Vertebral Body Stapling for Moderate Juvenile and Early Adolescent Idiopathic Scoliosis: Cautions and Patient Selection Criteria.

STUDY DESIGN: Single-surgeon retrospective case series. OBJECTIVE: To validate and further describe clinical and radiographic outcomes of patients undergoing vertebral body stapling (VBS), with the goal of learning if VBS is a safe and effective alternative to bracing for treating moderate idiopathic scoliosis (IS) in the growing pediatric patient. SUMMARY OF BACKGROUND DATA: VBS is a growth-modulation technique to control moderate idiopathic scoliosis (IS) while avoiding fusion. Existing studies state successful curve control rates equivalent to bracing, but the majority of reports have come from a single institution. METHODS: All IS patients who underwent VBS by 1 surgeon were included. Indications were brace intolerance and a structural coronal curve of 25° to 40°. Proportional nitinol staples were used in all cases. Pre- and postoperative radiographs, pulmonary function testing, and physical exam measurements were serially recorded. RESULTS: VBS was performed on 35 patients (28 females, 7 males) with mean age 10.5 years (range 7.0-14.6 years). Total of 31 patients (33 stapled curves) completed follow-up. Preoperative Risser grade was 0 in 31 patients, 1 in 1 patient, and 2 in 3 patients. Stapled curves were controlled with <10° of progression in 61% of cases. Curves <35° had a control rate of 75%, and patients <10 years had a 62% curve control rate. Eleven patients (31%) required subsequent fusions; two curves (6%) over-corrected. Preoperative supine flexibility > 30% was predictive of ultimate curve control. No neurologic complications were encountered; 5 patients (14%) developed small pneumothoraces. CONCLUSION: This series contains the most patients and longest followup reported for VBS. Successful curve control was achieved less frequently than in previous reports, particularly in patients <10 years. LEVEL OF EVIDENCE: 4.

High prevalence of cervical deformity and instability requires surveillance in Loeys-Dietz syndrome.

BACKGROUND: Loeys-Dietz syndrome is a connective tissue disorder characterized by vascular, craniofacial, and musculoskeletal malformation. Our goal was to report the manifestations, surgical treatment, and complications in the cervical spine in patients with Loeys-Dietz syndrome. METHODS: We reviewed the clinical and cervical spine imaging data of eighty patients with Loeys-Dietz syndrome who were seen at our institution from January 2005 through January 2014. Their mean age at presentation was 17.3 years (range, three months to seventy-five years). We tested associations with use of the Fisher exact test (type of TGF-ßR [transforming growth factor-beta receptor] mutation and cervical abnormalities) and the Student t test (age at presentation and type of TGF-ßR mutation) (significance, p = 0.05). RESULTS: Vertebral anomalies and cervical instability were common; we found no significant association of TGF-ßR-type with cervical abnormalities or age at presentation. Twenty-eight patients had atlas defects (anterior and/or posterior arch defects or hypoplasia), fifty-three had axis malformations (elongation, apex-anterior dens angulation, or spondylolysis), and twelve had focal kyphosis. Ten patients had hypoplastic subaxial vertebrae, leading to focal kyphosis (eight) and subaxial instability (nine). Eight patients had atlantoaxial instability. Of the thirteen patients with cervical instability, nine were treated surgically: fusion (eight patients) and halo application (one) (mean age, four years; range, three months to twelve years). Postoperative complications (seven patients) were pseudarthrosis, failure of fixation, junctional kyphosis or instability, and development of occipital-cervical instability. CONCLUSIONS: Cervical midline defects (most often C1-C3) are common in Loeys-Dietz syndrome. Patients have a high prevalence of cervical instability, particularly a pattern of instability at C2-C3 associated with C3 vertebral body hypoplasia and C2-C3 focal kyphosis. Patients requiring surgery typically present in early childhood.

Clinically significant differences exist between curves in operative idiopathic early-onset scoliosis and adolescent idiopathic scoliosis.

