Diagnosis and Treatment of Idiopathic Congenital Clubfoot.

Idiopathic congenital clubfoot is the most common serious musculoskeletal birth defect in the United States and the world. The natural history of the deformity is to persist into adult life with a significant decrease in function and quality of life. The Ponseti method (serial casting, Achilles tenotomy, and bracing of the clubfoot) has become the most effective and accepted treatment of children born with clubfoot worldwide. The treatment is successful, particularly when the Ponseti-trained practitioner (often a pediatric orthopedic surgeon), the primary care clinician, and the family work together to facilitate success. An important factor in the ultimate success of the Ponseti method is parental understanding of the bracing phase. There is a very high rate of recurrent deformity when bracing is not done properly or is stopped prematurely. The importance of positive education and support for the parents to complete the entire treatment protocol cannot be overstated. The goal of treatment is a deformity-free, functional, comfortable foot. Ponseti clubfoot programs have been launched in most countries throughout the world, including many countries with limited resources. Ultimately, the goal is that every infant born with a clubfoot will have access to care with the Ponseti method. This clinical report is intended for medical practitioners who are involved in the care of pediatric patients with clubfoot. Understanding the standard of care will help these practitioners to care for patients and their families.

Analysis of remaining motion using one innovative upper airway opening cervical collar and two traditional cervical collars.

The aim of this study was to compare the remaining motion of an immobilized cervical spine using an innovative cervical collar as well as two traditional cervical collars. The study was performed on eight fresh human cadavers. The cervical spine was immobilized with one innovative (Lubo Airway Collar) and two traditional cervical collars (Stifneck and Perfit ACE). The flexion and lateral bending of the cervical spine were measured using a wireless motion tracker (Xsens). With the Weinman Lubo Airway Collar attached, the mean remaining flexion was 20.0 ± 9.0°. The mean remaining flexion was lowest with the Laerdal Stifneck (13.1 ± 6.6°) or Ambu Perfit ACE (10.8 ± 5.8°) applied. Compared to that of the innovative Weinmann Lubo Airway Collar, the remaining cervical spine flexion was significantly decreased with the Ambu Perfit ACE. There was no significant difference in lateral bending between the three examined collars. The most effective immobilization of the cervical spine was achieved when traditional cervical collars were implemented. However, all tested cervical collars showed remaining motion of the cervical spine. Thus, alternative immobilization techniques should be considered.

A novel passive neck orthosis for patients with degenerative muscle diseases: Development & evaluation.

The current study evaluated the effect of a passive neck orthosis, developed for patients suffering from progressive muscular diseases, on neck muscle activity in 10 adult healthy participants. The participants performed discrete head movements involving pure neck flexion (-10 to 30°), pure neck rotation (up to 30° left and right) and combined neck flexion-rotation (-10 to 30°) in steps of 10° by moving a cursor on a screen to reach predefined targets and staying on target for 10 s. Surface electromyography (EMG) was recorded from upper trapezius and sternocleidomastoid muscles and amplitudes were averaged over the static phases in trials with and without the orthosis. Moreover, the variability in head position and time required to perform the tasks were compared between conditions. Wearing the orthosis caused significant reductions (p = 0.027) in upper trapezius activity (a change of 0.2-1.5% EMGmax) while working against gravity. The activity level of the sternocleidomastoid muscle increased (p ≤ 0.025) by 0.3-1.0% EMGmax during pure and combined rotations without any pain reported. The orthosis showed potential to reduce the activity level of the upper trapezius muscle, the main load bearing muscle of the neck. Further study will be carried out to evaluate the effect in different patient groups.

The Hudson Brace technique for emergency burr holes, an aide-memoire for the front-line military surgeon.

Traumatic brain injury is the leading cause of death in conflict and early surgical intervention achieves better outcomes. The British Army surgical kit includes a Hudson Brace and bit and Gigli saw for decompression of the cranial cavity. Here we demonstrate the Hudson Brace technique for non-neurosurgeons.

