Anterior vertebral tethering for adolescent idiopathic scoliosis: our initial ten year clinical experience.

BACKGROUND: Anterior vertebral tethering (AVT) is a minimally invasive alternative to fusion surgery for adolescent idiopathic scoliosis (AIS) that offers the potential for definitive scoliosis treatment with the possibility of preservation of the growth, motion, function and overall health of the spine. This study represents our first ten years using AVT to treat AIS. METHODS: In this retrospective review we analyzed our first 74 AIS patients treated with AVT 2010-2020. Multiple Lenke curve types 33-70° were treated with skeletal maturity spanning Risser -1 to 5. RESULTS: Of 74 consecutive AIS patients treated with AVT, 52 patients (47 female, 5 male) had sufficient 2-year follow-up for inclusion. Forty-six of these 52 patients (88%) with 65 curves (35T, 30TL/L) were satisfactorily treated with AVT demonstrating curve correction from 48.6° pre-op (range 33°-70°) at age 15.1 years (range 9.2-18.8) and skeletal maturity of Risser 2.8 (range -1 to 5) to 23.2° post-op (range 0°-54°) and 24.0° final (range 0°-49°) at 3.3 years follow-up (range 2-10 years). Curve corrections from pre-op to post-op and pre-op to final were both significant (p < 0.001). The 0.8° change from post-op to final was not significant but did represent good control of scoliosis correction over time. Thoracic kyphosis and lumbar lordosis were maintained in a normal range throughout while axial rotation demonstrated a slight trend toward improvement. Skeletal maturity of Risser 4 or greater was achieved in all but one patient. Four of the 52 patients (8%) required additional procedures for tether rupture (3 replacements) or overcorrection (1 removal) to achieve satisfactory treatment status after AVT. An additional 6 of the 52 patients (12%), however, were not satisfactorily treated with AVT, requiring fusion for overcorrection (2) or inadequate correction (4). CONCLUSIONS: In this study, AIS was satisfactorily treated with AVT in the majority of patients over a broad range of curve magnitudes, curve types, and skeletal maturity. Though late revision surgery for overcorrection, inadequate correction, or tether rupture was not uncommon, the complication of overcorrection was eliminated after our first ten patients by a refinement of indications. LEVEL OF EVIDENCE: IV.

Arthroscopic Patella Realignment for Children And Adolescents: A Single Incision Technique.

Management of patellofemoral conditions in children and adolescents can be extremely challenging. Apart from the patellofemoral instability patients, there are several other disorders that can cause significant morbidity, patellofemoral maltracking, patellar tilt, and Hoffa's fat pad impingement syndrome are common problems that may not respond to nonoperative management. Understanding the exact pathology and apply the appropriate management is critical for successful outcome. Identification of novel surgical interventions that can provide symptom relief in a safe manner is important. This technical note describes a surgical technique for patella realignment in young patients that combines safety, simplicity, and reproducibility.

Management of pediatric posterior cruciate ligament avulsion fractures: a systematic review.

PURPOSE: Both open and arthroscopic surgical techniques have been used for PCL avulsion fractures. The goal of this study is to evaluate the effectiveness and safety of the different management strategies proposed for PCL avulsion fractures in children. METHODS: A systematic literature review was performed utilizing Medline, Scopus, and EMBASE databases from 1977 to the present. PRISMA guidelines were followed. Data were selected and extracted by two independent reviewers. Inclusion criteria were clinical studies reporting injuries in pediatric patients with PCL avulsion injuries. Exclusion criteria were combined PCL and ACL injuries and ligamentous injuries requiring reconstruction. A subgroup analysis was performed between open reduction and arthroscopic surgeries. FINDINGS/RESULTS: Twenty-six studies were included in this systematic review. Patient sex was reported in 39 patients with a higher number of males (32/39). The age range was 7-18 years old. In the open group, 30/31 patients had clinical improvement or returned to pre-injury activity level with two complications. Lysholm scores ranged from 66 to 99. In the arthroscopic group, 11/12 patients experienced clinical improvement or returned to normal activity levels with only one complication. Lysholm scores ranged from 90 to 100 with a mean of 95. In the non-operative group, 3/3 recovered with evidence of fracture healing, full or near full knee range of motion. One Lysholm score was reported 14 months after injury and was 100/100. CONCLUSIONS: Open reduction and arthroscopic surgeries are effective and safe treatment options for pediatric PCL avulsion fractures-97% of open reduction and 92% of arthroscopic patients significantly improved symptoms. The complication rates for the open and arthroscopic groups were 11 and 9%, respectively. All three non-operative made full or near full recovery of pre-injury knee status. LEVEL OF EVIDENCE IV: Systematic review of Level-II-IV studies. Prospero Registration No CRD42021290899.