STUDY DESIGN: Retrospective analysis. OBJECTIVE: To determine if statistically significant differences exist between operative idiopathic early-onset scoliosis (IEOS) and adolescent idiopathic scoliosis (AIS) in primary curve characteristics, stable vertebra, kyphosis, or lumbar deformity and, if so, to identify the clinical significance of these differences. SUMMARY OF BACKGROUND DATA: To our knowledge, no study has statistically compared radiographical measures of operative IEOS and AIS. METHODS: We identified operative patients (60, IEOS; 1537, AIS) in 2 multicenter databases and measured preoperative radiographical parameters of interest. The measurements were compared using the Student t test and other appropriate statistical methods (significance, P = 0.05). RESULTS: The IEOS and AIS groups were significantly different in primary curve magnitude (70° ± 20° vs. 54° ± 13°, respectively; P < 0.001), stable vertebra location (L3.0 ± 1.4 vs. L2.1 ± 2.2, respectively; P = 0.001), and T2 to T12 kyphosis (40° ± 15° vs. 31° ± 13°, respectively; P < 0.001). Distribution of major curve apex was unimodal centered close to the thoracolumbar junction in IEOS versus bimodal in AIS. Primary curve type was thoracic in 83% and 79% and thoracolumbar/lumbar in 17% and 21% of patients with IEOS and AIS, respectively. When the overall cohorts were separated into curve types and these subsets were compared, statistically significant differences were found between IEOS and AIS in thoracic primary curves (apex, magnitude, direction, proximal and distal Cobb vertebrae, and lumbar deformity) and thoracolumbar/lumbar primary curves (magnitude). CONCLUSION: Significant radiographical differences exist between operative IEOS and AIS curves. IEOS curves are greater in magnitude, more kyphotic, less well compensated, and have a more caudal apex and stable vertebra. These findings suggest that younger patients may require more distal instrumentation and that proximal fixation techniques should consider the additional pullout forces created by the greater kyphosis.

Surgical Treatment of Scoliosis in Non-Ambulatory Spastic Quadriplegic Cerebral Palsy Patients: A Matched Cohort Comparison of Unit Rod Technique and All-Pedicle Screw Constructs.

STUDY DESIGN: Matched cohort. OBJECTIVE: To compare the unit rod instrumentation (UR) technique with all-pedicle screw (PS) constructs in the surgical care of scoliosis in Gross Motor Function Classification System IV/V non-ambulatory spastic quadriplegic cerebral palsy patients. SUMMARY OF BACKGROUND DATA: Over the past 20 years, there has been a transition from the UR technique to the use of pedicle screws and iliac screws in neuromuscular scoliosis. To date, no head-to-head comparative analysis has been reported between the UR technique and PS constructs for posterior segmental spinal instrumentation and fusion in cerebral palsy patients. METHODS: A matched cohort study was performed between 2 tertiary-care pediatric centers: 1 using UR technique and the other PS constructs. Minimum follow-up was 2 years postoperatively (PS 2.5 years, UR 4.6 years, not significant). Fourteen patients were matched from each center based on age (mean age: PS 15.4 years, UR 15.5 years), preoperative pelvic obliquity (mean: PS 33.8°, UR 29.1°) and major coronal Cobb angle (mean: PS 100.9°, UR 100.1°). RESULTS: There was posterior-only surgery in 14 of 14 PS and 11 of 14 UR surgeries. The final follow-up Cobb angle was lower in the PS group (13.5° vs. 34.3°, p < .05), with 86.5% correction in the PS group and 65.7% in the UR group. Final follow-up pelvic obliquity was similar (PS 8.5° vs. UR 3.3°; not significant). There were no major complications in the PS group. In the UR group, there was 1 deep infection and 1 reoperation for removal of a prominent sublaminar wire. CONCLUSIONS: This is the first study to directly compare UR with PS constructs using matched patient cohorts in this patient population. All-pedicle screw constructs had better correction of coronal Cobb angle, lower blood loss, and shorter hospital stays. There was no difference in the correction of pelvic obliquity, complications, or reoperations.

Tibial fractures after tibial tubercle osteotomies for patellar instability: a comparison of three osteotomy configurations.