Orthosis in Thoracolumbar Fractures: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

STUDY DESIGN: Systematic review and meta-analysis of randomized controlled trial (RCT). OBJECTIVE: The aim of this study was to evaluate radiological and clinical outcomes of acute traumatic thoracolumbar fractures in skeletally mature patients treated with orthosis, versus no immobilization. SUMMARY OF BACKGROUND DATA: Orthosis is traditionally used in conservative treatment of thoracolumbar fractures. However, recent studies suggest no benefit, and a possible negative impact in recovery. METHODS: Databases were searched from inception to June 2019. Studies were selected in two phases by two blinded reviewers; disagreements were solved by consensus. Inclusion criteria were: RCT; only patients with acute traumatic thoracolumbar fractures; primary conservative treatment; comparison between orthosis and no orthosis. Exclusion criteria were inclusion of nonacute fractures, patients with other significant known diseases and comparison of groups different than use of an orthosis. Two independent reviewers performed data extraction and quality assessment. Fixed-effects models were used upon no heterogeneity, and random-effects model in the remaining cases. A previous plan for extraction of radiological (kyphosis progression; loss of anterior height) and clinical (pain; disability; length of stay) outcomes was applied. PRISMA guidelines were followed. RESULTS: Eight articles/five studies were included (267 participants). None reported significant differences in pain, kyphosis progression, and loss of anterior height. One reported a better ODI with orthosis at 12 but not at 24 weeks. No other study reported differences in disability. All authors concluded an equivalence between treatments.Meta-analysis showed a significant increase of 3.47days (95% confidence interval 1.35-5.60) in mean admission time in orthosis group. No differences were found in kyphosis at 6 and 12 months; kyphosis progression between 0 to 6 and 0 to 12 months; loss of anterior height 0 to 6 months; VAS for pain at 6 months; VAS change 0 to 6 months. CONCLUSION: Orthosis seems to add no benefit in conservative treatment of acute thoracolumbar fractures. This should be considered in guidelines and reviews of health care policies. LEVEL OF EVIDENCE: 3.

Adolescent Idiopathic Scoliosis Bracing Success Is Influenced by Time in Brace: Comparative Effectiveness Analysis of BrAIST and ISICO Cohorts.

STUDY DESIGN: Comparative effectiveness study OBJECTIVE.: To evaluate factors leading to higher percentage of brace failures in a cohort of North American patients with adolescent idiopathic scoliosis relative to their peers in Italy. SUMMARY OF BACKGROUND DATA: Studies of bracing in United States have shown worse outcomes than studies from European centers, possibly due to sample characteristics or treatment approaches. METHODS: Sample: Braced patients, aged 10 to 15, Risser <3, Cobb 20°- to 40°, observed to Cobb ≥40° and/or ≥Risser 4 selected from prospective databases. Comparators: Bracing per Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST) (TLSO) and Italian Scientific Spine Institute (ISICO) protocol (SPoRT braces with or without SEAS exercises). Baseline characteristics (sex, age, BMI, Risser, Cobb, curve type) and average hours of brace wear/day. Differences in programs (e.g., SEAS, type of brace, weaning protocol) were captured by a variable named "SITE." OUTCOME: Treatment failure (Cobb ≥40 before Risser 4). STATISTICS: Comparison of baseline characteristics, analyses of risk factors, treatment components, and outcomes within and between cohorts using logistic regression. RESULTS: A total of 157 BrAIST and 81 ISICO subjects were included. Cohorts were similar at baseline but differed significantly in terms of average hours of brace wear: 18.31 in the ISICO versus 11.76 in the BrAIST cohort. Twelve percent of the ISICO and 39% of the BrAIST cohort had failed treatment. Age, Risser, Cobb, and a thoracic apex predicted failure in both groups. SITE was related to failure (odds ratio [OR] = 0.19), indicating lower odds of failure with ISICO versus BrAIST approach. With both SITE and wear time in the model, SITE loose significance. In the final model, the adjusted odds of failure were higher in boys (OR = 3.34), and those with lowest BMI (OR = 9.83); the odds increased with the Cobb angle (OR = 1.23), and decreased with age (OR = 0.41) and hours of wear (OR = 0.86). CONCLUSION: Treatment at the ISICO resulted in a lower failure rate, primarily explained by longer average hours of brace wear. LEVEL OF EVIDENCE: 3.

