The 18-cm Thoracic-Height Threshold and Pulmonary Function in Non-Neuromuscular Early-Onset Scoliosis: A Reassessment.

BACKGROUND: Thoracic spine height is cited as a crucial outcome measure in the treatment of early-onset scoliosis (EOS) because of its reported relationship to pulmonary function tests (PFTs). An 18-cm threshold has been proposed, although this single parameter might be overly simplistic for cases of different etiologies and deformity magnitude. We aimed to reevaluate pulmonary function in patients undergoing corrective surgery, assessing the role of residual scoliosis as well as spine elongation. METHODS: Patients undergoing EOS correction with a minimum of 5 years of follow-up since initial treatment were evaluated. Standard spirometry (forced vital capacity [FVC], forced expiratory volume in 1 second [FEV1]) was correlated to deformity magnitude and T1-T12 height. Patients were compared by age at first surgery (<5 or ≥5 years), final thoracic height (≤18 or >18 cm), and percentage of predicted pulmonary function (<60% or ≥60%). RESULTS: Twenty-nine patients (15 congenital, 11 syndromic, and 3 idiopathic cases) were tested at a mean of 8.5 years following initial surgery. Twenty-two patients (mean initial age, 4.8 years) had growth-sparing instrumentation, and 7 patients (age, 5.1 years) had definitive fusion performed. Age at initial surgery was not associated with a difference in PFT results at the time of follow-up, and both age groups had ominously low percentages of predicted pulmonary-function volumes (50% to 55%). Only 18 of the 29 patients achieved a T1-T12 height of >18 cm. Those with a thoracic height of ≤18 cm had similar percentage-of-predicted spirometry results at the time of follow-up as those with greater thoracic height, possibly because of increased deformity correction. Only 14 of 29 patients had spirometry of ≥60% of predicted volume at the time of follow-up. These 14 had slightly smaller curves and slightly greater T1-T12 heights but significantly better spirometry results than the 15 subjects with <60% of predicted volume. For those with a T1-T12 height of ≤18 cm, the residual Cobb angle negatively correlated with spirometry results. In those with a final T1-T12 height of >18 cm, spirometry did correlate with thoracic height, especially when residual deformity was ≥60°. CONCLUSIONS: Regardless of thoracic height of ≤18 or >18 cm, with residual curves of >50o, pulmonary function was ominously low in fully half of the patients, raising doubt about the value of this threshold as an EOS outcome parameter. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

This is a narrative review of the functional evaluation of clubfoot treatment with gait analysis.

Clinicians worldwide have embraced Ponseti's nonoperative approach in the treatment of clubfoot, primarily due to ubiquitous reports of successful outcomes. A crucial component in this measured success, has come from researchers assessing long-term physical function following nonoperative treatment. Gait analysis has been instrumental in objectively evaluating lower extremity kinematics and kinetics while plantar pressures demonstrate the load bearing patterns experienced in the foot. As technology improves, our ability to evaluate function can take place both in the laboratory setting, and in the community. For over 20 years, our institution has been studying the gait patterns of children treated for clubfoot. After adopting the nonoperative approach, we established a prospective research program that has allowed us to study functional outcomes in the very young walker, through growth to adolescents, and finally at skeletal maturity. We have seen over 450 children treated for clubfoot in the Movement Science Lab, for over 1,250 gait assessments over the span of this study. Early results in 105 children (154 feet) treated nonoperatively for clubfoot, showed 56% of children had normal sagittal plane ankle kinematics, however an incidence of 48% of Ponseti feet had increased dorsiflexion in stance phase, leading us to wonder if this was the result of the tenotomy. Intermediate follow up at age 5 years, showed that the incidence of increased dorsiflexion was reduced (24%) and ankle power did not appear to be affected (P>0.05 compared to controls). The research highlighted in this paper presents the application of functional evaluation through growth and the long-term effects of nonoperative treatment on gait and function. This is a review of the functional outcome studies from our experience at Scottish Rite for Children.

Comparison of Outcomes by Reconstructive Strategy in Patients with Prostheses for Proximal Femoral Focal Deficiency.

