Scoliosis-specific exercises: A state of the Art Review.

Scoliosis-specific exercises are prescribed and used by many centers either primarily or as an adjunct to other treatment methods for adolescent idiopathic scoliosis of mild to moderate severity. These methods are often used in Europe and are being used in the United States with increasing frequency. There are few publications about these methods in the spine or orthopedic literature. We have performed a review of the relevant literature from the PubMed database to evaluate the evidence for effectiveness of these treatments. We found no studies that provide valid evidence that an exercise method prevents progression of AIS (adolescent idiopathic scoliosis) in patients during their peak growth period. We report our review of selected relevant efforts and provide a description of many of the available treatment programs.

A glimpse into Texas Scottish Rite Hospital's educational, clinical care, and research development.

This article describes four areas of pediatric orthopaedic education, research, and clinical care undertaken at Texas Scottish Rite Hospital (TSRH) over the past 25 years. These areas include the weekly preoperative conferences, the evolution of the limb lengthening and deformity correction program, the development of the TSRH instrumentation system, and the evolution of the clubfoot treatment program.

Perfusion MRI in Early Stage of Legg-Calvé-Perthes Disease to Predict Lateral Pillar Involvement: A Preliminary Study.

BACKGROUND: Current radiographic classifications for Legg-Calvé-Perthes disease cannot be applied at the early stages of the disease. The purpose of this study was to quantify the perfusion of the femoral epiphysis in the early stages of Legg-Calvé-Perthes disease with use of perfusion magnetic resonance imaging (MRI) and to determine if the extent of epiphyseal perfusion can predict the lateral pillar involvement at the mid-fragmentation stage. METHODS: Twenty-nine patients had gadolinium-enhanced perfusion MRI at the initial stage or early fragmentation stage of Legg-Calvé-Perthes disease and were followed prospectively. The percent perfusion of the whole epiphysis and its lateral third was measured by four independent observers using image analysis software. The radiographs obtained at the mid-fragmentation stage were used for the lateral pillar classification. Intraclass correlation coefficient (ICC) and logistic regression analyses were performed. RESULTS: The mean age (and standard deviation) at diagnosis was 7.7 ± 1.7 years (range, 5.3 to 11.3 years). The mean interval between the MRI and the time of maximum fragmentation was 8.2 ± 5.5 months. The interobserver ICC for the percent perfusion of the lateral third of the epiphysis was 0.90 (95% confidence interval [CI]: 0.83 to 0.95). The mean percent perfusion of the lateral third of the epiphysis was 92% ± 2%, 68% ± 18%, and 46% ± 12% for the hips in which the lateral pillar was later classified as A, B, and C, respectively (p = 0.001). When the perfusion level was ≥90% in the lateral third of the epiphysis, the odds ratio of the lateral pillar being later classified as group A, as opposed to B or C, was 72.0 (CI: 3.5 to 1476). With a perfusion level of ≤55% in the lateral third of the epiphysis, the odds ratio of the lateral pillar being later classified as group C, as opposed to A or B, was 33.3 (CI: 2.8 to 392). Similar results were obtained for the whole epiphysis. CONCLUSIONS: Perfusion MRI measurements of the total epiphysis and its lateral third obtained at the early stages of Legg-Calvé-Perthes disease were predictive of lateral pillar involvement at the mid-fragmentation stage of the disease. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Bracing for idiopathic scoliosis: how many patients require treatment to prevent one surgery?

BACKGROUND: Although the efficacy of bracing for adolescent idiopathic scoliosis has been debated, recent evidence indicates a strong dose-response effect with respect to preventing curve progression of ≥6°. The purpose of this study was to investigate whether bracing, prescribed with use of current criteria, prevents surgery and how many patients must be treated with bracing to prevent one surgery. METHODS: Of 126 patients with adolescent idiopathic scoliosis measuring between 25° and 45° and with a Risser sign of ≤2, 100 completed a prospective study in which they were managed with a Boston brace fitted with a heat sensor that measured brace wear. Noncompliant patients were compared both with highly compliant patients and with the entire cohort, with the end point of progression to surgery. The absolute risk reduction (ARR) was calculated and used to calculate the number needed to treat (NNT) to prevent one surgery. RESULTS: Bracing was not effective in preventing surgery unless the patient was highly compliant with brace wear. For patients who were considered to be highly compliant, based on the hours per day that they wore the brace, the NNT was 3 (95% confidence interval [CI], 2 to 7). CONCLUSIONS: Within the limitations of a nonrandomized prospective study design, bracing for adolescent idiopathic scoliosis was found to substantially decrease the risk of curve progression to a range requiring surgery when patients were highly compliant with brace wear. Since many patients avoid surgery without wearing a brace, current indications appear to lead to marked overtreatment. Bracing appears to decrease the risk of curve progression to a magnitude requiring surgery, but current bracing indications include many curves that would not have progressed to a magnitude requiring surgery even if the patient had not worn the brace, and overall compliance with brace wear is low. Identifying these lower-risk patients and improving the compliance of those likely to have curve progression could substantially improve bracing results.

Posterior spinal fusion in patients with Ehlers-Danlos syndrome: a report of six cases.