Comparison of surgical and nonsurgical containment methods for patients with Legg-Calvé-Perthes disease of the onset ages between 6.0 and 8.0 years: Salter osteotomy versus a non-weight-bearing hip flexion-abduction brace.

Since bone healing potential decreases with age, patients with Legg-Calvé-Perthes disease should receive treatment appropriate to their age group. Nonsurgical treatment is commonly applied to patients under 6.0 years of age at the onset and surgical treatment is recommended for those over 8.0 years of age, but it remains unclear which is better for those between 6.0 and 8.0 years. The aim of this retrospective study was to compare outcomes of Salter osteotomy and a non-weight-bearing brace in this age group. Inclusion criteria were unilateral Legg-Calvé-Perthes disease patients who were 6.0-8.0 years of age at the onset, who had more than 50% femoral head involvement without hinge abduction, and who underwent either Salter osteotomy (n = 35) or a non-weight-bearing hip flexion-abduction brace (n = 18). Radiological and clinical outcomes at skeletal maturity were compared between the two groups. The mean follow-up durations were 9.4 years in the Salter osteotomy group and 10.0 years in the brace group. There was no significant difference in the modified Waldenström classification at the beginning of treatment and the Catterall and modified lateral pillar classifications evaluated at the fragmentation stage between the groups. At skeletal maturity, the Stulberg classification, the sphericity deviation score, femoral head overgrowth, and the articulo-trochanteric distance were similar between the groups, but the Salter osteotomy group showed significantly smaller lateralization of the femoral head and better acetabular shape and coverage than the brace group: femoral head lateralization (P < 0.001), acetabular depth-to-width ratio (P = 0.002), Sharp angle (P < 0.001), lateral acetabular shape (P = 0.027), acetabular head index (P < 0.001). There was no significant difference in hip pain and motion between the groups. In this age group, Salter osteotomy provides better femoral head position and acetabular shape and coverage than a non-weight-bearing brace.

Self-Experienced Trunk Appearance in Individuals With and Without Idiopathic Scoliosis.

STUDY DESIGN: Cross-sectional. OBJECTIVE: The aim of this study was to describe the self-experienced trunk appearance in individuals with and without idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: Idiopathic scoliosis is the most common spinal deformity. A large scoliotic deformity increases the risk of back pain and pulmonary dysfunction. The deformity has also a psychological impact. METHODS: The pictorial part of the spinal appearance questionnaire (pSAQ) was administered to 1416 individuals with idiopathic scoliosis (386 untreated, 529 brace treated, 501 surgically treated) and 272 individuals without scoliosis from the general population. Comparisons were made between individuals with and without scoliosis, between treatment groups and sex in the scoliosis group. RESULTS: Mean (95% confidence interval) age of the individuals with scoliosis was 36.2 (35.5-36.9) years and for the individuals without scoliosis 40.2 (37.9-42.4). pSAQ total was 12.3 (12.1-12.5) for individuals with scoliosis and 7.4 (7.3-7.6) for individuals without scoliosis (P < 0.001, adjusted for age and sex). pSAQ total was 11.5 (11.1-11.9) for untreated, 13.0 (12.6-13.3) for brace treated, and 12.3 (11.9-12.6) for surgically treated individuals (P < 0.001, adjusted for sex and curve size). The pSAQ total between males and females with idiopathic scoliosis did not differ (P = 0.22 adjusted for age and curve size). CONCLUSION: This study shows that individuals with idiopathic scoliosis have more concern about their body appearance than individuals without scoliosis. Untreated individuals are not as bothered of their spinal appearance as treated individuals. Males and females with scoliosis do not differ significantly in the perception of their spinal appearance. LEVEL OF EVIDENCE: 3.

Serial casting in early onset scoliosis: syndromic scoliosis is no contraindication.

