines had not been instrumented using the previous normative data. RESULTS: A total of 37 patients satisfied the inclusion criteria. Average age at initial surgery was 7.4±1.8 years (range, 4 to 12 y). Mean follow-up time was 71±26 months (range, 27 to 120 mo). Mean preoperative Cobb angle of 59±13.5 (range, 30 to 86) degrees was reduced to 35.1±17.5 (range, 11 to 78) degrees at the last follow-up. Mean preoperative T2-T12 kyphosis angle was 46.2±14.9 degrees (range, 22 to 84 degrees). At the latest follow-up, it was 44.8±16.2 degrees (range, 11 to 84 degrees) (P=0.93). Mean L1-S1 lordosis angle was 50.5±10.7 degrees (range, 30 to 72 degrees) preoperatively. At the latest follow-up, mean L1-S1 lordosis angle was 48.8±12.7 degrees (range, 26 to 74 degrees) (P=0.29). Mean preoperative pelvic incidence was 45.7±7.9 degrees (range, 30 to 68 degrees). At the latest follow-up, it was 46.7±8.4 degrees (range, 34 to 72 degrees) (P=0.303). The estimated average pelvic incidence was 49.5 degrees (P=0.012). CONCLUSIONS: Previously reported developmental changes of the sagittal spinal parameters were not observed in children who underwent posterior spinal instrumentation. Our findings suggest that spinal instrumentation impedes the natural development of the sagittal spinal profile. LEVEL OF EVIDENCE: Level IV-this is a retrospective case-series.

Is Magnetically Controlled Growing Rod the Game Changer in Early-onset Scoliosis? A Preliminary Report.

BACKGROUND: Magnetically controlled growing rod (MCGR) concept was introduced with the premise of minimizing the repetitive lengthening surgeries, which is default in traditional growing rod (TGR) treatment for early-onset scoliosis (EOS). Despite good radiographic outcomes, previous studies did not compare identical patient groups in terms of etiology and deformity characteristics; therefore, a true comparison of the MCGR and TGR is essential. This study was designed to compare 2 techniques in terms of clinical, radiologic, and health-related quality of life (HRQoL) outcomes. METHODS: Patients with long sweeping congenital curves who underwent convex growth arrest and concave distraction (with TGR or MCGR) were retrospectively reviewed. Instrumented all-posterior convex growth arrest and concave distraction with growing rod technique were performed. Demographic parameters, follow-up time, number of lengthening procedures, radiographic parameters, number of unplanned surgeries, and complications were recorded. The Early-Onset Scoliosis Questionnaire (EOSQ-24) was used to evaluate HRQoL outcomes. RESULTS: A total of 20 patients were included (10 MCGR, 10 TGR). No significant differences were found with regard to average age, follow-up time, radiographic parameters, or complications. Overall surgery per patient including index surgery, and planned and unplanned procedures were significantly lower in the MCGR group (8.8 vs. 1.3) (P=0.01). No patient in either group had graduated from growing rod treatment. HRQoL analysis revealed no significant difference between the 2 groups in any specific domain or in the overall score of the EOSQ-24. CONCLUSIONS: Although equally effective in controlling the deformity and superior in reducing the number of surgeries with comparable complication rates, MCGR does not offer any significant improvement in HRQoL outcomes or the overall complication rate. Despite the obvious advantages, according to this preliminary report, the current technology and technique of MCGR may not be sufficient to be the long-awaited "game changer" in the treatment of EOS.

Surgical Management of Progressive Thoracolumbar Kyphosis in Mucopolysaccharidosis: Is a Posterior-only Approach Safe and Effective?