BACKGROUND: The present study compares prosthetic treatment options for proximal femoral focal deficiency in terms of gait analysis, oxygen consumption, and patient-reported outcomes. METHODS: Twenty-three patients who had been managed with a prosthesis for unilateral proximal femoral focal deficiency underwent gait analysis; this group included 7 patients who had received an equinus prosthesis, 6 who had received a rotationplasty prosthesis, and 10 who had undergone Syme amputation and had received an above-the-knee prosthesis. Cadence parameters, kinematic and kinetic data, and oxygen consumption were measured, and the Gait Deviation Index (GDI) was calculated. Medical records and radiographs were reviewed. The Pediatric Outcomes Data Collection Instrument (PODCI) was completed by the child's parent. RESULTS: Patients underwent gait analysis at a mean age of 11.6 years (range, 4 to 19 years). Proximal femoral focal deficiency classification was not predictive of the chosen treatment. Patients in the rotationplasty group had undergone more procedures than those in the Syme amputation and equinus groups (mean, 3.3, 1.8, and 0.7 procedures, respectively) (p = 0.001). Oxygen cost did not differ between groups; however, all required greater energy expenditure than normal (170%, 144%, and 159%, in the equinus, rotationplasty, and Syme amputation groups, respectively) (p = 0.427). Likewise, hip power, abductor impulse, and GDI did not differ, but all groups had GDI scores >3 standard deviations below normative values. Patients in the equinus group walked faster (97% of normal for age) than those in the rotationplasty (84%) and Syme amputation groups (83%) (p = 0.018), whereas those in the Syme amputation group had superior knee range of motion (55° from the prosthetic knee) than those in the equinus (20°) and rotationplasty groups (15° generated from the ankle) (p = 0.003). There were no differences in terms of the PODCI subscales for pain, sport/physical function, happiness, or global function. Transfer/basic mobility improved with age (r = 0.516, p = 0.017), but no other associations were found between gait variables and PODCI scores. CONCLUSIONS: Rotationplasty provided no patient-reported benefit and no functional benefit in terms of gait parameters or oxygen consumption, despite requiring more surgical procedures compared with other prosthetic options. Patients with an equinus prosthesis walked the fastest, whereas treatment with a Syme amputation and prosthetic knee yielded equivalent gait parameters and oxygen consumption as compared with those for patients using an equinus prosthesis. These findings contradict those of previous reports that rotationplasty provides superior function over other proximal femoral focal deficiency prosthetic treatment options. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Plantar Pressures Following Surgical Release in Children With Clubfoot: Comparison of Posterior Release, Posteromedial Release, and Nonoperative Correction.

BACKGROUND: Functional deficits observed at long-term follow-up in surgically released clubfeet have led to the adoption of a nonoperative approach. Gait results reported at age 5 years found ankle motion was limited in clubfeet treated by posteromedial release (PMR), compared with those that required posterior release (PR) or remained nonoperative. The purpose of this study was to assess plantar pressures in clubfeet that required surgical correction by 5 years of age. METHODS: Pedobarograph data were collected at age 5 years on patients with clubfeet that underwent surgical correction due to residual deformity or recurrence. Plantar pressures were assessed by subdividing the foot into the medial/lateral hindfoot, midfoot, and forefoot regions. Variables included maximum force, contact area%, contact time% (CT%), the hindfoot-forefoot angle, and displacement of the center of pressure line. Surgical feet were divided into those that underwent an isolated PR versus PMR. A group of 72 clubfeet that remained nonoperative were matched by initial severity and used for comparison. RESULTS: Pedobarograph data from 53 patients (72 clubfeet; 25 PR and 47 PMR) showed minimal differences between the PR and PMR feet. Compared with the nonoperative group, both surgical groups had increased CT% in the medial hindfoot and medial midfoot regions. An increase in lateral hindfoot CT% was observed in the PMR group. In addition, CT% in the first metatarsal region in the PMR group was reduced compared with the nonoperative group. Lateralization is present across both surgical groups in the center of pressure line and hindfoot-forefoot angle. CONCLUSION: While there were minimal differences between surgical groups, patients who underwent PR exhibited pressure variables that were more comparable to the nonoperative group while the PMR group had greater deviations. LEVEL OF EVIDENCE: Level II-therapeutic.

Establishing consensus on the best practice guidelines for the use of bracing in adolescent idiopathic scoliosis.

STUDY DESIGN: Survey. OBJECTIVES: Bracing is the mainstay of conservative treatment in Adolescent Idiopathic Scoliosis (AIS). The purpose of this study was to establish best practice guidelines (BPG) among a multidisciplinary group of international bracing experts including surgeons, physiatrists, physical therapists, and orthotists utilizing formal consensus building techniques. Currently, there is significant variability in the practice of brace treatment for AIS and, therefore, there is a strong need to develop BPG for bracing in AIS. METHODS: We utilized the Delphi process and the nominal group technique to establish consensus among a multidisciplinary group of bracing experts. Our previous work identified areas of variability in brace treatment that we targeted for consensus. Following a review of the literature, three iterative surveys were administered. Topics included bracing goals, indications for starting and discontinuing bracing, brace types, brace prescription, radiographs, physical activities, and physiotherapeutic scoliosis-specific exercises. A face-to-face meeting was then conducted that allowed participants to vote for or against inclusion of each item. Agreement of 80% throughout the surveys and face-to-face meeting was considered consensus. Items that did not reach consensus were discussed and revised and repeat voting for consensus was performed. RESULTS: Of the 38 experts invited to participate, we received responses from 32, 35, and 34 for each survey, respectively. 11 surgeons, 4 physiatrists, 8 physical therapists, 3 orthotists, and 1 research scientist participated in the final face-to-face meeting. Experts reached consensus on 67 items across 10 domains of bracing which were consolidated into the final best practice recommendations. CONCLUSIONS: We believe that adherence to these BPG will lead to fewer sub-optimal outcomes in patients with AIS by reducing the variability in AIS bracing practices, and provide a framework future research. LEVEL OF EVIDENCE: Level IV.