BACKGROUND: Serial casting is a treatment for early onset scoliosis (EOS) in young children to achieve curve correction before bracing or to postpone initial surgical treatment until the patient is older. Good results have been reported for patients with idiopathic early onset scoliosis (IS). However, there are few reports of results in non-idiopathic cases, and the benefits of non-surgical methods in the syndromic-associated early onset scoliosis subgroup are unknown. METHODS: Retrospective single-institution study of patient charts and X-rays of all cases of sustained serial casting for EOS. Staged correction was obtained by applying three consecutive casts under general anaesthesia. These were changed every 4 weeks, followed by the implementation of a custom-made full-time Chêneau brace. Correction was measured by Cobb angle (CA) and rib-vertebra angle difference (RVAD) on whole spine anterior-posterior radiographs. Statistical analysis was performed via ANOVA. RESULTS: The study group consisted of 6 patiens with IS and 10 with non-idiopathic scoliosis (NIS) - exclusively syndromic-associated. The mean age at onset of treatment was 35 months (±15). The mean follow up was 21 months (±15). In IS patients average CA/RVAD before treatment was 46°(±8)/20°(±12). In NIS patients average CA/RVAD before treatment was 55°(±15)/24°(±14). After application of the third cast, the CA/RVAD was reduced to 20°(±11)/11°(±10) in IS patients. Whereas in NIS patients average CA/RVAD after the thrid cast was 28°(±12)/18°(±13). At latest follow-up the CA/RVAD was 16°(±7)/9°(±8) in IS patients and 31°(±11)/17° (±15) in NIS patients. CONCLUSION: Syndromic etiology is not a contraindication for serial casting in EOS. Our results show a curve correction, measured in CA, of 65% in IS patients and 44% in NIS patients. Significant reduction in the morphologic deformity, measured in RVAD, was achieved in the IS cohort, but not in the NIS cohort. In all cases surgical treatment could be delayed.

Increasing Brace Treatment for Pediatric Distal Radius Buckle Fractures: Using Quality Improvement Methodology to Implement Evidence-based Medicine.

BACKGROUND: Multiple randomized trials have showed equivalent outcomes and improved patient/family satisfaction using a removable brace to treat pediatric distal radius buckle fractures (DRBF). We tested the hypothesis that we could use quality improvement (QI) methodology to increase the proportion of patients with DRBF treated with removable braces at 2 tertiary care orthopaedic clinics from a baseline of 34.8% to 80%. METHODS: Clinic billing records were reviewed monthly to determine treatment (brace vs. cast) of DRBF and tracked using control charts (p-chart). Balance measures including correct application of the diagnostic criteria and algorithm were monitored. Process measures including the number of follow-up visits, radiographs obtained, and total cost of treatment were collected. Baseline data were obtained over a 3-month period, followed by a 12-month period of interventions using Plan-Do-Study-Act cycles targeting both individuals and groups of providers. RESULTS: The proportion of DRBF treated in a brace increased from a combined baseline of 34.8% to a combined 84% at the end of the study period. Following intervention, 83% (15/18) of providers began using braces for a majority of patients (defined as >67%), with only 1 provider continuing to use casts 100% of the time. Patient preference was cited as the most common reason for use of cast treatment. There was a significant decrease in the number of radiographs obtained at 1 of 2 institutions. The charges for brace treatment averaged $630 less per patient than for cast treatment, leading to an estimated medical-cost savings of $205,000 following intervention. CONCLUSIONS: Implementation of brace treatment for pediatric DRBF using QI methodology resulted in a shift toward brace treatment in the majority of patients, leading to substantial medical and nonmedical cost savings. Although patient preference was cited as the most common reason for persistent cast treatment, the data show the use of cast treatment to be more dependent upon individual provider preference. LEVEL OF EVIDENCE: Level II-therapeutic.

Brace treatment can serve as a time-buying tactic for patients with congenital scoliosis.