BACKGROUND: According to the current literature, the recommended surgical treatment is circumferential spinal fusion, including both anterior and posterior procedures, for progressive thoracolumbar kyphosis in mucopolysaccharidosis (MPS). The purpose of this study was to report our experience with the posterior-only approach and instrumented fusion for MPS kyphosis. METHODS: Six consecutive patients with MPS and thoracolumbar junctional kyphosis managed with the posterior-only approach were included. Demographic data, the type of MPS, medical comorbidities, and accompanying clinical manifestations were recorded. Measurements recorded on radiographs for the study included the presence of any coronal-plane deformity, fusion levels, changes in the local kyphosis angle (LKA), proximal and distal junctional kyphosis angles, and the apical vertebral wedge angle. RESULTS: The average age at the time of surgery was 6.6 (range, 4 to 12) years. The average follow-up duration was 52.6 (range, 44 to 64) months. The mean preoperative LKA of 63.1±15.8 (range, 48 to 92) degrees decreased to a mean of 16.6±8.4 (range, 5 to 30) degrees immediately after surgery. At the latest follow-up, the mean LKA was 19.6±8.8 (range, 8 to 34) degrees. Apical vertebral listhesis was reduced in all patients with surgical correction. The average apical vertebral wedge angle of 15 (range, 11 to 19) degrees at the early postoperative period decreased to 4.6 (range, 2 to 7) degrees at the latest follow-up. Adjacent-segment problems occurred in 2 patients. There were no neurological complications or implant failures in any of the patients. CONCLUSIONS: Posterior-only corrective techniques and instrumented fusion with pedicle screws for progressive thoracolumbar junctional kyphosis in MPS patients are safe and effective methods. Its results are comparable to those achieved with conventional circumferential fusion. However, patients should be monitored closely for adjacent-segment problems. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Anterior and Posterior Vertebral Column Resection Versus Posterior-only Technique: A Comparison of Clinical Outcomes and Complications in Congenital Kyphoscoliosis.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: The purpose of this study is to compare the anterior-posterior surgery to posterior-only vertebra resection for congenital kyphoscoliosis in pediatric patients. SUMMARY OF BACKGROUND DATA: Vertebral column resection is a very powerful correction technique mainly used in the treatment of severe and rigid spinal deformities. The technique can be applied with combined anterior and posterior vertebral column resection (APVCR) or posterior-only vertebral column resection (PVCR) approaches. PVCR has gained popularity recently due to several apparent advantages, but APVCR is still believed by some to be a viable alternative, despite the use of an anterior exposure. MATERIALS AND METHODS: A retrospective chart and radiographic review was performed including the patients with congenital kyphoscoliosis up to 16 years of age who were operated on by a single senior surgeon in our department after 2005. The data included surgical time, estimated blood loss, duration of hospital and postoperative intensive care unit stay, intraoperative and postoperative complications. Preoperative, postoperative, and follow-up radiographs were evaluated for scoliosis, kyphosis, and spinal balance. RESULTS: Twenty-six patients (20 girls, 6 boys) met the inclusion criteria. APVCR was performed on 17 (median age, 13.2 y) and PVCR on 9 (median age, 10.7 y). Scoliosis correction at the time of last follow-up was 54.3% and 52.6% for APVCR and PVCR, respectively, whereas the average kyphosis correction was 25.4 degrees in APVCR and 30.1 degrees in PVCR group. Surgical time, hospital stay, and estimated blood loss were all significantly higher in the APVCR group, whereas the complication rates were similar. No neurological or vascular complications were encountered. CONCLUSIONS: This study showed that although the operative time and surgical blood loss were higher with APVCR, there were no major complications and the radiologic outcomes were similar between APVCR and PVCR. APVCR should be considered as an acceptable technique especially in deformities where PVCR would be technically difficult or at the beginning of the spine surgeon's learning curve. LEVEL OF EVIDENCE: Level III.

Thoracic Spine Growth Revisited: How Accurate Is the Dimeglio Data?

STUDY DESIGN: Cross-sectional descriptive study. OBJECTIVE: To describe the normal rate pattern of thoracic spine growth in children without any spinal deformity. SUMMARY OF BACKGROUND DATA: The knowledge of thoracic spine growth and height is important for growing spine treatment and the decision of final fusion. Currently, pediatric spinal deformity is approached as early onset and late onset with an understanding of the fast growth during the first 5 years of life. The growth data that support this classification is often cited but has not been reconfirmed with follow-up studies. METHODS: Sagittal computed tomography (CT) reformations of thoracic vertebrae were examined in children without spinal deformity. The sagittal CT cut at the widest canal diameter was identified and the measurements were performed on this image. The length of the thoracic spine was measured from the posterosuperior corner of T1 to the posteroinferior corner of the T12. RESULTS: One hundred forty-four thoracic CT scans satisfied the inclusion criteria. The analysis of the data identified two break points in the growth velocity; one at the end of the 4th year of life and the other at the beginning of the 12th year. Specifically, growth rate between 1 and 4 years was 1.71 cm/yr, between 4 and 8 years was 0.55 cm/yr, between 8 and 10 was 0.74 cm/yr, between 10 and 12 was 0.69 cm/yr, and between 12 and 16 was 1.61 cm/yr. CONCLUSION: The results show that in growing children the thoracic spine demonstrates two major growth spurts. The initial growth spurt is between the birth to the end of the fourth year of life and the second is between the 12 and 16 years of age. Between 4 and 12 years there is a steady but slower increase in thoracic height. The findings show that the fastest growth velocity may be limited to a younger age group than previously believed. This data will help guide growth friendly management strategies. LEVEL OF EVIDENCE: 2.