Editorial Commentary: Waiting at Least 1 Month After an Intra-articular Corticosteroid Injection for Performing a Knee, Shoulder, and Hip Arthroscopy Could Minimize the Risk for Postoperative Infection: Platelet-Rich Plasma Is an Alternative.

An intra-articular corticosteroid is associated with a higher risk of joint infection. Identifying the necessary time interval from the injection to the arthroscopic procedure that does not impose an additional risk of infection is critical for the safety of our patients. Increasing evidence suggests that there is a high risk of infection at the first 4 weeks after the injection, but it seems that this risk declines to normal levels after that period. Interestingly, this time interval of 4 weeks is comparable between knee, shoulder, and hip injection and subsequent arthroscopy. A delay of an arthroscopic intervention at any joint for at least 4 weeks is recommended. Finally, platelet-rich plasma (PRP) is equally effective as corticosteroids in terms of pain management and anti-inflammatory response, with the advantage of promoting healing. PRP may also be associated with a lower risk of postoperative infection in patients undergoing arthroscopy, representing a biologic alternative.

Plastic and elastic biomechanical properties of anterior cruciate ligament autografts.

BACKGROUND: Anterior cruciate ligament (ACL) rupture is a common orthopedic injury, occurring in roughly 68.6 per 100,000 persons annually, with the primary treatment option being ACL reconstruction. However, debate remains about the appropriate graft type for restoring the native biomechanical properties of the knee. Furthermore, plastic graft elongation may promote increased knee laxity and instability without rupture. This study aims to investigate the plastic properties of common ACL-R graft options. METHODS: Patellar tendon (PT), hamstring tendon (HT), and quadriceps tendon (QT) grafts were harvested from 11 cadaveric knees (6 male and 5 female) with a mean age of 71(range 55-81). All grafts were mechanically tested under uniaxial tension until failure to determine each graft's elastic and plastic biomechanical properties. RESULTS: Mechanically, the QT graft was the weakest, exhibiting the lowest failure force and the lowest failure stress (QT < HT, p = 0.032). The PT was the stiffest of the grafts, having a significantly higher stiffness (PT > QT, p = 0.0002) and Young's modulus (PT > QT, p = 0.001; PT > HT, p = 0.041). The HT graft had the highest plastic elongation at 4.01 ± 1.32 mm (HT > PT, p = 0.002). The post-yield behavior of the HT tendon shows increased energy storage capabilities with the highest plastic energy storage (HT > QT, p = 0.012) and the highest toughness (HT > QT, p = 0.032). CONCLUSION: Our study agrees with prior studies indicating that the failure load of all grafts is above the requirements for everyday activities. However, grafts may be susceptible to yielding before failure during daily activities. This may result in the eventual loss of functionality for the neo-ACL, resulting in increased knee laxity and instability.

Cadaveric Biomechanical Laboratory Research Can Be Quantitatively Scored for Quality With the Biomechanics Objective Basic Science Quality Assessment Tool: The BOBQAT Score.

