Radiographic and patient-based outcome analysis of different bone-grafting techniques in the surgical treatment of idiopathic scoliosis with a minimum 4-year follow-up: allograft versus autograft/allograft combination.

BACKGROUND CONTEXT: Autograft and allograft have been equally successful in achieving arthrodesis, but whether there is any difference in their effect on patient outcome, especially early, has not been determined. PURPOSE: To determine if autograft in addition to allograft is associated with decreased healing period pain, increased early function, or both. STUDY DESIGN: This is a retrospective comparative case series. PATIENT SAMPLE: A sample of 47 patients, 20 years or younger with adolescent idiopathic scoliosis treated by the same surgeon at the same institution using third-generation segmental spinal instrumentation and arthrodesis. OUTCOME MEASURE: Function and pain were quantified at periodic intervals using the Scoliosis Research Society (SRS) health-related quality of life (HRQoL) questionnaire. Clinical and radiographic follow-ups were completed. METHODS: Freeze-dried corticocancellous allograft (AL) was used in 26 patients and allograft plus iliac crest autograft (AL-AU) in 21 patients. Radiographs and outcome measures, including SRS-24 or SRS-22 HRQoL questionnaires, were obtained preoperatively and at intervals with a 4-year follow-up available for 92% (25/26) of AL patients and 90% (19/21) of AL-AU patients. RESULTS: There were no differences between the AL and AL-AU groups' ages, curve patterns, and complications. Neither group had a major complication or pseudoarthrosis. There were no main curve size differences at any interval. Pain scores were similar at all intervals: AL/AL-AU preoperative, 4.1/4.0; early follow-up (<1 year), 3.7/4.1; midterm follow-up (1-2 years), 4.4/4.6; and late follow-up (>3 years), 4.1/4.0. Function scores were also similar at all intervals: AL/AL-AU preoperative, 4.7/4.6; early follow-up, 4.2/4.3; midterm follow-up, 4.9/4.9; and late follow-up, 4.5/4.4. CONCLUSIONS: The addition of autograft to allograft did not result in decreased pain or increased function at any time interval up to 4 years. We conclude that the addition of iliac crest autograft does not result in any advantage over freeze-dried allograft alone in the treatment of adolescent idiopathic scoliosis.

Residual deformity after treatment of pediatric femur fractures with flexible titanium nails.

INTRODUCTION: Procurvatum or anterior bow deformity is a potential complication after treatment of femur fractures with flexible titanium nails (FTNs). This article reports on a clinical evaluation of angulation after treating pediatric femur fractures with FTNs. The article also reports on a complementary investigation of potential causes of these deformities using a biomechanical model. METHODS: All pediatric femoral shaft fractures treated with FTNs over a 4-year period were reviewed. Fracture location, pattern, angulation, and nail shoe tip orientation were recorded from postoperative radiographs. Malunion was defined as greater than 10 degrees of angulation on the AP radiograph or greater than 15 degrees on the lateral view. As an adjunct to the clinical study, a synthetic femur model was created using midtransverse fractures. These femurs were nailed using 2 FTNs inserted so as to create constructs having the following combinations of nail shoe tip orientation: both anterior (AA), both posterior (PP), both neutral (NN), or 1 anterior and 1 posterior(AP). The resulting angular deformities noticeable upon gross inspection were then measured. RESULTS: Of the 70 fractures reviewed, malunion occurred in 16 fractures, of which 11 had increased anterior bow. A majority of malunions was observed in older children with middle third of the femur fractures. They were significantly more prevalent in transverse fractures compared with all other fracture patterns. Clinically, increased anterior bowing did not occur if 1 of the nails was positioned to resist procurvatum, as seen in the lateral radiograph. Depending on nail tip orientation, the biomechanical femur fracture model showed significant differences in mean deformations after nail placement: AA had 12.6 degrees of posterior bow compared with 14.8, 3.7, and 0.3 degrees of anterior bow for PP, NN, and AP, respectively. CONCLUSION: Anterior bowing greater than 15 degrees is the most common malunion noted in this series of femur fractures that were nailed using FTN's. We conclude that final nail shoe tip orientation influences the likelihood of anterior bow deformity. The likelihood of large anterior bowing may be reduced if at least 1 of the nails is inserted with the tip pointing in an anterior direction. LEVEL OF EVIDENCE/CLINICAL RELEVANCE: Level III.