The Influence of Body Habitus on Documented Brace Wear and Progression in Adolescents With Idiopathic Scoliosis.

BACKGROUND: Although studies have been published stating obese patients are less compliant with brace use, no objective studies measuring hours of daily brace wear have been performed to correlate brace wear and success with body mass index (BMI). The purpose of this study was to establish the relationship between BMI and brace compliance, and between BMI and progression to surgical magnitude of 50 degrees or more. METHODS: A total of 175 adolescents were prescribed thoracolumbarsacral orthosis for the treatment of an adolescent idiopathic scoliosis and followed to completion of treatment. BMI was measured at brace prescription, and divided into: (1) underweight (< 5th percentile), (2) normal (>5th, <85%), (3) overweight (>85%, <95%), and (4) Obese (>95%). Thermochron sensors were used to measure compliance. Radiographs were measured at brace prescription, and at time of brace discontinuation or surgery. Outcome was classified as successful if curve magnitude was <50 degrees and no surgery was performed. RESULTS: The underweight group wore their braces more hours than the other groups (15.7 h low, 12.5 h normal, 11.7 h high, and 9.0 h obese BMI (low vs. normal P=0.031, low vs. high P=0.01, low vs. obese P=0.01). The underweight group had the highest rate of surgical progression (60%), compared with 27.7% of normal BMI teens, 28.6% of overweight patients, and 55.6% of obese patients. The low BMI had a significantly higher rate of surgery than the normal BMI group (P=0.01). CONCLUSIONS: Although overweight and obese patients wear orthoses the least hours daily, the highest surgical risk is in underweight adolescents despite good compliance. LEVEL OF EVIDENCE: Level 2.

The Natural History of Early-onset Scoliosis.

BACKGROUND: Early-onset scoliosis (EOS) is defined as the diagnosis of a spinal deformity before the age of 5 years. It can be divided into idiopathic, neuromuscular/syndromic, and congenital etiologies. METHODS: The literature on the natural history of EOS was summarized. RESULTS: The natural history varies with the etiology of EOS. Idiopathic curves may benefit from early serial casting. The natural history of neuromuscular and syndromic scoliosis is highly dependent on the natural history of the underlying disorder. Congenital scoliosis has a variable prognosis depending on the location and extent of the congenital malformations. CONCLUSIONS: Treatment of children with EOS is customized to the particular disorder. While lack of treatment has been shown to lead to increased mortality, extensive early definitive fusion may lead to thoracic insufficiency. Delaying definitive surgery and the use of growing instrumentation may provide benefit in maintaining pulmonary health. CLINICAL RELEVANCE: Potential disturbance of growth must be considered in the treatment of young children with scoliosis.

Functional Outcomes Following Operative Treatment of Tibial Tubercle Fractures.

BACKGROUND: Quantitative evaluation of the functional results of surgically managed tibial tubercle fractures in adolescents is unreported in the orthopaedic literature. METHODS: All patients treated surgically for unilateral tibial tubercle fractures at a single institution from 2007 to 2011 were invited to return for functional evaluation. Fractures were classified using the Ogden classification system. Clinical examination at follow-up included passive knee range of motion and thigh circumference. Side-to-side knee extension strength deficits were evaluated using a Biodex dynamometer. Patient-reported outcomes were assessed using the Pediatric-International Knee Documentation Committee Subjective Knee Form (Pedi-IKDC), Tegner-Lysholm Knee Scoring Scale, and Visual Analog Pain Scale. Chart review was performed to determine postoperative protocols including the use of physical therapy and protected weight bearing. Functional parameters were compared between the involved and uninvolved extremities using the Wilcoxon Signed Ranks Test and the Spearman correlations were performed to identify any relationships between perioperative factors, functional parameters, and subjective outcomes. RESULTS: In total, 19 of 42 patients completed clinical and functional testing and 18 of 19 completed all outcome surveys. Average age at injury was 13.9 years and average follow-up was 3.0 years. There was no statistical difference in knee range of motion between sides, however, thigh circumference was slightly smaller in the injured extremity (median difference, 1.7 cm at 15 cm above the patella and 4.0 cm at 50% of the length of the thigh). In total 5/19 subjects (26%) had a significant quadriceps extension strength deficit on the involved leg compared with the contralateral side. The median Visual Analog Pain Scale for affected limbs was 8/100 and for unaffected limbs was 6/100 (P=0.017). The Tegner-Lysholm Scale revealed 9 excellent results, 5 good, 4 fair, and 1 poor (median, 90/100). Results of the Pedi-IKDC were 11 excellent, 3 good, 2 fair, and 3 poor results (median, 91/100). Outcome scores did not correlate to diminished strength or thigh circumference. No difference in outcome based upon body mass index, postoperative weight-bearing status, Ogden classification, or postoperative physical therapy was noted using regression analysis. CONCLUSIONS: Despite promising objective results, clinical outcomes measured by subjective validated surveys are not all excellent. LEVEL OF EVIDENCE: Level III.