PURPOSE: The purpose of this study was to develop a quality appraisal tool for the assessment of cadaveric biomechanical laboratory and other basic science biomechanical studies. METHODS: For item identification and development, a systematic review of the literature was performed. The content validity index (CVI) was used either to include or exclude items. The content validity ratio (CVR) was used to determine content validity. Weighting was performed by each panel member; the final weight was either up- or downgraded to the closest of 5% or 10%. Face validity was scored on a Likert scale ranked from 1 to 7. Test-retest reliability was determined using the Fleiss kappa coefficient. Internal consistency was assessed with Cronbach's alpha. Concurrent criterion validity was assessed against the Quality Appraisal for Cadaveric Studies scale. RESULTS: The final Biomechanics Objective Basic science Quality Assessment Tool (BOBQAT) score included 15 items and was shown to be valid, reliable, and consistent. Five items had a CVI of 1.0; 10 items had a CVI of 0.875. For weighting, 5 items received a weight of 10%, and 10 items a weight of 5%. CVR was 1.0 for 6 items and 0.75 for 9 items. For face validity, all items achieved a score above 5. For test-retest reliability, almost-perfect test-retest reliability was observed for 10 items, substantial agreement for 4 items, and moderate agreement for 1 item. For internal consistency, Cronbach's alpha was calculated to be 0.71. For concurrent criterion validity, Pearson's product-moment correlation was 0.56 (95% confidence interval [CI] = 0.38-0.70, P = .0001). CONCLUSION: Cadaveric biomechanical and laboratory research can be quantitatively scored for quality based on the inclusion of a clear and answerable purpose, demographics, specimen condition, appropriate bone density, reproducible technique, appropriate outcome measures, appropriate loading conditions, appropriate load magnitude, cyclic loading, sample size calculation, proper statistical analysis, results consistent with methods, limitations considered, conclusions based on results, and disclosure of funding and potential conflicts. CLINICAL RELEVANCE: Study quality assessments are important to evaluate internal and external validity and reliability and to identify methodological flaws and misleading conclusions. The BOBQAT score will help not only in the critical appraisal of cadaveric biomechanical studies but also in guiding the designs of such research endeavors.

Editorial Commentary: Personalized Anterior Cruciate Ligament Reconstruction and Rehabilitation Mitigate Postoperative Arthrofibrosis: Prevention Is the Best Approach.

Arthrofibrosis after anterior cruciate ligament reconstruction can become a major complication requiring surgical intervention. The reported incidence approximates 8% but varies widely (2%-35%) and, as not all patients require surgery, may be underreported. Several risk factors are involved. Female sex, older age, surgery within the first month after injury, and meniscus repair are consistently associated with increased risk. Other factors include graft size and type, concomitant procedures, use of anticoagulants, and genetic factors. By identifying risk factors, we can modify our surgical technique and rehabilitation to meet each patient's needs with fewer complications.

While the Incidence of Venous Thromboembolism After Shoulder Arthroscopy Is Low, the Risk Factors Are a Body Mass Index Greater than 30 and Hypertension.

Purpose: This study aims to determine the overall incidence of venous thromboembolism (VTE) following shoulder arthroscopy and to define potential risk factors associated with its development that may help define guidelines for the use of thromboprophylaxis. Methods: A systematic review was performed using PubMed, Embase, Web of Science, CINAHL, and Cochrane databases per PRISMA guidelines. The search terms consisted of variations of "Venous Thromboembolism" and "Shoulder Arthroscopy." Information regarding arthroscopy indication, risk factors, outcomes, and patient demographics was recorded and analyzed, and pooled odds ratios were reported for each variable. Results: Six hundred eighty-five articles were identified in the initial search, and 35 articles reported DVT, PE, or VTE incidence following shoulder arthroscopy. Seventeen nonoverlapping articles with a unique patient population incidence rates. Four articles were then used for subgroup meta-analysis. The incidence rate of VTE was 0.24%, ranging from 0.01% to 5.7%. BMI >30 (OR = 1.46; 95% CI = [1.22, 1.74]; I2 = 0%) and hypertension (OR = 1.64; 95% CI = [1.03, 2.6]; I2 = 75%) were significant risk factors (P < .05) for developing VTE following shoulder arthroscopy. Diabetes (OR = 1.2; 95% CI = [0.97, 1.48]; I2 = 0%), insulin-dependent diabetes (OR = 5.58; 95% CI = [0.12, 260.19]; I2 = 85%), smoking (OR = 1.04; 95% CI = [0.79, 1.37]; I2 = 12%), male sex (OR = 0.95; 95% CI = [0.49, 1.85]; I2 = 86%) and age over 65 (OR = 4.3; 95% CI = [0.25, 72.83]; I2 = 85%) were not associated with higher VTE risk. Conclusion: The VTE incidence following shoulder arthroscopy is low at 0.24%. Patients with BMI >30 and hypertension are at a higher risk for VTE after shoulder arthroscopy. Level of Evidence: Level IV, systematic review and meta-analysis of Level I-IV studies.

Conservative Treatment of Isolated Dorsal Dislocations of Fourth and Fifth Carpometacarpal Joints: A Report of a Rare Case.

