Rib-on-Pelvis Deformity and Reported Pain in Neuromuscular Early-Onset Scoliosis.

BACKGROUND: Neuromuscular early-onset scoliosis (N-EOS) often presents with a long sweeping thoracolumbar scoliosis and pelvic obliquity. With severe pelvic obliquity, the ribs come into contact with the high side of the pelvis, termed rib-on-pelvis deformity (ROP). The goal of this study is to evaluate whether ROP is associated with reported pain and other health-related quality of life (HRQOL) measures. We hypothesize that ROP is associated with increased pain and negative HRQOL. METHODS: A multicenter international registry was queried for all nonambulatory patients with N-EOS from 2012 to 2022. Both surgical and nonsurgical patients were included. ROP was classified as a binary radiographic assessment of preoperative (surgical patients) and most recent follow-up (nonsurgical patients) upright radiographs. Reported pain and other HRQOL measures were assessed through the 24-Item Early Onset Scoliosis Questionnaire (EOSQ-24). Patients with nonupright radiographs or EOSQ-24 questionnaires and corresponding radiographs >4 months apart were excluded. RESULTS: Totally, 225 patients (8.4±3.1 y, 55% female) were included. The median major curve was 63.3 (IQR: 40.6 to 81.2) degrees and median pelvic obliquity was 15.5 degrees (IQR: 8.8 to 26.4). Eighty-three patients (37%) had ROP. ROP was associated with both frequency (P<0.001) and severity (P<0.001) of pain. ROP was associated with worse general health (P=0.01), increased difficulty with vocalization (P=0.02), increased frequency of shortness of breath (P=0.002), and increased difficulty sitting upright (P=0.04). Regarding overall EOSQ-24 domains, ROP was associated with worse general health, pain/discomfort, pulmonary function, and physical function (P<0.01). In a subanalysis of 76 patients who underwent surgical intervention with at least 2 years of follow-up, patients with preoperative ROP experienced significantly greater improvements in both frequency (P=0.004) and severity (P=0.001) of pain than the patients without preoperative ROP at 2 years postoperatively. CONCLUSIONS: The overall incidence of ROP in N-EOS is about 37%. ROP is associated with greater pain and worse HRQOL through the EOSQ-24 questionnaire. Furthermore, these patients experienced a greater reduction in pain after surgery. Clinicians and parents must be aware that ROP is possibly a pain generator, but responds positively to surgical intervention. LEVEL OF EVIDENCE: Level III.

Predicting brace holiday eligibility in juvenile idiopathic scoliosis.

PURPOSE: The psychological effects of scoliosis bracing can be difficult, and thus clinicians sometimes recommend a brace holiday when the curve corrects to less than 25°. However, the clinical indications for taking a break from the brace before reaching maturity have yet to be described. We hypothesized there would be a relationship between brace holiday eligibility and degree of curve at presentation, change in curve magnitude while bracing, and level of bracing compliance. METHODS: A retrospective cohort study at a single institution was performed from 2016 to 2022. Objective brace compliance I-button data were collected on patients aged 3-9 years old. Patients with other etiologies besides idiopathic scoliosis before the age of 10 were excluded. Binary logistic regression was performed to determine the effect of significant variables on the likelihood of brace holiday. RESULTS: Fifty-six patients met inclusion criteria. Of these, 20 were able to get a brace holiday. Patients with higher brace compliance and larger in-brace curve correction were more likely to get a brace holiday (P = 0.015, 0.004). Patients with higher BMIs and larger curves at initial presentation were less likely to get a brace holiday (P = 0.002, 0.014). CONCLUSION: Compliant brace wearers with good in-brace correction are most likely to be eligible for a brace holiday. While some elements remain immutable, others are modifiable, such as bracing compliance. Understanding how outcomes differ between patients who do and do not take a brace holiday will be crucial to elucidating if the psychological benefit of taking a break from the brace can be justified.

A modified position for optimized skeletal maturity assessment of AIS patients and its impact on 3D spinal and pelvic parameters.