Functional Outcomes Following Treatment for Clubfoot: Ten-Year Follow-up.

BACKGROUND: The purpose of this study was to assess function, at the age of 10 years, of children initially treated nonoperatively for clubfoot with either the Ponseti or French physiotherapy program and to compare outcomes in feet that had undergone only nonoperative treatment with those that required subsequent surgery. METHODS: Gait analysis, isokinetic ankle strength, parent-reported outcomes, and daily step activity data were collected when patients who had been treated for idiopathic clubfoot reached the age of 10 years. Patients who had undergone only nonoperative treatment were compared with those who subsequently underwent extra-articular surgery or intra-articular surgery (posterior release or posteromedial release). The clubfoot groups were compared with age-matched controls. RESULTS: Of 263 treated clubfeet in 175 patients, 148 had only been treated nonoperatively, 29 underwent extra-articular surgery, and 86 underwent intra-articular surgery (posterior release in 42 and posteromedial release in 44). Significant abnormalities were found in ankle kinetics and isokinetic ankle strength in the feet treated with intra-articular surgery compared with the nonoperatively treated feet (p < 0.017). Compared with controls (n = 40 feet), all groups showed reduced ankle plantar flexion during gait, resulting in a deficit of 9% to 14% for dynamic range of motion, 13% to 20% for ankle moment, and 13% to 23% for power (p < 0.013). Within the intra-articular group, feet that underwent posteromedial release had decreased plantar flexion strength (15%; p = 0.008), dorsiflexion strength (6%; p = 0.048), and parent-reported global function scores (p = 0.032) compared with the posterior release group. The patients with clubfoot took 10% fewer steps (p = 0.015) and had 11% less total ambulatory time (p = 0.001) than the controls. CONCLUSIONS: Examination of patients when they had reached the age of 10 years showed better ankle power and isokinetic strength for clubfeet treated without surgery compared with those that underwent intra-articular surgery for residual deformity or recurrence. Compared with controls, both nonoperatively and surgically treated clubfeet had significant limitations in ankle plantar flexion resulting in decreased range of motion, moment, and power. Gastrocnemius-soleus complex strength was decreased after both nonoperative and surgical treatment of clubfeet. Although activity was diminished in the clubfoot population, no differences in function were perceived by the patients' parents. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Gross Motor Function at 10 Years of Age in Children With Clubfoot Following the French Physical Therapy Method and the Ponseti Technique.

PURPOSE: To evaluate gross motor skills [Bruininks-Oseretsky Test of Motor Proficiency, 2nd ed (BOT-2)] of patients with idiopathic clubfoot initially treated nonoperatively with either the French functional physical therapy (PT) method or the Ponseti technique, at age 10 years. METHODS: The BOT-2 was administered by trained physical therapists on patients with idiopathic clubfoot at age 10 years. The cohort was divided by initial treatment method (PT or Ponseti), and compared. Subsequent analyses included comparisons of: initial clubfoot severity (Dimeglio scores: ≤13 vs. >13), laterality (unilateral vs. bilateral), and surgical versus nonoperative outcome. RESULTS: Of the 183 patients tested, 172 were included. The Ponseti and PT groups did not significantly differ according to age, height, weight, body mass index, ankle dorsiflexion, sex, average initial Dimeglio score, laterality, or surgical versus nonsurgical outcome. Overall, patients with treated clubfoot had average gross motor BOT-2 scores compared with age-matched peers. Patients in the PT group scored higher on Running Speed/Agility (P=0.019), Body Coordination percentile rank (P=0.038), and Strength and Agility percentile rank (P=0.007) than patients treated by the Ponseti technique. Patients with bilateral clubfoot scored significantly lower on the Balance subtest (P<0.01), and Body Coordination percentile rank (P<0.01), than those with unilateral clubfoot. Patients who required surgery scored significantly lower on the Balance subtest (P=0.04) than those who did not require surgery. CONCLUSIONS: Clubfoot may impair balance in 10 year olds with bilateral involvement and those requiring surgery. Future research should evaluate whether components of the PT method may improve gross motor outcomes as a supplement to the Ponseti technique. LEVELS OF EVIDENCE: Level II.