Absent pedicles in campomelic dysplasia.

OBJECTIVES: The objective of the present study is to report a case of campomelic dysplasia illustrating the absence of cervical and thoracic pedicles. This report reiterates the importance of this clinical peculiarity in the setting of spine instrumentation. MATERIALS AND METHODS: A 10-year-old female patient with campomelic dysplasia presented with progressive kyphoscoliosis and signs of neural compromise. Imaging studies confirmed thoracic level stenosis and demonstrated absence of multiple pedicles in cervical and thoracic spine. The patient underwent decompression and instrumentation/fusion for her spinal deformity. RESULTS: The patient was instrumented between C2 and L4 with pedicle screws and sublaminar cables. However, pedicle fixation was not possible for the lower cervical and upper-mid thoracic spine. Also, floating posterior elements precluded the use of laminar fixation in the lower cervical spine. Cervicothoracic lumbosacral orthosis (CTLSO) was used for external immobilization to supplement the tenuous fixation in the cervicothoracic area. The patient improved neurologically with no signs of implant failure at the 2-year follow-up. CONCLUSIONS: Absence of pedicles and floating posterior elements present a challenge during spine surgery in campomelic dysplasia. Surgeons should prepare for alternative fixation methods and external immobilization when planning on spinal instrumentation in affected patients. LEVEL OF EVIDENCE: Level IV Case Report.

Outcomes of Pediatric Fractures Managed With Closed Reduction by Orthopaedic Residents in the Emergency Department.

BACKGROUND: Closed reduction of pediatric fractures is commonly performed by orthopaedic residents using conscious sedation in the emergency department (ED). The purpose of this study was to determine the rate of satisfactory reductions as performed by residents, and to determine the outcomes of these procedures. METHODS: A retrospective review was performed of all fractures that underwent closed reduction under conscious sedation in the ED of a level 1 pediatric trauma center between January 1, 2010 and November 30, 2014. Initial and subsequent radiographs were reviewed and a determination was made as to whether the initial reduction was satisfactory, based on predetermined criteria for angulation and displacement. If a second reduction attempt in the operating room was necessary, this was noted. Chart notes were reviewed until a documented endpoint was reached, such as uneventful healing, malunion, nonunion, or growth arrest. RESULTS: A total of 838 subjects were identified. The upper extremity was involved in 85% of the fractures. Of the initial 838 fracture reductions performed, 39 (4.7%) were unsatisfactory. Residents on their first pediatric orthopaedic rotation had a higher unsatisfactory reduction rate compared with more experienced residents (7.0% vs. 3.4%, P=0.01). A second reduction was performed for 94 of 749 (12.6%) fractures. Of these, 35 (37.2%) required an open procedure to accomplish a satisfactory reduction. Fractures with initially satisfactory reductions were significantly less likely to require a second reduction attempt than those with initially unsatisfactory reductions (9.2% vs. 80.0%, P<0.01). The likelihood of a satisfactory reduction was significantly higher in the upper extremity than in the lower extremity. Overall, the vast majority (99.2%) of fractures had a satisfactory final outcome. CONCLUSIONS: Most attempts at closed reduction of pediatric fractures in the ED by orthopaedic residents are successful, and the likelihood of a satisfactory reduction was associated with increased levels of resident experience. Fractures with an initially successful reduction were far less likely to require remanipulation. LEVEL OF EVIDENCE: Level IV-this is a therapeutic case series.

Does a Weekly Didactic Conference Improve Resident Performance on the Pediatric Domain of the Orthopaedic In-Training Examination?