PURPOSE: A hands-on-wall (HOW) position for low-dose stereoradiography of adolescent idiopathic scoliosis (AIS) patients would allow for skeletal maturity assessment of the hand and wrist. Our aims were twofold: confirm the reliability and validity of skeletal maturity assessment using the HOW radiographs and compare the spinal and pelvic 3D parameters to those of standard hands-on-cheeks (HOC) stereoradiographs. METHODS: Seventy AIS patients underwent two successive stereoradiographs and a standard hand and wrist radiograph on the same day. Patients were randomly assigned to begin with HOW and follow with HOC, or vice versa. Raters assessed digital skeletal age (DSA), Sanders Simplified Skeletal Maturity (SSMS) and Thumb Ossification Composite Index (TOCI). 3D reconstructions of the spine and pelvis bones were performed for each stereoradiograph to measure nine clinically relevant spinal and pelvic 3D parameters. RESULTS: Inter-rater and intra-rater reliabilities were excellent for DSA, SSMS and TOCI with both standard radiographs and HOW (ICC > 0.95). Strong correlation was found between ratings of both imaging types (ICC > 0.95). In the 3D reconstructions, kyphosis and sacral slope were slightly decreased in the HOW position, but within the clinical margin of error. All other parameters did not differ significantly between positions (p < 0.05). CONCLUSION: The results suggest that HOW stereoradiographs allow clinicians to assess skeletal maturity of the hand and wrist with adequate reliability and validity. We recommend that scoliosis clinics adopt the HOW position to assess skeletal maturity because there is no significant clinical impact on the spinal and pelvic evaluation, and on radiation exposure, cost or time.

Perioperative management and outcomes for posterior spinal fusion in patients with Friedreich ataxia: A single-center, retrospective study.

BACKGROUND: Friedreich ataxia is a rare genetic disorder associated with progressive mitochondrial dysfunction leading to widespread sequelae including ataxia, muscle weakness, hypertrophic cardiomyopathy, diabetes mellitus, and neuromuscular scoliosis. Children with Friedreich ataxia are at high risk for periprocedural complications during posterior spinal fusion due to their comorbidities. AIM: To describe our single-center perioperative management of patients with Friedreich ataxia undergoing posterior spinal fusion. METHODS: Adolescent patients with Friedreich ataxia presenting for spinal deformity surgery between 2007 and 2023 were included in this retrospective case series performed at the Children's Hospital of Philadelphia. Perioperative outcomes were reviewed along with preoperative characteristics, intraoperative anesthetic management, and postoperative medical management. RESULTS: Seventeen patients were included in the final analysis. The mean age was 15 ± 2 years old and 47% were female. Preoperatively, 35% were wheelchair dependent, 100% had mild-to-moderate hypertrophic cardiomyopathy with preserved systolic function and no left ventricular outflow tract obstruction, 29% were on cardiac medications, and 29% were on pain medications. Intraoperatively, 53% had transesophageal echocardiography monitoring; 12% had changes in volume status on echo but no changes in function. Numerous combinations of total intravenous anesthetic agents were used, most commonly propofol, remifentanil, and ketamine. Baseline neuromonitoring signals were poor in four patients and one patient lost signals, resulting in 4 (24%) wake-up tests. The majority (75%) were extubated in the operating room. Postoperative complications were high (88%) and ranged from minor complications like nausea/vomiting (18%) to major complications like hypotension/tachycardia (29%) and need for extracorporeal membrane oxygenation support in one patient (6%). CONCLUSIONS: Patients with Friedreich ataxia are at high risk for perioperative complications when undergoing posterior spinal fusion and coordinated multidisciplinary care is required at each stage. Future research should focus on the utility of intraoperative echocardiography, optimal anesthetic agent selection, and targeted fluid management to reduce postoperative cardiac complications.

Predicting early return to the operating room in early-onset scoliosis patients using machine learning techniques.

PURPOSE: Surgical treatment of early-onset scoliosis (EOS) is associated with high rates of complications, often requiring unplanned return to the operating room (UPROR). The aim of this study was to create and validate a machine learning model to predict which EOS patients will go on to require an UPROR during their treatment course. METHODS: A retrospective review was performed of all surgical EOS patients with at least 2 years follow-up. Patients were stratified based on whether they had experienced an UPROR. Ten machine learning algorithms were trained using tenfold cross-validation on an independent training set of patients. Model performance was evaluated on a separate testing set via their area under the receiver operating characteristic curve (AUC). Relative feature importance was calculated for the top-performing model. RESULTS: 257 patients were included in the study. 146 patients experienced at least one UPROR (57%). Five factors were identified as significant and included in model training: age at initial surgery, EOS etiology, initial construct type, and weight and height at initial surgery. The Gaussian naïve Bayes model demonstrated the best performance on the testing set (AUC: 0.79). Significant protective factors against experiencing an UPROR were weight at initial surgery, idiopathic etiology, initial definitive fusion construct, and height at initial surgery. CONCLUSIONS: The Gaussian naïve Bayes machine learning algorithm demonstrated the best performance for predicting UPROR in EOS patients. Heavier, taller, idiopathic patients with initial definitive fusion constructs experienced UPROR less frequently. This model can be used to better quantify risk, optimize patient factors, and choose surgical constructs. LEVEL OF EVIDENCE: Prognostic: III.

