The effect of antibiotic-impregnated calcium sulfate beads and Medical Optimization Clinic attendance on the acute surgical site infection rate in high-risk pediatric neuromuscular and syndromic scoliosis patients.

BACKGROUND: Neuromuscular and syndromic (NMS) scoliosis patients are at higher risk of acute surgical site infections (SSIs). Despite following POSNA's endorsed consensus-based guidelines for SSI prevention, our institutional rates of acute SSI have varied dramatically. This variability drove simultaneous strategies to lower SSI rates: the creation of a preoperative Medical Optimization Clinic (MOC) and use of antibiotic-impregnated (Abx-I) calcium sulfate beads. METHODS: Patients undergoing index PSF at a single institution between 2016 and 2022 were retrospectively reviewed. Patients with ≥ 2 risk factors were included: (1) BMI < 18.5 or > 25; (2) incontinence; (3) instrumentation to pelvis; (4) non-verbal; (5) GMFCS IV/V. SSI was defined as deep infection within 90 days. We compared patients who attended MOC and received Abx-I (MOC + Abx-I) to those receiving neither intervention (control) nor a single intervention. RESULTS: 282 patients were included. The overall infection rate was 4.26%. Higher GMFCS (p = 0.0147), non-verbal status (p = 0.0048), and longer fusions (p = 0.0298) were independently associated with infection rate. Despite the MOC + Abx-I group having larger Cobb angles (88° ± 26°), higher GMFCS levels (4.5 ± 0.9), ASA class (3 ± 0.4), and more frequent instrumentation to the pelvis (85%), they had the lowest infection rate (2.13%) when compared to the control (4.2%) or single intervention groups (5.7%, 4.6%) (p = 0.9). CONCLUSION: The study examined the modern infection rate of NMS patients following the implementation of two interventions: MOC and Abx-I. Despite having higher risk factors (curves (88°), GMFCS level (4.5), ASA class (3), higher % instrumentation to the pelvis (85%)), the patients treated with both interventions demonstrated the lowest infection rate (2.13%).

Health-related quality of life and clinical outcomes for magnetically controlled growing rod patients after treatment termination.

PURPOSE: To determine the health-related quality of life (HRQoL) and clinical outcomes of children with early onset scoliosis (EOS) treated with magnetically controlled growing rods (MCGR) followed to definitive fusion (DF). METHODS: A retrospective review of EOS patients treated with MCGR and followed to DF was performed. Outcomes included HRQoL scores, radiographic, clinical, and unplanned returns to the operating room (UPROR) data collected at pre-MCGR implantation, immediately post-MCGR implantation, pre-DF, and post-DF. HRQoL scores were collected at least 6 months post-DF. RESULTS: Twenty-eight patients (57.1% females, mean age at MCGR insertion 7.19 ± 1.5 years, mean pre-MCGR Cobb 64.7° ± 17.6) met inclusion criteria. MCGR treatment resulted in an overall 30.2% improvement in coronal plane deformity following DF. The mean growth rates between MCGR implantation and pre-DF for T1-T12 height and T1-S1 length were 0.33 ± 0.23 mm/month and 0.49 ± 0.28 mm/month, respectively. Of the 28 included patients, 26 (92.9%) experienced at least one UPROR, with a total of 52 surgical complications occurring in the total cohort, representing 1.9 UPROR/patient. Interestingly, there was a decline in scores reported between post-MCGR implantation and the pre-DF time-point (N = 16, 78.2 ± 14.9 vs 69.7 ± 17.8, p = 0.02). These scores recovered post-DF, resulting in an overall unchanged HRQoL when comparing pre-MCGR to post-DF (N = 11, 79.9 ± 15.1 vs 76.7 ± 17.9, p = 0.44). CONCLUSION: While MCGR treatment achieves coronal plane deformity control and facilitates spinal growth, only 7.1% of children experienced a complication-free treatment course when followed to definitive fusion. Patients achieved modest curve correction and spinal growth, while maintaining stable HRQoL outcomes between pre-MCGR and post-DF.