BACKGROUND: Infantile patients with congenital scoliosis (CS) can be confronted with increasing risk of mortality and morbidity. To date, the effectiveness of conservative treatment in CS has not been sufficiently investigated. We aimed to evaluate the bracing outcome in patients with CS and to investigate whether wearing brace can effectively delay the surgical procedures. METHODS: A total of 39 braced CS patients including 25 boys and 14 girls were reviewed for the eligibility to be included in this study. Radiographic parameters including curve magnitude and T1 to T12 height were evaluated for each patient at the initiation of the treatment and at the final follow-up (FU), respectively. Duration of the follow-up and requirement of surgical interventions were also recorded. The student t test was used to compare the radiographic parameters between the initial visit and the last FU. RESULTS: The mean initial age at bracing was 4.1 ± 2.3 years, and 7.5 ± 1.8 brace modifications were performed during a mean FU period of 42.1 ± 26.5 months. The mean curve magnitude before bracing was 44.1 ± 12.2°, which was corrected to 41.3 ± 13.5° at the final visit (p = 0.33). T1-T12 height increased from 13.4 ± 2.5 to 17.1 ± 2.8 cm during the treatment (P < 0.001). Nine patients underwent surgical intervention due to the curve progression more than 5°, with the time of surgery delayed for 32.1 ± 18.2 months. CONCLUSIONS: Brace treatment is an effective time-buying modality for CS patients, which may help maintain the body growth and delay the surgical intervention.

Is unilateral lower leg orthosis with a circular foot unit in the treatment of idiopathic clubfeet a reasonable bracing alternative in the Ponseti method? Five-year results of a supraregional paediatric-orthopaedic centre.

BACKGROUND: In the Ponseti treatment of idiopathic clubfoot, children are generally provided with a standard foot abduction orthosis (FAO). A significant proportion of these patients experience irresolvable problems with the FAO leading to therapeutic non-compliance and eventual relapse. Accordingly, these patients were equipped with a unilateral lower leg orthosis (LLO) developed in our institution. The goal of this retrospective study was to determine compliance with and the efficacy of the LLO as an alternative treatment measure. The minimum follow-up was 5 years. RESULTS: A total of 45 patients (75 ft) were retrospectively registered and included in the study. Compliance with the bracing protocol was 91% with the LLO and 46% with the FAO. The most common problems with the FAO were sleep disturbance (50%) and cutaneous problems (45%). Nine percent of patients experienced sleep disturbance, and no cutaneous problems occurred with the LLO. Thirteen percent of patients being treated with an FAO until the age of four (23 patients; 40 ft) underwent surgery because of relapse, defined by rigid recurrence of any of the components of a clubfoot. Fourteen percent of patients being treated with an LLO (22 patients; 35 ft), mostly following initial treatment with an FAO, experienced recurrence. CONCLUSION: Changing from FAO to LLO at any point during treatment did not result in an increased rate of surgery and caused few problems.

Type II Fractures in Older Adults: Can They Be Treated Conservatively?: A Single-Center Experience and Review of the Literature.

BACKGROUND: Odontoid fractures are the most common acute cervical spinal fractures in the geriatric population. Their rate is increasing along with the rising age of the elderly population. Whereas conservative management with external immobilization is reported as the treatment of choice for type I and III odontoid fractures, there are no clear indications concerning the best treatment for type II fractures. In younger patients surgical management is considered the best choice, but in older adults the rate of good outcomes worsens and operative risk because of comorbidities increases. METHODS: We report our retrospective single-center experience with conservative treatment of type II odontoid fractures in an elderly population, focusing on both radiologic and functional outcomes to compare our results with the recent literature. RESULTS: Among the 21 selected subjects with a minimum follow-up of 18 months, 19 (90.5%) showed a satisfactory clinical outcome, with an adequate bony healing in 10 cases and nonsymptomatic pseudarthrosis in 9 patients. All these patients were satisfied with the conservative results and could stop use of the collar. Two patients (9.5%) did not show any improvement and had to keep the collar indefinitely. CONCLUSIONS: Our study was limited because it was a retrospective review, with a limited number of patients. Nevertheless, the clinical and radiologic outcomes of our patients differ from the results of other studies, suggesting that conservative management of these fractures in this population does not necessarily lead to a bad clinical outcome or delayed surgery.

What factors impact on the implementation of clubfoot treatment services in low and middle-income countries?: a narrative synthesis of existing qualitative studies.