Nationwide Effect of COVID-19 on Cases Performed During Pediatric Orthopaedic Surgery Fellowship Training in the United States.

INTRODUCTION: The COVID-19 pandemic negatively affected surgical training in the United States. We hypothesized that reported case volume during pediatric orthopaedic surgery fellowship training would decrease markedly during the 2019 to 2020 academic year, which corresponded with the COVID-19 outbreak. METHODS: The Accreditation Council for Graduate Medical Education provided nationwide case logs for accredited pediatric orthopaedic surgery fellows (2017 to 2021). Annual reported case volumes were extracted and summarized as means ± SD. Parametric tests were used to compare annual case volumes. RESULTS: A total of 149 pediatric orthopaedic fellows from 23 accredited fellowships were included. A 16% year-over-year (YoY) decrease was noted in the reported case volume during the 2019 to 2020 academic year (238 ± 80 vs. 255 ± 60, P < 0.001). Nonacute case categories had the most notable YoY percentage decreases: Soft Tissue: Transfer, Lengthen, Release (-42%); Clubfoot (-34%); and Foot and Ankle Deformity (-31%). Acute case categories had the most notable YoY percentage increases: Trauma Lower Limb (12%) and Trauma Upper Limb (10%). A subsequent 42% YoY increase was noted in the reported case volume during the 2020 to 2021 academic year. DISCUSSION: A 16% YoY decrease was noted in the reported case volume during the 2019 to 2020 academic year, which corresponded to widespread economic shutdowns during the initial COVID-19 outbreak. Nonacute cases experienced the greatest negative effect. The results from this study may inform the orthopaedic surgery community on the effect of future national emergencies, such as viral outbreaks.

Impact of Social Determinants of Health on Adolescent Idiopathic Scoliosis Curve Severity.

INTRODUCTION: Social determinants of health have been shown to influence the health and outcomes of pediatric patients. Adolescent idiopathic scoliosis (AIS) may be particularly sensitive to such factors as early diagnosis and treatment can obviate the need for surgical intervention. The purpose of this study was to analyze the effect that social determinants of health have on the severity of AIS at presentation and at the time of surgery. METHODS: A retrospective review was conducted for consecutive patients who underwent posterior spinal fusion for AIS from 2020 to 2022. Demographic data was collected, while insurance status (private vs. public) and childhood opportunity index (COI) categories (LOW vs. HIGH) were used as a proxy for socioeconomic status. Curve magnitude at the initial presentation and at the latest preoperative visit were recorded with a threshold of 25 to 40 degrees considered within the bracing range. Univariate and multivariate analysis was done to compare differences between subgroups as appropriate. RESULTS: A total of 180 patients with mean initial and preoperative major curve angles of 48 and 60 degrees were included. Statistically significant differences in race and insurance types were appreciated, with the LOW COI group having a higher proportion of underrepresented minority and publicly insured patients than the HIGH COI group ( P <0.001). Patients within the LOW COI group presented with an initial curve that was, on average, 6 degrees more severe than those within the HIGH group ( P =0.009) and a preoperative curve that was 4 degrees larger than those within the HIGH group ( P =0.015). Similarly, only 13% of patients within the LOW COI group presented with curves within the bracing threshold, compared with 31% in the HIGH COI group ( P =0.009). CONCLUSION: Socioeconomic status plays a significant role in the severity of AIS. Specifically, patients with lower COI tend to present with curve magnitudes beyond what is responsive to nonsurgical treatment, leading to larger curves at the time of surgery. Future work should focus on addressing social inequalities to optimize the treatment and outcomes of AIS patients. LEVEL OF EVIDENCE: Level III- Retrospective Comparative Study.