BACKGROUND: Performance on the Orthopaedic In-training Examination (OITE) has been correlated with performance on the written portion of the American Board of Orthopaedic Surgery examination. Herein we sought to discover whether adding a regular pediatric didactic lecture improved residents' performance on the OITE's pediatric domain. METHODS: In 2012, a didactic lecture series was started in the University of Pittsburgh Medical Center (UPMC) Hamot Orthopaedic Residency Program (Hamot). This includes all topics in pediatric orthopaedic surgery and has teaching faculty present, and occurs weekly with all residents attending. A neighboring program [UMPC Pittsburgh (Pitt)] shares in these conferences, but only during their pediatric rotation. We sought to determine the effectiveness of the conference by comparing the historic scores from each program on the pediatric domain of the OITE examination to scores after the institution of the conference, and by comparing the 2 programs' scores. RESULTS: Both programs demonstrated improvement in OITE scores. In 2008, the mean examination score was 19.6±4.3 (11.0 to 30.0), and the mean percentile was 57.7±12.6 (32.0 to 88.0); in 2014, the mean examination score was 23.5±4.2 (14.0 to 33.0) and the mean percentile was 67.1±12.1 (40.0 to 94.0). OITE scores and percentiles improved with post graduate year (P<0.0001). Compared with the preconference years, Hamot residents answered 3.99 more questions correctly (P<0.0001) and Pitt residents answered 2.93 more questions correctly (P<0.0001). Before the conference, site was not a predictor of OITE score (P=0.06) or percentile (P=0.08); there was no significant difference found between the mean scores per program. However, in the postconference years, site did predict OITE scores. Controlling for year in training, Hamot residents scored higher on the OITE (2.3 points higher, P=0.003) and had higher percentiles (0.07 higher, P=0.004) than Pitt residents during the postconference years. CONCLUSIONS: This study suggests that adding a didactic pediatric lecture improved residents' scores on the OITE and indirectly suggests that more frequent attendance is associated with better scores. LEVEL OF EVIDENCE: Level III-retrospective case-control study.

Is There Value in Having Radiology Provide a Second Reading in Pediatric Orthopaedic Clinic?

BACKGROUND: The Joint Commission on Accreditation of Healthcare Organizations specifically mandates the dual interpretation of musculoskeletal radiographs by a radiologist in addition to the orthopaedist in all hospital-based orthopaedic clinics. Previous studies have questioned the utility of this practice. The purpose of this study was to further investigate the clinical significance of having the radiologist provide a second interpretation in a hospital-based pediatric orthopaedic clinic. METHODS: A retrospective review was performed of all patients who had plain radiographs obtained in the pediatric orthopaedic clinic at an academic children's hospital over a 4-month period. For each radiographic series, the orthopaedist's note and the radiology interpretation were reviewed and a determination was made of whether the radiology read provided new clinically useful information and/or a new diagnosis, whether it recommended further imaging, or if it missed a diagnosis that was reflected in the orthopaedist's note. The hospital charges associated with the radiology read for each study were also quantified. RESULTS: The charts of 1570 consecutive clinic patients who were seen in the pediatric orthopaedic clinic from January to April, 2012 were reviewed. There were 2509 radiographic studies performed, of which 2264 had both a documented orthopaedist's note and radiologist's read. The radiologist's interpretation added new, clinically important information in 1.0% (23/2264) of these studies. In 1.7% (38/2264) of the studies, it was determined that the radiologist missed the diagnosis or clinically important information that could affect treatment. The total amount of the professional fees charged for the radiologists' interpretations was $87,362. On average, the hospital charges for each occurrence in which the radiologist's read provided an additional diagnosis or clinically important information beyond the orthopaedist's note were $3798. CONCLUSIONS: The results of this study suggest that eliminating the requirement to have the radiologist interpret radiographs in the pediatric orthopaedic clinic would have few clinical consequences. LEVEL OF EVIDENCE: Level III-This is a diagnostic retrospective cohort study.

Advances in growing rods treatment for early onset scoliosis.

PURPOSE OF REVIEW: The goal of treatment in early onset scoliosis is to correct the deformity while allowing the thoracic growth for optimal cardiopulmonary functions. Growing rods treatment is a distraction-based, growth-friendly method that is commonly used in treatment of early onset scoliosis with its specific indications. Magnetically controlled growing rods (MCGR) method has been introduced to avoid morbidity of recurrent lengthening procedures. In this review, recent developments in traditional growing rods and MCGR are summarized. RECENT FINDINGS: As the experience with growing rods increased and favorable results were reported, its indications have expanded. Recent studies focused on patient outcomes and complications. Another area of interest is the effects of growing rods in the sagittal spinal alignment. Midterm results demonstrated that MCGR treatment is promising but not free of complications. In MCGR, there is no consensus on the frequency and amount of distraction per session. Rod contouring and behavior of the magnet under MRI are major issues. SUMMARY: Growing rods treatment successfully controls the deformity while preserving the growth of spine and thorax, despite high complication rates. Magnetically controlled systems are introduced to avoid repetitive surgical lengthening procedures. Although preliminary results are promising, there are still significant challenges and unknowns for MCGR.