BACKGROUND: Around 100,000 children are born annually with clubfoot worldwide and 80% live in low and middle-income counties (LMICs). Clubfoot is a condition in which children are born with one or both feet twisted inwards and if untreated it can limit participation in everyday life. Clubfoot can be corrected through staged manipulation of the limbs using the Ponseti method. Despite its efficacy and apparent availability, previous research has identified a number of challenges to service implementation. The aim of this study was to synthesise these findings to explore factors that impact on the implementation of clubfoot services in LMICs and strategies to address them. Understanding these may help practitioners in other settings develop more effective services. METHODS: Five databases were searched and articles screened using six criteria. Articles were appraised using the Critical Appraisal Skills Programme (CASP) checklist. 11 studies were identified for inclusion. A thematic analysis was conducted. RESULTS: Thematic analysis of the included studies showed that a lack of access to resources was a challenge including a lack of casting materials and abduction braces. Difficulties within the working environment included limited space and a need to share treatment space with other clinics. A shortage of healthcare professionals was a concern and participants thought that there was a lack of time to deliver treatment. This was exacerbated by the competing demands on clinicians. Lack of training was seen to impact on standards, including the nurses and midwives attending to the child at birth that were failing to diagnose the condition. Financial constraints were seen to underlie many of these problems. Some participants identified failures in communication and cooperation within the healthcare system such as a lack of awareness of clinics. Strategies to address these issues included means of increasing resource availability and the delivery of targeted training. The use of non-governmental organisations to provide financial support and methods to disseminate best practice were discussed. CONCLUSIONS: This study identified factors that impact on the implementation of clubfoot services in LMIC settings.Findings may be used to improve service delivery.

The Efficacy of Brace Treatment for Thoracolumbar Kyphosis in Patients With Achondroplasia.

STUDY DESIGN: A retrospective study. OBJECTIVES: The aim of this study was to evaluate the outcome of brace treatment in the correction of thoracolumbar kyphosis (TLK) for patients with achondroplasia and to determine the factors associated with bracing efficacy. SUMMARY OF BACKGROUND DATA: Brace treatment has been used to correct TLK in patients with achondroplasia. However, there was a paucity of knowledge concerning its effectiveness. METHODS: A total of 33 achondroplasic patients treated by bracing were included in this study. Radiographic parameters including TLK, lumbar lordosis, curve magnitude, apical vertebral translation (AVT), percentage of apical vertebral wedging, pelvic tilt (PT), and pelvic incidence were recorded for each patient at the visit. Comparison of these parameters between the initial visit and the final visit was performed using the Student t test. Factors associated with the correction of TLK were evaluated using the logistic regression analysis. RESULTS: The mean age at presentation was 27.5 ±â€Š13.4 months. The mean period of treatment was 32.2 ±â€Š15.7 months, and the mean period of follow-up was 25.7 ±â€Š11.3 months. At the initial visit, the mean value of TLK and the percentage of apical vertebral wedging were 41.7 ±â€Š15.4° and 61.4% ±â€Š16.2%, respectively. At the final visit, the TLK and apical vertebral wedging were remarkably reduced to 29.5 ±â€Š20.8° and 52.1% ±â€Š18.7%, respectively. The logistic regression analysis showed that initial TLK, AVT, percentage of apical vertebral wedging, and PT were independent factors associated with the correction of TLK. CONCLUSION: Brace treatment can effectively correct TLK and restore the morphology of apical vertebral body for patients with achondroplasia. Large TLK, severe apical vertebral wedging, presence of AVT, and low PT may be indicative of an unfavorable outcome, which should be taken into account at the initiation of bracing. LEVEL OF EVIDENCE: 4.

Variations in Treatment of C2 Fractures by Time, Age, and Geographic Region in the United States: An Analysis of 4818 Patients.