BrAIST-Calc: Prediction of Individualized Benefit From Bracing for Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Prospective multicenter study data were used for model derivation and externally validated using retrospective cohort data. OBJECTIVE: Derive and validate a prognostic model of benefit from bracing for adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: The Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST) demonstrated the superiority of bracing over observation to prevent curve progression to the surgical threshold; 42% of untreated subjects had a good outcome, and 28% progressed to the surgical threshold despite bracing, likely due to poor adherence. To avoid over-treatment and to promote patient goal setting and adherence, bracing decisions (who and how much) should be based on physician and patient discussions informed by individual-level data from high-quality predictive models. MATERIALS AND METHODS: Logistic regression was used to predict curve progression to <45° at skeletal maturity (good prognosis) in 269 BrAIST subjects who were observed or braced. Predictors included age, sex, body mass index, Risser stage, Cobb angle, curve pattern, and treatment characteristics (hours of brace wear and in-brace correction). Internal and external validity were evaluated using jackknifed samples of the BrAIST data set and an independent cohort (n=299) through estimates of discrimination and calibration. RESULTS: The final model included age, sex, body mass index, Risser stage, Cobb angle, and hours of brace wear per day. The model demonstrated strong discrimination ( c -statistics 0.83-0.87) and calibration in all data sets. Classifying patients as low risk (high probability of a good prognosis) at the probability cut point of 70% resulted in a specificity of 92% and a positive predictive value of 89%. CONCLUSION: This externally validated model can be used by clinicians and families to make informed, individualized decisions about when and how much to brace to avoid progression to surgery. If widely adopted, this model could decrease overbracing of AIS, improve adherence, and, most importantly, decrease the likelihood of spinal fusion in this population.

Pregnancy and Childbirth After Spinal Fusion for Adolescent Idiopathic Scoliosis.

BACKGROUND: Little data exist on pregnancy and childbirth for adolescent idiopathic scoliosis (AIS) patients treated with a spinal fusion. The current literature relies on data from patients treated with spinal fusion techniques and instrumentation, such as Harrington rods, that are no longer in use. The objective of our study is to understand the effects of spinal fusion in adolescence on pregnancy and childbirth. METHODS: Prospectively collected data of AIS patients undergoing posterior spinal fusion that were enrolled in a multicenter study who have had a pregnancy and childbirth were reviewed. Results were summarized using descriptive statistics and compared with national averages using χ 2 test of independence. RESULTS: A total of 78 babies were born to 53 AIS patients. As part of their pre-natal care, 24% of patients surveyed reported meeting with an anesthesiologist before delivery. The most common types of delivery were spontaneous vaginal delivery (46%, n=36/78) and planned cesarean section (20%, n=16/78). Compared with the national average, study patients had a higher rate of cesarean delivery ( P =0.021). Of the women who had a spontaneous vaginal birth, 53% had no anesthesia (n=19/36), 19% received intravenous intermittent opioids (n=7/36), and 31% had regional spinal or epidural anesthesia (n=11/36). spontaneous vaginal delivery patients in our study cohort received epidural or spinal anesthesia less frequently than the national average ( P <0.001). Of those (n=26 pregnancies) who did not have regional anesthesia (patients who had no anesthesia or utilized IV intermittent opioids), 19% (n=5 pregnancies) were told by their perinatal providers that it was precluded by previous spine surgery. CONCLUSION: The majority of AIS patients reported not meeting with an anesthesiologist before giving birth and those who had a planned C-section did so under obstetrician recommendation. The presence of instrumentation after spinal fusion should be avoided with attempted access to the spinal canal but should not dictate a delivery plan. A multidisciplinary team consisting of obstetrician, anesthesiologist, and orthopaedic surgeon can provide the most comprehensive information to empower a patient to make her decisions regarding birth experience anesthesia based on maternal rather than provider preference. LEVEL OF EVIDENCE: IV.

Rib-to-spine and rib-to-pelvis magnetically controlled growing rods: does the law of diminishing returns still apply?