Clubfoot Does Not Impair Gross Motor Development in 5-Year-Olds.

PURPOSE: To evaluate the gross motor development of 5-year-olds using the Peabody Developmental Motor Scales, 2nd Edition (PDMS-2), test after initial nonoperative management of clubfoot as infants. METHODS: The PDMS-2 Stationary, Locomotion, and Object Manipulation subtests were assessed on 128 children with idiopathic clubfeet at the age of 5 years. Children were categorized by their initial clubfoot severity as greater than 13, unilateral or bilateral involvement, and required surgery. RESULTS: Children with treated clubfeet had average gross motor scores (99 Gross Motor Quotient) compared with age-matched normative scores. Children with more severe clubfeet required surgery significantly more than children with less severe scores (P < .01). Peabody scores were not significantly different according to initial clubfoot severity, unilateral versus bilateral involvement, and surgical versus nonsurgical outcomes. CONCLUSIONS: Clubfoot does not significantly impair gross motor development in 5-year-olds.

How Is Pulmonary Function and Exercise Tolerance Affected in Patients With AIS Who Have Undergone Spinal Fusion?

STUDY DESIGN: Prospectively enrolled AIS patients who underwent spinal fusion, with 2 year follow-up. OBJECTIVES: To evaluate the cardiovascular fitness and activity level in patients with AIS pre- and post-spinal fusion and to determine if initial curve magnitude or pulmonary function is predictive of exercise capacity. SUMMARY OF BACKGROUND DATA: Researchers have tried to link pulmonary function testing (PFT) to exercise capacity; the results are mixed. Some report no improvement in PFTs or aerobic activity after surgical correction, and PFT measures were not predictive of exercise capacity. Conflicting results have shown Vo2max results to fall within normal range in AIS patients while PFTs show minimal impairment. METHODS: AIS patients underwent PFT and oxygen consumption (VO2) testing during a submaximal graded exercise test (GXT) pre- and post-spinal fusion. Vo2max was predicted in those patients who completed the test to 85% of maximal heart rate. Pre- to postoperative changes were assessed and then compared to age-matched control subjects. Correlations between Vo2max and curve severity, pulmonary function, and activity level were assessed. RESULTS: Thirty-seven patients participated. Vo2max was predicted in 23 patients pre- and postoperation. There was a significant reduction in Vo2max postfusion (39.5 ± 6.5 mL/kg/min vs 42.1 ± 8.1 mL/kg/min, p = .033); however, compared with controls (40.5 ± 6.5 mL/kg/min), all data were within the normal range (p > .05). AIS patients reporting high activity had significantly greater Vo2max than those reporting low activity both pre and postoperatively, but this difference only met statistical significance preop (p < .05). Curve magnitude and PFT measures were not found to correlate with Vo2max (p > .05). CONCLUSIONS: Vo2max in patients with AIS is within normal range both pre- and postfusion. Pulmonary limitations are accommodated for with a slightly increased breathing rate and a slightly reduced overall workload. Activity level rather than curve severity affects Vo2max outcomes following fusion in AIS.

Brace Success Is Related to Curve Type in Patients with Adolescent Idiopathic Scoliosis.

BACKGROUND: Curve magnitude and skeletal maturity are important factors in determining the efficacy of bracing for the treatment of adolescent idiopathic scoliosis, but curve morphology may also affect brace success. The purpose of this study was to determine the influence of curve morphology on the response to bracing with a thoracolumbosacral orthosis (TLSO). METHODS: A retrospective review of patients managed with an orthosis for the treatment of adolescent idiopathic scoliosis who were prospectively enrolled at the initiation of brace wear and followed through completion of bracing or surgery was performed. Inclusion criteria were main curves of 25° to 45° and a Risser stage of 0, 1, or 2 at the time of brace prescription. Compliance with bracing was measured with Maxim Integrated Thermochrons. Radiographs made at brace initiation, brace cessation, and final follow-up were used to retrospectively categorize curves with use of the modified Lenke (mLenke) classification system and more broadly to categorize them as main thoracic or main lumbar. The effect of morphology on outcome was evaluated using chi-square and Fisher exact tests. RESULTS: One hundred and sixty-eight patients were included. There was no difference in curve magnitude at the time of brace initiation (p = 0.798) or in average hours of daily brace wear (p = 0.146) between groups. The rate of surgery or progression of the curve to ≥50° was 34.5% (29 of 84) in mLenke-I curves, 54.5% (6 of 11) in mLenke-II curves, 29.4% (10 of 34) in mLenke-III curves, 17.6% (3 of 17) in mLenke-V curves, and 13.6% (3 of 22) in mLenke-VI curves. There were no mLenke-IV curves at the time of brace initiation. The rate of surgery or progression to ≥50° was 34.1% (44 of 129) in the combined thoracic group and 15.4% (6 of 39) in the combined lumbar group (p = 0.0277). In brace-compliant patients (>12.9 hours/day), the rate of surgery or progression to ≥50° was 30.3% (20 of 66) in main thoracic curves and 5.3% (1 of 19) in main lumbar curves (p = 0.0239). One-tenth of curves changed morphology during bracing. The rate of surgery or progression to ≥50° was 35.8% (43 of 120) in persistent main thoracic curves, 20.0% (6 of 30) in persistent main lumbar curves, 12.5% (1 of 8) in main thoracic curves that became main lumbar curves, and 0% (0 of 9) in main lumbar curves that became main thoracic curves (p = 0.0383). CONCLUSIONS: Thoracic curves are at greater risk for brace failure than lumbar curves are despite similar initial curve magnitudes and average amount of daily brace wear. A change in curve pattern may imply flexibility and is associated with brace success. Patients with thoracic curves should be counseled accordingly. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Adolescent Idiopathic Scoliosis: Update on Bracing, Surgical Techniques, and Patient Safety.