The Development of Thoracic Vertebral Sagittal Morphology During Childhood.

STUDY DESIGN: This is a cross-sectional descriptive study objectives to describe normal development of thoracic vertebrae during childhood and document contribution of individual vertebral shape to the sagittal alignment. SUMMARY OF BACKGROUND DATA: Sagittal spinal alignment changes during growth. The changes in sagittal alignment during adolescent growth spurt as well as the individual shapes of thoracic vertebrae have been implicated as factors for the development of adolescent idiopathic scoliosis (AIS). The contribution of individual vertebral shape to the sagittal alignment and the changes in the vertebral shape with growth is not known. METHODS: Sagittal computed tomographic (CT) scans of thoracic vertebrae were examined in children without any evidence of spinal deformity. Vertical distances between the endplates at the most anterior and most posterior sides of vertebral body were measured as anterior vertebral height (aVH) and posterior vertebral height (pVH), respectively. RESULTS: There were a total of 133 CT scans done on 71 male and 62 female children. The children were grouped as follows: Group I (0-2 years of age), Group II (3-6 years of age), Group III (7-9 years of age), Group IV (10-12 years of age), and Group V (13-16 years of age). A-P ratios of vertebral heights were grouped as T1-T5, T6-T8, and T9-T12. Measurements demonstrated that the anterior and posterior heights in each vertebra grew longitudinally and consistently with increasing age. The aVH/pVH ratio of each individual vertebra showed no significant difference according to age. Measurements of thoracic vertebrae on sagittal spinal CT images did not show any differences in the relative growth and heights of the anterior versus posterior walls of the vertebral bodies in any of the segments in any age or age group. CONCLUSIONS: The sagittal alignment changes during growth are likely related to maintenance of sagittal balance rather than the shapes of individual vertebrae. LEVEL OF EVIDENCE: Level II.

A brief history and review of modern casting techniques in early onset scoliosis.

PURPOSE: Body casts have a long history in the treatment of spinal deformity. Currently the use of body casts is limited to early onset scoliosis. Here, we aim to provide a brief narrative of the evolution of cast application for the management of spinal deformity. METHODS: A history of cast application is provided with a brief review of the orthopedic literature. The current indications for cast application and the authors' preferred technique are described. RESULTS: Serial casting is an effective treatment method for early onset scoliosis. It may be definitive for most idiopathic curves or used to delay surgical intervention in more severe idiopathic, syndromic and even congenital curves. CONCLUSIONS: Surgeons who treat children with early onset scoliosis should familiarize themselves with serial cast application techniques.

Adult spinal deformity: a very heterogeneous population of patients with different needs.

OBJECTIVE: The purpose of this study was to analyze and demonstrate the heterogeneity in adult spinal deformity (ASD) populations by baseline health-related quality of life (HRQL) data. METHODS: ASD was defined as patients over 18 years of age with any of the following: coronal deformity >20°, sagittal vertical axis (SVA) >5 cm, pelvic tilt >25°, or thoracic kyphosis >60°. Three hundred fifty-two patients meeting the above definition of ASD were analyzed for measures of HRQL (Oswestry disability index [ODI], SRS-22 [Scoliosis Research Society-22], and SF-36 [Short form-36 health survey] questionnaires) at presentation. Age groups were defined as 18-40, 40-60, and >60 years. Deformity was analyzed as either degenerative (DS) or idiopathic (IS) (294 patients; 71 degenerative, 223 idiopathic). RESULTS: There were significant differences between age groups--predominantly between the lower age group (18-40) and others--for all HRQL parameters except SRS-22 mental health and SF-36 mental component score. Similarly, HRQL measures for DS and IS deformities were significantly different. Regarding location of main curves, thoracolumbar/lumbar (TL/L) (70.2%) was dominant for the DS group and thoracic (55%) for the IS group. Mean age was 65 years for the DS group and 36 for the IS group, which were significantly different. Radiographic parameters were also significantly different between these groups, with IS patients having more coronal deformity and better sagittal balance. CONCLUSION: ASD patients are very heterogeneous at presentation, depending on age and diagnosis. There is a distinct need to stratify ASD as early and late presentation ASD and/or by diagnosis. Patients with IS deformity may be very different from those with DS deformity, even at time of presentation. These differences must be taken into consideration in treatment of these patients, as well as for the analysis of the results of treatment.