PURPOSE: The Law Of Diminishing Returns (LODR) has been demonstrated for traditional growing rods, but there is conflicting data regarding the lengthening behavior of Magnetically Controlled Growing Rods (MCGR). This study examines a cohort of patients with early-onset scoliosis (EOS) with rib-to-spine or rib-to-pelvis-based MCGR implants to determine if they demonstrate the LODR, and if there are differences in lengthening behaviors between the groups. METHODS: A prospectively collected multicenter EOS registry was queried for patients with MCGR with a minimum 2-year follow-up. Patients with rib-based proximal anchors and either spine- or pelvis-based distal anchors were included. Patients with non-MCGR, unilateral constructs, < 3 lengthenings, or missing > 25% datapoints were excluded. Patients were further divided into Primary-MCGR (pMCGR) and Secondary-MCGR (sMCGR). RESULTS: 43 rib-to-spine and 31 rib-to-pelvis MCGR patients were included. There was no difference in pre-implantation, post-implantation and pre-definitive procedure T1-T12 height, T1-S1 height, and major Cobb angles between the groups (p > 0.05). Sub-analysis was performed on 41 pMCGR and 19 sMCGR rib-to-spine patients, and 31 pMCGR and 17 sMCGR rib-to-pelvis patients. There is a decrease in rod lengthenings achieved at subsequent lengthenings for each group: rib-to-spine pMCGR (rho = 0.979, p < 0.001), rib-to-spine sMCGR (rho = 0.855, p = 0.002), rib-to-pelvis pMCGR (rho = 0.568, p = 0.027), and rib-to-pelvis sMCGR (rho = 0.817, p = 0.007). Rib-to-spine pMCGR had diminished lengthening over time for idiopathic, neuromuscular, and syndromic patients (p < 0.05), with no differences between the groups (p > 0.05). Rib-to-pelvis pMCGR neuromuscular patients had decreased lengthening over time (p = 0.01), but syndromic patients had preserved lengthening over time (p = 0.65). CONCLUSION: Rib-to-spine and rib-to-pelvis pMCGR and sMCGR demonstrate diminished ability to lengthen over subsequent lengthenings.

Changes in research quality and surgical trends at the international congress on early-onset scoliosis.

PURPOSE: The founding of the International Congress for Early Onset Scoliosis (ICEOS) and first annual meeting in 2007 represented a significant milestone in advancing the care of patients with EOS. Due to the complexity and rarity of EOS, this annual conference is the premiere venue for physicians, researchers, and advanced practice providers to identify and understand the best treatments for children with EOS. This study examines the trend of various treatment modalities presented at ICEOS and the changes in research quality since its inception. METHODS: Podium presentations from the 2007 through 2021 ICEOS annual meetings were reviewed to determine the number of study patients, use of a study group, and key features of study design. Treatment strategies being evaluated were recorded and included non-operative treatments (casting/bracing), traditional growing rods (TGR), vertical expandable prosthetic titanium rib (VEPTR), Shilla growth guidance, magnetically controlled growing rods (MCGR), and vertebral body tethering (VBT). Linear regressions were performed to analyze changes in research topic and study group utilization. RESULTS: A total of 532 abstracts were reviewed. An average of 97.5 ± 81.3 patients were included per study with a significant increase from 42.3 ± 89.7 in 2007 to 337.6 ± 587.4 in 2021 (r2 = 0.632, p < 0.001). A total of 130 (24.4%) abstracts resulted from multicenter study groups with the proportion increasing significantly from 13.0% in 2007 to 36.4% in 2021 (p = 0.039, r2 = 0.289). The majority (96.2%) of study group-based projects were from either the Growing Spine Study Group (GSSG), Chest Wall and Spine Deformity Study Group (CWSDG), Children's Spine Study Group (CSSG), or the Pediatric Spine Study Group (PSSG). Additionally, a significant increase in studies utilizing patient-reported outcome measures (PROMs) was observed (r2 = 0.336, p = 0.023). Significant increases in the proportion of presentations discussing MCGR (r2 = 0.738, p < 0.001) and VBT (r2 = 0.294, p = 0.037) as surgical treatments were observed. CONCLUSION: The trends in EOS device implantation observed in registry studies align with the trends in research presented at ICEOS including the increased proportion of studies focusing on MCGR and VBT over the past decade. An attempt to increase the quality of research presented at ICEOS through multicenter study groups, increased patient recruitment, and utilization of PROMs has been seen since its inception. LEVEL OF EVIDENCE: V.

Re-evaluating consensus and uncertainty among treatment options for early onset scoliosis: a 10-year update.