Carpometacarpal (CMC) dislocations without associated fractures of the adjacent bones are extremely infrequent injuries. Dorsal or volar dislocations occur after high-energy injuries and may lead to early post-traumatic arthritis and carpal instability. The purpose of this study was to present a case of dorsal dislocation of both the fourth and fifth CMC joints that were treated with closed reduction and casting. A 31-year-old man developed severe acute pain, functional limitation, and deformity of the wrist after falling from a height. The clinical examination revealed intense localized tenderness, swelling, and palpable prominence over the fourth and fifth metacarpals. Standard anteroposterior and lateral views demonstrated dislocations of the examined CMC joints without any accompanied fracture. The injury was treated with anatomic closed reduction and cast immobilization for overall five weeks followed by early mobilization. Twelve weeks after injury, the patient had regained grip strength, and six months post-traumatically he satisfactorily returned to his previous hard labor-intensive activities without any functional deficits or chronic pain. Conclusively, CMC dislocations can be treated conservatively in case of early diagnosis and stable anatomic closed reduction.

Editorial Commentary: Patellofemoral Instability Results in Osteoarthritis, and Nonanatomic Surgery and Surgical Over-constraint May Also Cause Osteoarthritis.

When we are looking at the stars, we are in fact looking back in time. This is because it takes years for the light from the stars to reach us. In similar fashion, when we are evaluating data on osteoarthritis after patellofemoral surgery, we need to consider what kind of procedure was performed. Furthermore, it is extremely important to answer the question of whether the patellofemoral instability itself or the surgical procedure is causing the arthritis. Recent evidence suggests that recurrent patellofemoral instability is causing cartilage degeneration and stopping this process via surgical restoration of the anatomy and biomechanics of the patellofemoral joint may significantly reduce the risk of osteoarthritis. Shear loading of the cartilage can be detrimental. An instability event elicits inflammatory markers that are shown to induce arthritis. On the other hand, there is the argument that over-constraint may lead to arthritis owing to an increase in cartilage loading. Another argument is that surgery may not fully restore the patellofemoral anatomy. Appropriate patient selection and continuous evolution of our surgical procedures are key elements toward successful management of patellofemoral instability.

Editorial Commentary: Major Technical Advances in Knee Anterior Cruciate Ligament Reconstruction Address Anatomy, Biomechanics, and Healing.

The surgical techniques in knee anterior cruciate ligament (ACL) reconstruction continue to evolve significantly. Improved understanding of the anatomy, biomechanics, and healing of the ACL has offered the foundation for several advances. The goal of these innovations is to successfully restore the native anatomy and biomechanical function of the native ligament, provide a stable and pain-free knee joint, allow return to prior level of activity, prevent rerupture, and prevent osteoarthritis. Taken in sum, these are lofty goals. The shift toward anatomic ACL reconstruction, development of diverse graft options and configurations, and the addition of reinforcement techniques, such as the anterolateral ligament reconstruction and lateral tenodesis techniques, are major advancements in ACL reconstruction.

Editorial Commentary: Addition of the Sartorius Tendon to Small-Diameter Hamstring Anterior Cruciate Ligament Autografts May Improve Outcomes in Pediatric and Revision Cases.

Graft selection in anterior cruciate ligament reconstruction can have a pivotal role in a successful outcome. One of the major concerns with hamstring autograft is the variability of the diameter of each tendon, and grafts with a diameter of less than 8 mm may result in an increased failure rate. The addition of the sartorius tendon as a fifth strand in small-diameter hamstring autografts increases graft strength and diameter. This may improve outcomes in pediatric and revision cases.

Editorial Commentary: Biologic Augmentation of Meniscus Repair Is Complex.

In the setting of biological augmentation for meniscus repair, it is extremely important to evaluate all aspects, including effectiveness, costs, potential risks, benefits, and limitations. It seems that everything matters in healing: the aspirate source of the bioactive agents, cell content, presence of stem cells and their type, growth factors, cytokines, biomechanical scaffold, and the quality of the tissue. There are several differences among mesenchymal, adipose, and peripheral blood stem cells, with the cell origin affecting the differentiation potential towards bone, cartilage and ligament. Moreover, different aspirate sources and fibrin clots have different content in cells, growth factors, and cytokines. In this equation, it is not as simple as the more the better. Different doses of growth factors may have different effects in the different cell types. And as this was not complicated enough, synergistic phenomena between cells and between growth factors can play a huge role. Add to that the role of the biomechanical environment, the proper timing of the healing phases and the inherent patient characteristics. There is very, very much to learn, and finally, we acknowledge that not all menisci repairs can always heal.