The primary goal in the management of adolescent idiopathic scoliosis is to prevent the progression of spinal deformity either with the use of a brace or with surgery. The goals of surgery, if indicated, are to correct the spinal deformity safely and to preserve overall spinal balance and as many motion segments as possible, which maximizes the long-term health of a patient's spine. Recently, tremendous advances have been made in the surgical techniques that are used to correct adolescent idiopathic scoliosis, and improved tools have allowed surgeons to perform spinal deformity surgery as safely and with as few complications as possible. Surgeons should be aware of recent evidence that demonstrates the efficacy of bracing in patients who have adolescent idiopathic scoliosis. In addition, surgeons should understand recent advances in spinal deformity surgery with regard to fusion level selection, implant placement, three-dimensional deformity correction, and techniques that are used to minimize perioperative complications.

Plantar Pressures After Nonoperative Treatment for Clubfoot: Intermediate Follow-up at Age 5 Years.

INTRODUCTION: Worldwide, a nonoperative approach in the treatment of idiopathic clubfoot has been taken in an attempt to reduce the incidence of surgical outcomes. Although both the Ponseti casting (Ponseti) and the French physiotherapy (PT) methods have shown gait and pedobarograph differences at age 2 years, improved gait results have been reported by age 5 years. The purpose of this study was to assess plantar pressures in feet treated with the Ponseti versus the PT methods at this intermediate stage. METHODS: Clubfoot patients treated nonoperatively (Ponseti or PT) underwent pedobarograph data collection at age 5 years. The foot was subdivided into the medial/lateral hindfoot, midfoot, and forefoot regions. Variables included Peak Pressure, Maximum Force, Contact Area%, Contact Time%, Pressure Time Integral, the hindfoot-forefoot angle, and displacement of the center of pressure (COP) line. Twenty controls were used for comparison. RESULTS: Pedobarograph data from 164 patients (238 feet; 122 Ponseti and 116 PT) showed no significant differences between the Ponseti and the PT feet, except the PT feet had a significantly less medial movement of the COP than the Ponseti feet (P=0.0379). Compared with controls, both groups had decreased plantar pressures in the hindfoot and first metatarsal regions, whereas the midfoot and lateral forefoot experienced significant increases compared with controls. This lateralization was also reflected in the hindfoot-forefoot angle and the COP. CONCLUSIONS: Feet that remain nonoperative and avoid surgical intervention are considered a good clinical result. However, pedobarograph results indicate mild residual deformity in these feet despite clinically successful outcomes. LEVEL OF EVIDENCE: Level II-therapeutic.

The Effect of the Risser Stage on Bracing Outcome in Adolescent Idiopathic Scoliosis.