PURPOSE: Consensus and uncertainty in early onset scoliosis (EOS) treatment were evaluated in 2010. It is currently unknown how treatment preferences have evolved over the past decade. The purpose of this study was to re-evaluate consensus and uncertainty among treatment options for EOS patients to understand how they compare to 10 years ago. METHODS: 11 pediatric spinal surgeons (similar participants as in 2010) were invited to complete a survey of 315 idiopathic and neuromuscular EOS cases (same cases as in 2010). Treatment options included the following: conservative management, distraction-based methods, growth guidance/modulation, and arthrodesis. Consensus was defined as ≥ 70% agreement, and uncertainty was < 70%. Associations between case characteristics and consensus for treatments were assessed via chi-squared and multiple regression analyses. Case characteristics associated with uncertainty were described. RESULTS: Eleven surgeons [31.7 ± 7.8 years of experience] in the original 2010 cohort completed the survey. Consensus for conservative management was found in idiopathic patients aged ≤ 3, whereas in 2010, some of these cases were selected for surgery. There is currently consensus for casting idiopathic patients aged 1 or 2 with moderate curves, whereas in 2010, there was uncertainty between casting and bracing. Among neuromuscular cases with consensus for surgery, arthrodesis was chosen for patients aged 9 with larger curves. CONCLUSION: Presently, preferences for conservative management have increased in comparison to 2010, and casting appears to be preferred over bracing in select infantile cases. Future research efforts with higher levels-of-evidence should be devoted to elucidate the areas of uncertainty to improve care in the EOS population. LEVEL OF EVIDENCE: Level V.

Why Don't Adolescents Wear Their Brace? A Prospective Study Investigating Psychosocial Characteristics That Predict Scoliosis Brace Wear.

BACKGROUND: Although bracing for adolescent idiopathic scoliosis can prevent curve progression and reduce the risk for future surgery, children frequently do not wear their braces as prescribed. The purpose of this study is to investigate how a broad array of psychosocial characteristics predict future compliance with scoliosis brace wear. METHODS: This was a single institution, prospective cohort study. All adolescents prescribed a first-time brace for adolescent idiopathic scoliosis were eligible. Patients and their parents completed a separate series of questionnaires that assessed baseline psychosocial characteristics across 6 domains: (1) brace-specific attitudes; (2) body image and self-esteem; (3) school performance and social relationships; (4) psychological health; (5) family functioning; and (6) demographics and scoliosis-specific details (242 total questions across 12 validated questionnaires). Objective brace compliance was collected using temperature-sensitive monitors. Defining compliance as percentage of brace prescription completed, comparative analyses were performed to identify baseline psychosocial characteristics that were associated with future wear. A composite measure (Bracing Fidelity Follow-Up Scale [BFFS]) of the 12 most predictive individual questions across all domains (both parent and adolescent) was constructed to help assess which adolescents were at highest risk of failure to wear their brace. Total BFFS score for each parent-adolescent dyad who completed all the included surveys was then determined by awarding one point for each factor that positively influenced future brace wear (maximum 12 points), and a correlation was calculated between total score and percent adherence to prescribed brace wear. RESULTS: A total of 41 patients were included. On average, patients with high self-esteem, above average peer relationships and poor brace-specific attitudes had lower brace compliance, although patients with increased loneliness and parental religiousness had higher compliance. Body image, socioeconomic status, family dynamics, and school performance had no significant relationship with brace use. Total score on the Bracing Fidelity Follow-Up Scale (BFFS) was significantly associated with improved brace wear (r=0.687, P <0.001). Those with a score of 6 or above (n=15/33 [45%], median compliance 96%) were more reliable users (15/15 with compliance >75%), and those with a score of 5 or less (n=18/33 [55%], median compliance 50%) had less consistent brace wear (9/18 with compliance <50%). CONCLUSION: This prospective study identifies numerous baseline psychosocial factors that are associated with future compliance with scoliosis brace wear. Although in need of further validation before widespread clinical application, the novel BFF scale offers a potential opportunity to partially discriminate between compliant and noncompliant scoliosis brace users such that supportive resources (eg, supportive counseling, peer-support groups, additional provider-based education, etc.) can be targeted to those patients most likely to benefit. LEVEL OF EVIDENCE: II.

Strategies reducing risk of surgical-site infection following pediatric spinal deformity surgery.