Assessment of Skeletal Maturity and Postoperative Growth Disturbance After Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients: A Systematic Review.

BACKGROUND: Growth disturbance is an uncommon but potentially serious complication after anterior cruciate ligament (ACL) reconstruction in skeletally immature patients. PURPOSE: To describe how the pediatric ACL literature has assessed preoperative skeletal maturity and the amount of growth remaining and to comprehensively review the incidence, reporting, and monitoring of postoperative growth disturbance. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: This review included studies reporting original research of clinical outcomes of skeletally immature patients after ACL reconstruction. Patient characteristics, surgical techniques, preoperative assessments of skeletal maturity or growth remaining, and postoperative assessments of growth disturbances were extracted. RESULTS: A total of 100 studies met inclusion criteria. All studies reported chronological age, and 28 studies (28%) assessed skeletal age. A total of 44 studies (44%) used Tanner staging, and 12 studies (12%) obtained standing hip-to-ankle radiographs preoperatively. In total, 42 patients (2.1%) demonstrated a leg length discrepancy (LLD) >10 mm postoperatively, including 9 patients (0.5%) with LLD >20 mm; furthermore, 11 patients (0.6%) with LLD underwent growth modulation. Shortening was the most common deformity overall, but overgrowth was reported more frequently in patients who had undergone all-epiphyseal techniques. Most LLDs involved the femur (83%). A total of 26 patients (1.3%) demonstrated a postoperative angular deformity ≥5°, and 9 of these patients underwent growth modulation. The most common deformities were femoral valgus (41%), tibial recurvatum (33%), and tibial varus (22%). Although standing hip-to-ankle radiographs were the most common radiographic assessment of growth disturbance, most studies inadequately reported the clinical and radiographic methods of assessment for growth disturbance. Additionally, only 35% of studies explicitly followed patients to skeletal maturity. CONCLUSION: This systematic review described significant variability in the reporting and monitoring of growth-related complications after ACL reconstruction in skeletally immature patients. The incidence of LLD and angular deformity appeared to be low, but the quality of research was not comprehensive enough for accurate assessment. REGISTRATION: CRD42019136059 (PROSPERO).

Biomechanical Studies for Glenoid Based Labral Repairs With Suture Anchors Do Not Use Consistent Testing Methods: A Critical Systematic Review.

PURPOSE: The purpose of this systematic review was to investigate variability in biomechanical testing protocols for laboratory-based studies using suture anchors for glenohumeral shoulder instability and SLAP lesion repair. METHODS: A systematic review of Medline, Embase, Scopus, and Google Scholar using Covidence software was performed for all biomechanical studies investigating labral-based suture anchor repair for shoulder instability and SLAP lesions. Clinical studies, technical notes or surgical technique descriptions, or studies treating glenoid bone loss or capsulorrhaphy were excluded. Risk of bias (ROB) was assessed with the ROBINS-I tool. Study quality was assessed with the Quality Appraisal for Cadaveric Studies. Heterogeneity was assessed with the I2 statistic. RESULTS: A total of 41 studies were included. ROB was serious and critical in 27 studies, moderate in 13, and low in 1; 6 studies had high quality, 21 good quality, 10 moderate quality, 2 low quality, and 2 very low quality. Thirty-one studies used and 22 studies included cyclic loading. Angle of anchor insertion was reported by 33 studies. The force vector for displacement varied. The most common directions were perpendicular to the glenoid (n = 9), and anteroinferior or anterior (n = 8). The most common outcome measures were load to failure (n = 35), failure mode (n = 23), and stiffness (n = 21). Other outcome measures included load at displacement, displacement at failure, tensile load at displacement, translation, energy absorbed, cycles to failure, contact pressure, and elongation. CONCLUSION: This systematic review demonstrated a clear lack of consistency in those cadaver studies that investigated biomechanical properties after surgical repair with suture anchors for shoulder instability and SLAP lesions. Testing methods between studies varied substantially with no universally applied standard for preloading, load to failure and cyclic loading protocols, insertion angles of suture anchors, or direction of loading. To allow comparability between studies standardization of testing protocols is strongly recommended.