BACKGROUND: The optimal form of treatment for C2 spine fractures is controversial. This investigation analyzed the variations in treatment of C2 fractures over time, by age group, and by geographic location. METHODS: The Nationwide Emergency Department Sample database was queried to identify patients 18 years and older who sustained C2 fracture without neurologic injury from 2006 to 2012. Subsequently, patients were further filtered based on the intervention they received: collar, halo, and surgery. Regions of hospital used in analysis were defined as Northeast, Midwest, South, and West. Linear regression models were used to analyze trends for C2 incidence rates and treatment type. Analysis of variance tests were used to determine differences among procedure groups when stratified by regions and age groups. RESULTS: Surgical intervention for C2 fracture increased from 36.5% in 2006 to 55.7% in 2012 (r = 0.116, P < 0.001). In contrast, the rate of halo use decreased from 57.8% in 2006 to 37.1% in 2012 (r = -0.139, P < 0.001). Surgery displayed increasing trend across all age groups. A greater proportion of patients in the Northeast were treated by collar compared with all other regions (P < 0.001). In contrast, halo use was significantly lower in the Northeast than the other 3 regions (P < 0.001). CONCLUSIONS: This investigation demonstrated that surgical management of C2 fractures is increasing in frequency over time and at all age groups. Furthermore, the treatment of these fractures varies by region-the Northeast had the highest incidence of collar use and lowest rate of halo use.

Whether Orthotic Management and Exercise are Equally Effective to the Patients With Adolescent Idiopathic Scoliosis in Mainland China?: A Randomized Controlled Trial Study.

STUDY DESIGN: A prospective randomized controlled trial. OBJECTIVE: The aim of this study was to investigate the effectiveness of orthotic management versus exercise on spinal curvature, body symmetry, and quality of life. SUMMARY OF BACKGROUND DATA: A number of well-designed studies comparing conservative treatment of adolescent idiopathic scoliosis (AIS) have been conducted and the evidence becomes stronger. However, there is a lack of the information on the effectiveness of orthotic management versus exercise. METHODS: The inclusion criteria recommended by the Scoliosis Research Society (SRS) and the international Society on Scoliosis Orthopedic and Rehabilitation Treatment (SOSORT) were used during enrollment. Eligible patients were randomly assigned to either bracing group or exercise group. Patients in the bracing group were prescribed with a rigid thoracolumbosacral orthosis and requested to wear 23 h/day, while patients in the exercise group were treated with the protocol of the Scientific Exercise Approach to Scoliosis. Data regarding angle of trunk inclination, Cobb angle, shoulder balance, body image, and quality of life (QoL) were collected every 6 months. RESULTS: Twenty-four patients in the bracing group and 29 patients in the exercise group participated in this study. For the intergroup comparison, the bracing group showed better results about the correction of spinal curvature (Cobb angle at the first 12 months of intervention, P = 0.039), scores concerning QoL, especially function (P < 0.001), mental health (P < 0.001), and total score (P < 0.001), were higher than that of the exercise group. The results of body symmetry evaluation did not differ significantly between the two groups. For the intragroup comparison, parameters of spinal curvature (baseline vs. 12-month, P < 0.03 in the exercise group and P < 0.001 in the bracing group), QoL (baseline vs. 12-month, P < 0.001), and TAPS (baseline vs. 12-month, P < 0.033) significantly improved over the studied period. Shoulder balance (baseline vs. 12-month, P < 0.005) showed significant improvement only in the bracing group. CONCLUSION: Both interventions of bracing and exercise showed significant treatment effectiveness on the patients with AIS. Bracing was superior to capture corrections in parameters of spinal curvature and body symmetry, while the QoL, especially in aspect of the functional and psychological status, was significantly better in the exercise group. LEVEL OF EVIDENCE: 1.