BACKGROUND: Identifying beneficial preventive strategies for surgical-site infection (SSI) in individual patients with different clinical and surgical characteristics is challenging. The purpose of this study was to investigate the association between preventive strategies and patient risk of SSI taking into consideration baseline risks and estimating the reduction of SSI probability in individual patients attributed to these strategies. METHODS: Pediatric patients who underwent primary, revision, or final fusion for their spinal deformity at 7 institutions between 2004 and 2018 were included. Preventive strategies included the use of topical vancomycin, bone graft, povidone-iodine (PI) irrigations, multilayered closure, impermeable dressing, enrollment in quality improvement (QI) programs, and adherence to antibiotic prophylaxis. The CDC definition of SSI as occurring within 90 days postoperatively was used. Multiple regression modeling was performed following multiple imputation and multicollinearity testing to investigate the effect of preventive strategies on SSI in individual patients adjusted for patient and surgical characteristics. RESULTS: Univariable regressions demonstrated that enrollment in QI programs and PI irrigation were significantly associated, and topical vancomycin, multilayered closure, and correct intraoperative dosing of antibiotics trended toward association with reduction of SSI. In the final prediction model using multiple regression, enrollment in QI programs remained significant and PI irrigation had an effect in decreasing risks of SSI by average of 49% and 18%, respectively, at the individual patient level. CONCLUSION: Considering baseline patient characteristics and predetermined surgical and hospital factors, enrollment in QI programs and PI irrigation reduce the risk of SSI in individual patients. Multidisciplinary efforts should be made to implement these practices to increase patient safety. LEVEL OF EVIDENCE: Prognostic level III study.

Lengthening Behavior of Magnetically Controlled Growing Rods in Early-Onset Scoliosis: A Multicenter Study.

BACKGROUND: The "law of diminishing returns" is described for traditional growing rods. Magnetically controlled growing rods (MCGRs) have become a preferred implant for the surgical treatment of early-onset scoliosis (EOS). We examined a large cohort of patients with EOS to determine whether the law of diminishing returns applies to MCGRs. METHODS: A prospectively collected, multicenter registry was queried for patients with EOS treated with MCGRs. Patients with only spine-based implants and a minimum of 2 years of follow-up were included; patients with congenital scoliosis, single rods, <3 lengthenings, or >25% missing data were excluded. Patients were analyzed in 3 cohorts: primary MCGR (pMCGR) had first-time MCGR implants, secondary MCGR (sMCGR) were converted from an MCGR to a new MCGR, and conversion MCGR (cMCGR) were converted from a non-MCGR implant to MCGR. RESULTS: A total of 189 patients in the pMCGR group, 44 in the cMCGR group, and 41 in the sMCGR group were analyzed. From post-MCGR placement to the most recent follow-up or pre-definitive procedure, there were no differences in the changes in major Cobb angle, T1-S1 height, or T1-T12 height over time between the pMCGR and cMCGR groups. There was a decrease in length achieved at subsequent lengthenings in all cohorts (p < 0.01), and the sMCGR group had a significantly poorer ability to lengthen at each subsequent lengthening versus the pMCGR and cMCGR groups (p < 0.02). The 1-year survival rate was 90.5% for pMCGR, 84.1% for sMCGR, and 76.4% for cMCGR; 2-year survival was 61.5%, 54.4%, and 41.4%, respectively; and 3-year survival was 37.6%, 36.7%, and 26.9%, respectively. Excluding MCGRs still expanding, 27.6% of pMCGRs, 8.8% of sMCGRs, and 17.1% of cMCGRs reached the maximum excursion. Overall, 21.7% reached the maximum excursion. Within the pMCGR cohort, idiopathic and neuromuscular etiologies had a decline in lengthening achieved over time (p < 0.001), while syndromic EOS demonstrated a preserved ability to lengthen over time (p = 0.51). When the etiological groups were compared with each other, the neuromuscular group had the least ability to lengthen over time (p = 0.001 versus syndromic, p = 0.02 versus idiopathic). CONCLUSIONS: The MCGR experiences the law of diminishing returns in patients with EOS. We found that only 21.7% of rods expanded to within 80% of the maximum excursion. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Outcomes of Posterior Spinal Fusion in Pediatric Patients with Down Syndrome.