PURPOSE: There is a paucity of literature describing posterior spinal fusion (PSF) in the Ehlers-Danlos syndrome (EDS) patient. The vast majority of these studies diagnosed EDS clinically. The purpose of this study is to discuss the management and complications of EDS patients with scoliosis treated with PSF at a single institution. METHODS: Clinical and radiographic data are presented describing six patients who had PSF for EDS. The diagnoses were confirmed by a geneticist. RESULTS: All of the patients in the current cohort underwent posterior fusion only, with no anterior approach. Neuromonitoring was also used in the majority. Half of our patients experienced complications. One patient had a hemoperitoneum that was initially treated nonoperatively but, unfortunately, they expired 1 month after discharge from abdominal bleeding. Another patient suffered neuropathic pain attributed to the type of implant used. A third underwent a total of seven procedures beginning at the age of 3 years in a different era of spinal surgery. The mean major curve, percentage correction, and estimated blood loss of the current cohort are similar to previous studies. CONCLUSION: The fragility of the EDS patient population cannot be overlooked. Despite a conservative surgical approach, half of our patients experienced complications. The surgeon choosing to operate on EDS patients must do so with extreme caution.

How much varus is optimal with proximal femoral osteotomy to preserve the femoral head in Legg-Calvé-Perthes disease?

BACKGROUND: Although proximal femoral varus osteotomy is an established operative treatment for Legg-Calvé-Perthes disease, there is a lack of data on how much varus at the osteotomy is optimal for preserving the spherical shape of the femoral head. The purpose of this study was to determine if there is a correlation between the amount of varus used and the Stulberg radiographic outcome at maturity and to determine if the varus angulation improved over time. METHODS: The database and the radiographs of fifty-two patients treated with proximal femoral varus osteotomy from a multicenter prospective study were analyzed. The neck-shaft angles were measured before the operation, after the operation, and at the time of final follow-up, and the amount of varus placed was correlated with the Stulberg outcome at skeletal maturity. Spearman correlations and logistic regression were used for statistical analysis. RESULTS: All patients were six years of age or older at the time of diagnosis (mean 8.0 ± 1.4 years), and all were skeletally mature at the time of follow-up (mean age [and standard deviation] at the time of follow-up, 16.5 ± 2.0 years). The mean neck-shaft angle was 138° ± 7° preoperatively and 115° ± 11° postoperatively with a mean varus change of 23° ± 10°. No significant correlation was observed between the postoperative neck-shaft angle at maturity and the Stulberg outcome (r = -0.15, p = 0.17) and between the amount of varus placed and the Stulberg outcome (r = 0.14, p = 0.36). However, when the lateral pillar groups were analyzed separately with use of logistic regression, a significant relationship was observed for the lateral pillar group B (p = 0.025), with a higher postoperative neck-shaft angle having a greater probability of being associated with a Stulberg class-I or II outcome. At maturity, the mean neck-shaft angle had improved from 115° ± 11° following the initial surgery to 124° ± 8°. However, nineteen (37%) of the fifty-two patients showed no improvement (defined as a change of >5°) and fifteen (29%) of the fifty-two patients had an overriding greater trochanter. CONCLUSIONS: Contrary to the conventional belief, greater varus angulation does not necessarily produce better preservation of the femoral head following proximal femoral varus osteotomy. Given the results, our recommendation is to achieve 10° to 15° of varus correction when performing proximal femoral varus osteotomy on hips that are in the early stages of Legg-Calvé-Perthes disease.

Brace wear control of curve progression in adolescent idiopathic scoliosis.

BACKGROUND: The efficacy of brace treatment for patients with adolescent idiopathic scoliosis remains controversial, and effectiveness remains unproven. We accurately measured the number of hours of brace wear for patients with this condition to determine if increased wear correlated with lack of curve progression. METHODS: Of 126 patients with adolescent idiopathic scoliosis curves measuring between 25 degrees and 45 degrees , 100 completed a prospective study in which they were managed with a Boston brace fitted with a heat sensor that measured the exact number of hours of brace wear. Orthopaedic teams prescribed either sixteen or twenty-three hours of brace wear and were blinded to the wear data. At the completion of treatment, the number of hours of brace wear were compared with the frequency of curve progression of > or =6 degrees and with curve progression requiring surgery. RESULTS: The total number of hours of brace wear correlated with the lack of curve progression. This effect was most significant in patients who were at Risser stage 0 (p = 0.0003) or Risser stage 1 (p = 0.07) at the beginning of treatment and in patients with an open triradiate cartilage at the beginning of treatment. Logistic regression analyses showed a "dose-response" curve in which the greater number of hours of brace wear correlated with lack of curve progression. Brace wear to school and immediately afterward was most successful. Curves did not progress in 82% of patients who wore the brace more than twelve hours per day, compared with only 31% of those who wore the brace fewer than seven hours per day (p = 0.0005). The number of hours of brace wear also correlated inversely with the need for surgical treatment (p = 0.0005). The number of hours of wear were similar for the patients who were advised to wear the brace sixteen or twenty-three hours daily. CONCLUSIONS: The Boston brace is an effective means of controlling curve progression in patients with adolescent idiopathic scoliosis when worn for more than twelve hours per day.