BACKGROUND: To determine the influence of the Risser sign on the need for surgery in children wearing orthoses for the treatment of adolescent idiopathic scoliosis (AIS), data on compliance with brace wear were collected and analyzed. METHODS: One hundred and sixty-eight patients were prospectively enrolled at the time that brace wear had been prescribed and were followed until the cessation of bracing or the need for surgery. Inclusion criteria were a curve magnitude between 25° and 45°; a Risser stage of 0, 1, or 2; and, if female, <1 year post menarche at the time of brace prescription. Compliance was measured using thermal monitors. RESULTS: The prevalence of surgery, or progression to a curve magnitude of ≥50°, was 44.2% for patients at Risser stage 0 (n = 120), 6.9% for patients at Risser stage 1 (n = 29), and 0% for patients at Risser stage 2 (n = 19). Brace wear averaged 11.3, 13.4, and 14.2 hours per day for the Risser stage-0, 1, and 2 groups, respectively. While the groups had no difference in initial curve magnitude (p = 0.11), more patients at Risser stage 0 had progression to surgery than did patients at Risser stage 1 or stage 2 despite bracing (p < 0.0001). Twenty-six (41.9%) of 62 Risser stage-0 patients who wore braces ≥12.9 hours per day had progression to surgery. Ten patients at Risser stage 0 with closed triradiate cartilage wore braces ≥18 hours per day, and none underwent surgery. In comparison, 7 of 10 patients at Risser stage 0 with open triradiate cartilage and similar daily brace wear underwent surgery. Of 9 patients at Risser stage 0 with open triradiate cartilage who wore braces ≥12.9 hours daily for curves measuring <30°, 7 had a nonsurgical outcome. CONCLUSIONS: Patients at Risser stage 0 are at risk for surgery despite brace wear. In these patients, 12.9 hours of daily wear-the number of hours linked with a successful outcome in the BRAIST (Bracing in Adolescent Idiopathic Scoliosis Trial)-did not prevent surgery. Patients with open triradiate cartilage were at highest risk, especially those with curves of ≥30°. Risser stage-0 patients should be prescribed a minimum of 18 hours of brace wear. Bracing should be initiated for curves of <30° in patients at Risser stage 0, especially those with open triradiate cartilage. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Effect of Compliance Counseling on Brace Use and Success in Patients with Adolescent Idiopathic Scoliosis.

BACKGROUND: Outcomes of orthotic management of idiopathic scoliosis depend on patient compliance with brace wear. The purpose of this study was to determine if counseling based on objective compliance data increases brace wear and therefore reduces the likelihood of surgery. METHODS: Two hundred and twenty-two patients with adolescent idiopathic scoliosis were prospectively enrolled in a study to determine if physician counseling based on data obtained from compliance monitors (sensors embedded in the brace) improves brace use and decreases curve progression. Patients were placed into two groups. In the counseled group, patients were aware of the compliance monitor in the brace and were counseled at each visit regarding downloaded brace-usage data. The patients in the noncounseled group were not told the purpose of the monitor in their brace, and the compliance data were not made available to the physician, orthotist, or patient. RESULTS: Ninety-three patients who were counseled with use of the compliance data and seventy-eight patients who were not so counseled completed bracing or underwent surgery; twenty-five patients were lost to follow-up before completing brace treatment, and twelve were still undergoing brace treatment at the time of the study review. The average curve magnitude at the initiation of bracing was 33.2° in the counseled group and 33.9° in the noncounseled group (p = 0.21 [not significant]). Patients in the counseled group wore their orthosis an average of 13.8 hours per day throughout their management, while noncounseled patients wore their brace an average of 10.8 hours per day (p = 0.002). Of the counseled patients who finished brace treatment, 59% did not have curve progression of ≥6°, whereas 25% had progression to ≥50° or to surgery. In the noncounseled group, 46% did not have curve progression of ≥6°, whereas 36% had progression to ≥50° or to surgery. Noncounseled patients who had curve progression to a magnitude requiring surgery wore their brace an average of 9.6 hours per day compared with 12.6 hours per day for the counseled patients who required surgery. The amount of daily brace wear by children who did not have curve progression to a magnitude requiring surgery was significantly greater than that by children who did require surgery (p = 0.029). CONCLUSIONS: Providing patients undergoing bracing for adolescent idiopathic scoliosis with feedback about their compliance with brace wear improves that compliance. Patients who wore their brace more hours per day had less curve progression. Patients in both groups who had curve progression to a magnitude requiring surgery wore their brace less than their counterparts for whom bracing was successful. Compliance monitoring and counseling based on that monitoring should become part of the clinical orthotic management of patients with adolescent idiopathic scoliosis.

The Relationship Between Gait, Gross Motor Function, and Parental Perceived Outcome in Children With Clubfeet.

BACKGROUND: Assessment of children treated nonoperatively for idiopathic clubfoot, has primarily focused on the kinematic and kinetic results measured with gait analysis (GA). Excellent results in ankle motion and push-off power during gait have been reported at age 5; however, the assessment of gross motor function, has not been evaluated. The purpose of this study was to look at the relationship between gait measures, Peabody Developmental Motor Scales and parent-perception of their child's outcome [measured with the Pediatric Outcomes Data Collection Instrument (PODCI)]. METHODS: A total of 81 children with idiopathic clubfoot were seen for both GA and Peabody testing. Children who initially underwent the Ponseti technique (n=29), the French Physical Therapy method (PT) (n=23), and a group of children initially treated nonoperatively, but who required surgical intervention before GA at 5 years of age (n=29) were enrolled. Pearson's correlation coefficient was used to establish significant relationships between gait variables, Peabody, and PODCI scores. RESULTS: Gait data showed that the Ponseti treated feet had significantly greater ankle power than feet treated surgically (P=0.0075). The Peabody results showed that the PT feet had higher stationary (P=0.0332) and overall gross motor quotient percent (GMQ%) scores (P=0.0092) than the surgical feet. No differences were found in PODCI scores. Ankle power was weakly correlated to the GMQ% (r=0.29; P=0.0102); however, the GMQ% showed a strong correlation to the parent report of Global Functioning Scale on the PODCI (r=0.48; P=0.0005). CONCLUSIONS: Minimal gait disturbances do not interfere with function or parental assessment of abilities and satisfaction at 5-year follow-up in children with idiopathic clubfeet. Nonoperative correction of clubfeet should be the goal when possible, as the Peabody scores show better function as early as 5 years of age when surgery is not required.