Fixed (Congenital) Patellar Dislocation.

Congenital dislocation of the patella is a rare condition characterized by lateral dislocation of the patella that is irreducible without surgical correction. Although there is no clear inheritance pattern, it is associated with several congenital syndromes. Patients often demonstrate flexion contracture, loss of active knee extension, increased tibial external rotation, and absent patella in the trochlea. Treatment requires surgical management and is comprised of lateral release, medial stabilization, quadriceps lengthening, and distal realignment. Results are generally favorable after treatment; persistent flexion contracture and redislocation are the most common complications. Further study is needed to define the optimal timing and treatment strategy for this uncommon condition.

Knee orthopedics as a template for the temporomandibular joint.

Although the knee joint and temporomandibular joint (TMJ) experience similar incidence of cartilage ailments, the knee orthopedics field has greater funding and more effective end-stage treatment options. Translational research has resulted in the development of tissue-engineered products for knee cartilage repair, but the same is not true for TMJ cartilages. Here, we examine the anatomy and pathology of the joints, compare current treatments and products for cartilage afflictions, and explore ways to accelerate the TMJ field. We examine disparities, such as a 6-fold higher article count and 2,000-fold higher total joint replacement frequency in the knee compared to the TMJ, despite similarities in osteoarthritis incidence. Using knee orthopedics as a template, basic and translational research will drive the development and implementation of clinical products for the TMJ. With more funding opportunities, training programs, and federal guidance, millions of people afflicted with TMJ disorders could benefit from novel, life-changing therapeutics.

Comparison between partial and full coverage repair in massive rotator cuff tears. A minimum five year follow-up.

BACKGROUND: Massive rotator cuff surgical management can be challenging. Controversy exists in the literature regarding the potential benefit of full head coverage for arthroscopic rotator cuff repair. The purpose of this study was to compare re-tear rate and clinical outcome of arthroscopic repair of massive rotator cuff tears in relation to the achievement of full humeral head footprint coverage or not. Hypothesis We hypothesized that there will be no difference in re-tear rate and clinical outcomes between full and partial coverage rotator cuff repairs. PATIENTS AND METHODS: A retrospective analysis of all adult patients with a massive rotator cuff tear who underwent arthroscopic repair with a minimum five years follow-up was performed. Outcomes analyzed included re-tear rate, the American Shoulder and Elbow Surgeons (ASES) Shoulder Score, and the Penn Shoulder Score. Correlation and subgroup analyses were performed in order to evaluate whether age, symptom duration, tear size, coverage percentage, and fatty infiltration had any effect in outcome. RESULTS: The average ASES score was 76.3±25.2, and average Penn Shoulder Score was 75.8±23.1 at 7.9 years mean follow-up in 27 patients analyzed. Re-tear rate was similar between full and partial footprint coverage repair with 2 versus 4 failures, respectively (p=0.64). ASES and Penn Shoulder scores were 84.2 and 83.7 for full rotator cuff repair versus 70.6 and 71.1, for partial coverage repair (p=0.20 and p=0.22, respectively). The percentage of head coverage and the tear size were both found to be significantly correlated with outcome, with coefficient of determination R2 of 0.40 and 0.217, respectively, while a global fatty degeneration index GFDI <1.5 was associated with improved functional outcome. DISCUSSION: No difference in failure rate and functional outcome was detected between full and partial coverage rotator cuff repair. The size of the tear and fatty infiltration were inversely correlated with functional score while the percentage of coverage achieved was positively correlated with favorable outcome. LEVEL OF EVIDENCE: III; retrospective comparative study.

A Thoracoscopic Technique Used in Anterior Vertebral Tethering for Adolescent Idiopathic Scoliosis.

Anterior vertebral tethering (AVT) is a relatively recent alternative to posterior spinal fusion for progressive curves in growing patients with idiopathic scoliosis. AVT uses a thoracoscopic approach to minimize trauma to the thoracic wall and chest cavity. There are limited technical descriptions of this method. Patients benefit from proficiency and reproducibility to allow for appropriate spinal curve correction over time. This Technical Note outlines the steps of the thoracoscopic approach to AVT and reviews the current indications for AVT over posterior spinal fusion, as well as the most recently published clinical outcomes of this procedure.