Radiographic and clinical outcomes after definitive spine fusion for skeletally immature patients with idiopathic scoliosis.

PURPOSE: To assess the intermediate-term radiographic and clinical outcomes of skeletally immature idiopathic scoliosis (IS) patients that underwent definitive fusion (DF). METHODS: A retrospective review of patients with IS who were Risser 0 with open tri-radiate cartilages at the time of DF with minimum 5-year follow-up. Outcomes included Scoliosis Research Society (SRS)-30 scores, major Cobb angle, pulmonary function tests (PFTs), and unplanned returns to the operating room (UPROR). Adding-on was defined as progression of the major Cobb angle > 5° or tilt of the lowest instrumented vertebra > 5°. RESULTS: Thirty-two patients (78% female, mean age 12.2 ± 1.3 years old, mean preoperative major Cobb 64.8° ± 15.9) were included. Of these patients, 20 (62.5%) experienced adding-on and 6 (18.8%) required a revision surgery to correct their progressive spinal deformity. Adding-on was associated with lower 5-year postoperative SRS scores for appearance (3.7 ± 0.7 vs 4.4 ± 0.3, p = 0.0126), mental health (4.2 ± 0.6 vs 4.6 ± 0.3, p = 0.0464), satisfaction with treatment (4.0 ± 0.8 vs 4.7 ± 0.4, p = 0.0140), and total score (4.0 ± 0.4 vs 4.4 ± 0.2, p = 0.0035). The results of the PFTs did not differ between groups. Patients experienced an average of 0.53 UPROR/patient. CONCLUSION: DF in skeletally immature patients results in a high rate of adding-on, which adversely affects Health-Related Quality of Life. However, reoperation rates, both planned and unplanned, remain lower when compared to patients undergoing growth-friendly treatment.

Repeat surgical interventions following "definitive" instrumentation and fusion for idiopathic scoliosis: a 30-year update.

PURPOSE: Although spinal fusion (SF) is considered "definitive" treatment in juvenile/adolescent idiopathic scoliosis (JIS/AIS), complications requiring reoperation continue to occur. The purpose of this study was to characterize the evolving rates of reoperation following SF in JIS/AIS. METHODS: Single-center retrospective review of patients who underwent SF for JIS/AIS as their index surgical treatment between 2013 and 2019. Patient data were collected to identify complications requiring reoperation and factors associated with reoperation. Complication rates from 2013 to 2019 were compared to patients from 1988 to 2012 at the same institution. RESULTS: This study analyzed 934 patients (81.7% female, mean age at surgery 14.5 ± 2.1). Thirty-eight patients (4.1%) required a total of 47 reoperations, a > 50% decrease in overall complication rate from the 2008-2012 population (4.1% vs 9.6%, respectively, p < 0.001). The decrease stemmed mainly from decreases in rates of infection (1.1% vs 4.1%, p < 0.001) and symptomatic implants (0.4% vs 2.1%, p = 0.004). There were, however, non-significant increases in implant failures (0.6% vs 0.2%, p = 0.4367) and pseudoarthrosis (1.0% vs 0.4%, p = 0.5202). Both of these complications were associated with patients with a higher mean weight (implant failure: 70.4 kg ± 21.1 vs 56.1 kg ± 14.9, p = 0.002; pseudoarthrosis: 85.8 kg ± 27.9 vs 55.9 ± 14.5, p = 0.001). CONCLUSIONS: Reoperation following SF for JIS/AIS has decreased over the past 7 years when compared to 25 years of historical controls. The changing landscape of reoperation demands further research into the risk factors for those reoperations that have become more common.

An Analysis of Scoliosis in Autism Spectrum Disorder.