Radiographic Assessment of Shoulder Position in 619 Idiopathic Scoliosis Patients: Can T1 Tilt Be Used as an Intraoperative Proxy to Determine Postoperative Shoulder Balance?

BACKGROUND: The purpose of this study is to assess radiographic shoulder measures from the preoperative to the postoperative time period, specifically to determine whether T1 tilt could be used as an intraoperative proxy for shoulder balance determination. This study focused on radiographic shoulder measures of 619 adolescent idiopathic scoliosis patients who underwent spinal deformity surgery. METHODS: A prospective, multicenter database of adolescent idiopathic scoliosis was queried to identify all patients who had undergone spinal deformity surgery with >2 years of follow-up postoperatively. Radiographic analysis focused on measures of shoulder balance: T1 tilt, clavicle angle, and radiographic shoulder height. RESULTS: A total of 619 patients were included in this analysis. Mean age at surgery was 14.8 years with 83% female. Mean preoperative curve size was 58.0 degrees. Mean T1 tilt preoperatively was -0.10 degrees and postoperatively 2.42 degrees. Mean clavicle angle preoperatively was -1.39 degrees and postoperatively 0.79 degrees. Mean radiographic shoulder height preoperatively was -7.04 mm and postoperatively 1.63 mm. All 3 radiographic parameters demonstrated reasonable correlation preoperatively and postoperatively to each other. To assess the viability of T1 tilt as an intraoperative proxy for shoulder balance, standardized ratios between the variables were created. Analysis of these ratios demonstrated little or no relationship preoperatively to postoperatively, hence the relationship of T1 tilt to radiographic shoulder height does not remain constant. CONCLUSIONS: Analysis of the relationship of T1 tilt to radiographic shoulder height from preoperative to postoperative did not demonstrate consistency. Lenke 3 and 6 curve patterns demonstrated preoperative to postoperative correlation, both with nonstructural proximal thoracic curves; however, for the remaining curve patterns T1 tilt cannot be used as an intraoperative proxy for shoulder balance. LEVEL OF EVIDENCE: Level IV.

A Longitudinal Review of Gait Following Treatment for Idiopathic Clubfoot: Gait Analysis at 2 and 5 Years of Age.

BACKGROUND: Initial correction following nonoperative (NonOp) treatment for idiopathic clubfoot has been reported in 95% of feet by age 2; however, by age 4, approximately one third of feet undergo surgery due to relapse. The purpose of this study was to assess the longitudinal effect of growth and surgical (Sx) intervention on gait following NonOp and Sx treatment for clubfoot. METHODS: Children with idiopathic clubfoot were seen for gait analysis at 2 and 5 years of age. Kinematic data were collected at both visits, and kinetic data were collected at age 5 years. Group comparisons were made between feet treated with the Ponseti casting technique (Ponseti) and the French physical therapy method (PT) and between feet treated nonoperatively and surgically. Comparisons were made between feet treated with a limited release or tendon transfer (fair) and those treated with a full posteromedial release (poor). The α was set to 0.05 for all statistical analyses. RESULTS: Gait data from 181 children with 276 idiopathic clubfeet were collected at both age 2 and 5 years. Each foot was initially treated with either the Ponseti (n=132) or PT (n=144) method but by the 5-year visit, 30 Ponseti and 61 PT feet required surgery. Gait outcomes showed limitations primarily in the Sx clubfeet. Normal ankle motion was only present in 17% of Ponseti and 21% of PT feet by age 5 following Sx management. Sx PT feet showed persistent intoeing at age 2 and 5. Within the Sx group, feet initially treated with PT had a clinically significant reduction in ankle power compared with those treated initially by the Ponseti method. Feet treated with posteromedial releases had significantly less ankle power than those treated with limited surgery or that remained NonOp at 5 years. CONCLUSIONS: This longitudinal study shows subtle changes between 2 and 5 years, and continues to support a NonOp approach in the treatment of clubfoot. LEVEL OF EVIDENCE: Level II-therapeutic.