BACKGROUND: Trisomy 21 or Down syndrome is associated with multiple orthopaedic manifestations. Although cervical instability is the most common spinal condition associated with Down syndrome, the prevalence of scoliosis has been estimated at 4.8% to 8.7%. Very few prior studies have documented the role of spinal fusion in this population, and all have included ≤10 patients. METHODS: An institutional review board-approved multicenter retrospective analysis of patients with Down syndrome treated with spinal fusion between January 2009 and December 2019 was performed by cross-referencing Current Procedural Terminology (CPT) and International Classification of Diseases, Ninth and Tenth Revisions (ICD-9 and ICD-10) codes. Patients were followed for ≥2 years, with a mean follow-up of 3.77 years. Clinical and radiographic outcomes were collected, and complications were documented using the Clavien-Dindo-Sink (CDS) classification. RESULTS: A total of 23 patients were included: 96% had ≥1 medical comorbidities, including 16 (70%) with congenital heart disease, of whom 88% had previous cardiac surgery, and 10 (44%) with thyroid disorders. All 23 patients underwent posterior spinal fusion. The mean estimated blood loss was 617 ± 459 mL, the mean length of the surgical procedure was 290 ± 92.7 minutes, and the mean length of hospital stay was 6.03 ± 2.91 days. The major Cobb angle measured 61.7° ± 17.6°, which corrected to 19.4° ± 14.8° (68.6% correction; p < 0.001), with well-maintained correction at 2 years of 22.0° ± 10.3° (64.3% correction; p = 0.158). Thirteen (57%) of 23 patients had a change in curve of >5°. There were no intraoperative complications; however, 12 patients (52%) sustained postoperative complications (e.g., need for reoperation, implant failure, and pulmonary complications), including 6 patients with CDS type 3 or 4 (e.g., wound dehiscence, late superficial abscess, pleural effusion, pseudarthrosis, and readmission for hypoxia). Four patients (17%) required a revision surgical procedure. One patient (4%) required an unplanned intensive care unit admission. CONCLUSIONS: Although instrumented spinal fusion can effectively correct spinal deformity in these patients, complications are more frequent than in children with adolescent idiopathic scoliosis, with over half of patients sustaining a complication. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

A Modern Day Timeline for In-Hospital Monitoring in Perfused, Pulseless Pediatric Supracondylar Humerus Fractures.

BACKGROUND: The perfused, pulseless supracondylar humerus fracture (ppSCHF) remains a consistent topic of discussion in the literature. Inpatient observation of these patients postoperatively for worsening vascular exam or compartment syndrome is frequently recommended but not well studied. The purpose of this study was to evaluate the postoperative complications in a cohort of ppSCHF patients and their timeline to discharge. METHODS: This study is a retrospective review of a prospectively maintained database of all operatively treated supracondylar humerus fractures from a tertiary pediatric hospital from 2013 to 2019. All patients without a palpable pulse were included. We excluded patients with <4 weeks follow-up. Demographic, operative, and postoperative data were collected, including time from presentation to operating room (OR), time from OR to discharge, and incidence of postoperative complications, including return to OR, compartment syndrome, new neurovascular deficits, and Volkmann contractures. The descriptive statistics were used to summarize the data. RESULTS: Among 1371 operatively treated supracondylar humerus fractures, 39 (2.8%) presented with a ppSCHF. Five (15%) had a signal on doppler ultrasound, whereas 34 (85%) had no signal. Thirty-seven (95%) patients had a Gartland type III fracture and 2 (5%) had type IV fractures. Twenty-two (56%) patients had a neurological deficit, of which 14 had an anterior interosseous nerve deficit. The average time to OR was 6.9 (range 2.2 to 15) hours; 6 (15%) required open reduction. At the time of discharge, 85% of patients had a palpable pulse and 13% had a dopplerable signal. Postoperatively, no patients were returned to the OR for any secondary procedures. The average length of stay after the operation was 25 (range 8.5 to 40) hours, with 92% of patients being discharged by 36 hours postoperatively. No patients developed compartment syndrome, new neurological deficits, or Volkmann contractures at a mean follow-up of 112 (range 34 to 310) days. CONCLUSIONS: In our study of 39 patients presenting with ppSCHF, no patient required an unexpected return to the OR, or developed post-treatment compartment syndrome, neurological deficits, or Volkmann contractures. The average time from OR to discharge for ppSCHF was 25 hours. LEVEL OF EVIDENCE: Level II.