PURPOSE: Tibial tubercle osteotomies (TTOs) are a seemingly straightforward technique; however problems with bony union, implant failure, wound infections, and fractures have been reported in the literature. METHODS: A database search identified all patients who had a TTO performed for patellofemoral instability between 1 March 2000 and 30 July 2008 by a single surgeon. The TTO technique was modified twice during the study period (December 2003 and June 2007, respectively), thereby creating three similar patient cohorts. RESULTS: TTOs were performed in 101 knees (90 patients), in which 34 knees (29 patients) received the blunt technique (TTO-B), 32 knees (30 patients) the sloped technique (TTO-S), and 35 knees (31 patients) the greenstick technique (TTO-G). Mean age of the patients (75 females, 15 males) was 16.0 years (range 12.2-20.2 years). Overall, six patients had complications, namely, six tibia fractures and no nonunions, for an overall complication rate of 5.9%. In the TTO-B group, four patients had four tibia fractures for an overall bony complication rate of 11.8%. In the TTO-S group, two patients had two delayed unions which developed into tibia fractures for an overall bony complication rate of 6.2%. There were no complications (0%) in the TTO-G group. No correlation was identified between TTO screw size and complications. The caudal aspect of the osteotomy was the location of the tibia fracture in five knees and the caudal screw in 1 knee, at a mean of 11 weeks postoperatively. All fractures were treated only with splint or cast immobilization and protected weight-bearing. CONCLUSION: The overall bony complication rate was 5.9% for the TTOs in this study. Utilizing the TTO-G technique with rigid two-screw, bicortical fixation the complication rate could be lowered to 0%. Avoidance of periosteal stripping, and secondary cortical devascularization at the caudal aspect of the TTO appears to optimize bony consolidation, thereby minimizing fractures. CLINICAL RELEVANCE: Bony complications are an infrequent problem after TTO. Greensticking the distal end of the TTO can minimize postoperative tibia fractures. Running and sports should not be permitted until complete cortical healing is documented on the lateral radiograph.

Outcomes after patellar realignment surgery for recurrent patellar instability dislocations: a minimum 3-year follow-up study of children and adolescents.

BACKGROUND: The purpose of this study was to report early outcomes after patellar realignment surgery (PRS) was performed for patellar instability in children and adolescents. METHODS: The study cohort consisted of 23 patients (27 knees) who had PRS between March 1, 2000 and July 30, 2004, by a single surgeon, with a minimum 3-year follow-up and validated outcome measures. Preoperative diagnoses were dislocations in 22 knees and subluxations in 5 knees. The mean age was 14 years and 1 month. RESULTS: Postoperatively, 2 knees had possible recurrent dislocation/subluxation episodes; neither required surgery. Persistent patellofemoral mechanical symptoms have been reported in 10 knees. At a mean follow-up of 5 years and 1 month, the mean Lysholm score was 69.3 and the mean International Knee Documentation Committee (IKDC) score was 65.6. The mean Tegner activity level was 5.4. Patients reported improvement in knee function and pain in 26 of 28 knees (93%). Significant group differences were identified for age at surgery, preoperative diagnosis, and length of preoperative knee symptoms. The group with scores ≥ 70 were younger (13.1 vs. 14.9 y), were all patellar dislocators (vs. 66% in the < 70 group), and with shorter length of symptoms (13 mo vs. 24 mo). In the ≥ 70 groups the Tegner activity levels were higher at 6.8 versus the < 70 group at 4.3. CONCLUSIONS: At a mean of 5 years after PRS, 93% of patients reported persistent improvement in knee function and pain, and recurrent patellar dislocation/subluxation episodes were infrequent (7%). Despite the low rate of postoperative patellar instability the patients' subjective opinion of knee function was less than expected (mean IKDC 65.5). Further investigation is warranted to identify causes for this suboptimal outcome at a mean of 5 years postoperatively. CLINICAL RELEVANCE: These data reinforce the recurring theme documented in other areas of orthopaedics of a disconnection between the "surgical" success (93% improved) and patient's subjective outcome (mean IKDC of 65.6). LEVEL OF EVIDENCE: Level III.