Predictability of Supine Radiographs for Determining In-Brace Correction for Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Retrospective radiographic study. OBJECTIVE: To assess whether flexibility as revealed by the supine radiograph, predicts in-brace curve correction. SUMMARY OF BACKGROUND DATA: Currently there is no consensus regarding a standard method to assess curve flexibility and immediate brace effectiveness in treating adolescent idiopathic scoliosis (AIS). Brace fabrication methods may be variable but ideally it should achieve maximal curve correction. Curve flexibility governs the degree of curve correction in-brace and hence dynamic radiographs are commonly performed prior to brace fitting. METHODS: This was a radiographic analysis of AIS patients treated with underarm bracing. Correlation of pre-brace, supine, and immediate in-brace Cobb angles was performed. Relationship with possible contributing factors including age, sex, body height, weight, age at menarche and Risser staging was studied. Major and minor curves were compared independently for correlation but the regression model was constructed based on the major curve only. RESULTS: From 105 patients with mean age of 12.2 ±â€Š1.2 years at brace fitting, supine Cobb angle measurement has significant correlation with immediate in-brace Cobb angle (r = 0.740). Univariate analyses showed no significant relationship with age, weight, height, date of menarche, Risser stage or pre-brace Cobb angle. Our regression model (in-brace Cobb angle = 0.809 × supine Cobb angle) had good fit of the data. CONCLUSION: Supine radiograph predictably determines the flexibility of the scoliotic curve to brace treatment. It can be used as a guideline to determine the amount of correction achievable with brace-wear. The effectiveness of the brace is dependent on the inherent flexibility of the curve rather than its size or type. LEVEL OF EVIDENCE: 3.

With a biomechanical treatment in knee osteoarthritis, less knee pain did not correlate with synovitis reduction.

BACKGROUND: Braces are used to treat pain in patellofemoral joint osteoarthritis (PFJOA). In a trial, we previously reported pain improvement after 6-weeks brace use. The pain reduction did not correlate with changes in Magnetic Resonance Imaging (MRI) assessed Bone Marrow Lesion volume or static synovial volume. Studies show that changes in the synovium on dynamic contrast enhanced (DCE) MRI are more closely associated with symptom change than static synovial volume changes. We hypothesised change in synovitis assessed using dynamic imaging could explain the reduction in pain. METHOD: One hundred twenty-six men and women aged 40-70 years with painful radiographically confirmed PFJOA were randomised to either brace wearing or no brace for 6-weeks. Pain assessment and DCE-MRI were performed at baseline and 6 weeks. DCE data was analysed using Tofts's equation. Pain measures included a VAS of pain on nominated aggravating activity (VASNA), and the KOOS pain subscale. Paired t-tests were used to determine within person change in outcome measures and Spearman's correlation coefficients were used to determine the correlation between change in pain and change in the DCE parameters. RESULTS: Mean age of subjects was 55.5 years (SD = 7.5) and 57% were female. There was clear pain improvement in the brace users compared to controls (VASNA - 16.87 mm, p = <0.001). There was no significant change to the dynamic synovitis parameters among brace users nor was pain change correlated with change in dynamic synovitis parameters. CONCLUSION: The reduction in knee pain following brace wearing in patients with PFJOA is not explained by changes in synovitis. TRIAL REGISTRATION: Trial registration number UK. ISRCTN50380458 /Registered 21.5.2010.

Historical Patterns and Variation in Treatment of Injuries in NFL (National Football League) Players and NCAA (National Collegiate Athletic Association) Division I Football Players.

We conducted a study to identify and contrast patterns in the treatment of common injuries that occur in National Football League (NFL) players and National Collegiate Athletic Association (NCAA) Division I football players. Orthopedic team physicians for all 32 NFL and 119 NCAA Division I football teams were asked to complete a survey regarding demographics and preferred treatment of a variety of injuries encountered in football players. Responses were received from 31 (97%) of the 32 NFL and 111 (93%) of the 119 NCAA team physicians. Although patellar tendon autograft was the preferred graft choice for both groups of team physicians, the percentage of NCAA physicians who allowed return to football 6 months or less after anterior cruciate ligament reconstruction was significantly (P = .03) higher than that of NFL physicians. Prophylactic knee bracing, which may prevent medial collateral ligament injuries, was used at a significantly (P < .0001) higher rate by NCAA teams (89%) than by NFL teams (28%). Ketorolac injections were given by a significantly (P < .01) higher percentage of NFL teams (93%) than of NCAA teams (62%). Understanding the current trends in the management of these injuries is beneficial in designing studies that may help improve the treatment and prevention of injuries in football players.