Convex Instrumented Hemiepiphysiodesis With Concave Distraction: A Treatment Option for Long Sweeping Congenital Curves.

BACKGROUND: Convex hemiepiphysiodesis has been reported to have mixed results in the treatment of congenital spine deformities. Multiple modifications of the original technique were suggested to improve the results. The purpose of this study is to report the results and complications of an instrumented convex growth arrest procedure modified with concave distraction. METHODS: The records of 11 patients with long sweeping congenital curves (involving multiple anomalous vertebrae) who underwent convex instrumented hemiepiphysiodesis with concave distraction were evaluated. Mean age at index operation was 58 months (range, 29 to 101 mo). Lengthening of the concave distraction rod was done every 6 months. The magnitude of coronal/sagittal deformity and T1-T12 height were measured on the preoperative, postoperative, and latest follow-up radiographs. Average follow-up was 44.9 months (range, 24 to 89 mo). RESULTS: In the coronal plane, the convex hemiepiphysiodesis segment was corrected from an average of 60.5 to 40.4 degrees postoperatively and further improved to 35.5 degrees at the latest follow-up. The distracted segment was corrected from 33.4 to 15.2 degrees postoperatively and to 12.7 degrees at the latest follow-up. Sagittal plane alignment was minimally affected. The average T1-T12 height was 157.1 mm in the early postoperative period and 181.1 mm at last follow-up. During follow-up, we identified partial pull-out of screws on the distraction side in 5 of the 11 patients and rod breakages in 3 patients. These were revised during planned lengthenings. There were no unplanned surgeries, deep wound infections, nor neurological complications. CONCLUSIONS: Convex instrumented hemiepiphysiodesis with concave distraction resulted in good curve correction while maintaining the growth of thorax. The correction of the anomalous segment improved over time, proving the effectiveness of the hemiepiphysiodesis. Addition of a concave distraction construct appears to enhance spinal growth, thereby augmenting the hemiepiphysiodesis effect.

Utilizing the "Stable-to-be Vertebra" Saves Motion Segments in Growing Rods Treatment for Early-Onset Scoliosis.

BACKGROUND: There is no consensus on the selection of distal instrumentation levels in growing rod surgery. Many surgeons utilize the stable zone of Harrington, but there is not overwhelming evidence to support this preference. The aim of this study was to determine the value of bending/traction radiographs in selection of distal instrumentation levels of a growing rod construct in children with idiopathic or idiopathic-like early-onset scoliosis (EOS). METHODS: Twenty-three consecutive patients with idiopathic or idiopathic-like EOS who underwent growing rod surgery at 2 separate institutions between 2006 and 2011 were included. Lengthening procedures were performed periodically at 6-month intervals. Analyses were performed retrospectively for age at index surgery, follow-up period, and radiographic measurements. Lower instrumented levels, neutral vertebra, stable vertebrae (SV), and stable-to-be vertebrae (StbV) were identified on the preoperative radiographs. Coronal Cobb angles, tilt of lower instrumented vertebra (LIV) and LIV+1, and disk wedging under the LIV and LIV+1 were measured on the early postoperative and latest follow-up radiographs. RESULTS: Average age at index surgery was 83.6 months. Mean follow-up period was 68.1 months. Initial analysis showed that the relationship of LIV to the StbV was a better predictive of LIV+1 tilt than the SV at the final follow-up. Therefore, the patients were grouped according to the relationship of the LIV to the StbV. LIV was the StbV in 9 patients, proximal to the StbV in 8 patients, and distal to the StbV in 6 patients. At the latest follow-up, tilt of LIV+1 exceeded 10 degrees in 7 of the 8 patients where LIV was proximal to the StbV, whereas only in 1 of 9 patients where LIV was StbV, and in none of the 6 patients where LIV was distal to the StbV. The data indicate that selection of the StbV as the LIV could spare an average of 1.8 vertebral segments when compared with the SV, as StbV is never distal but almost always proximal to the SV. CONCLUSIONS: Choosing the StbV as the LIV saves motion segments and prevents distal adding on, while providing satisfactory deformity correction in idiopathic and idiopathic-like EOS. LEVEL OF EVIDENCE: Level III-retrospective comparative study.