BACKGROUND: Children with autism/Asperger are grouped into the diagnosis of autism spectrum disorder (ASD). It remains uncertain whether children with ASD and scoliosis have radiographic and clinical outcomes similar to idiopathic scoliosis (IS) patients. METHODS: A single-center, retrospective review of a prospective scoliosis registry evaluated patients who had a posterior spinal fusion±Anterior Spinal Fusion and an underlying diagnosis of ASD between 1990 and 2021. A 2:1 match with AIS patients by age and sex was compared using demographic, radiographic, intraoperative, and SRS-22/30 variables. RESULTS: Thirty patients with ASD (63% male, mean age at surgery 14.6±2.5 y) met inclusion criteria, with a follow-up of 2.46±1.00 years. Despite no differences in curve magnitude preoperatively, patients with ASD had a higher percent correction at 2-year follow-up (66% vs. 57%, P =0.01) and improved mean curve magnitude (20±10 degrees) at 2-year follow-up compared with IS patients (27±11 degrees, P <0.01). ASD patients had less lumbar lordosis preoperatively (40±12 vs. 53±14, P <0.01), but there were no significant differences in sagittal parameters at 2-year follow-up. There were no significant differences in the rate of complications at 2-year follow-up between ASD and AIS cohorts. CONCLUSIONS: Although patients with ASD exhibited decreased lordosis compared with IS patients preoperatively, their radiographic outcomes at 2-year follow-up were the same. In addition, ASD patients maintained greater curve correction than IS patients at 2 years follow-up. LEVEL OF EVIDENCE: Prognostic retrospective study.

Management of Pediatric Anterior Cruciate Ligament Injuries: A Critical Analysis.

¼ Overall evidence for the treatment of an anterior cruciate ligament (ACL) injury in a pediatric or skeletally immature patient remains lows.¼ An ACL reconstruction is recommended with concomitant repairable chondral and meniscus injury or with symptoms of persistent instability despite high-quality rehabilitation.¼ Treatment decision for pediatric ACL reconstruction should use a shared decision-making model weighing the risks and benefits of both a nonoperative vs. surgical treatment.

The evolution of pre-operative SRS scores over time in patients with adolescent idiopathic scoliosis.

PURPOSE: To determine if preoperative Health Related Quality of Life (HRQoL) has declined in the past two decades for patients with Adolescent Idiopathic Scoliosis (AIS), as measured by the Scoliosis Research Society (SRS) questionnaire. METHODS: A retrospective review was conducted on AIS patients that underwent surgery at a single institution between 2002 and 2022. Patients were included if they completed an SRS questionnaire preoperatively. A multivariate linear regression was performed with the SRS domains as the dependent variables. The independent variables were surgery year, gender, race/ethnicity, BMI, Lenke type, and major Cobb angle. A second regression was performed where the SRS scores for AIS patients were dichotomized as being above or below normal based on a threshold set at two standard deviations below the mean SRS scores of a healthy adolescent population. The binary SRS scores were used as the outcome of interest in a second regression. RESULTS: A total of 1380 patients (79.2% female, mean age 14.9 ± 2.0 years old) were included for analysis. Surgery year had a negative association with Pain (coefficient = - 0.03, p < 0.0001), Activity (coefficient = - 0.02, p < 0.0001), Mental Health (coefficient = - 0.01, p < 0.0001), and Total score (coefficient = - 0.01, p < 0.0001), indicating declining HRQoL over time. Similarly, AIS patients became more likely to fall below 2SD of the healthy adolescent means in Pain (OR: 1.061, p < 0.0001), Appearance (OR: 1.023, p = 0.0301), Activity (OR: 1.044, p = 0.0197), and Total score (OR: 1.06, p < 0.0001). CONCLUSION: Over the past two decades, patients with surgical AIS have experienced a significant decline in various HRQoL domains preoperatively.

Increasing soft tissue depth is associated with stalling of magnetically controlled growing rods.

Background: Magnetically controlled growing rods (MCGR) represent the most used implant for the treatment of early onset scoliosis (EOS). These implants lengthen through the application of a remote magnetic field but distraction force generation has been negatively correlated with increasing soft tissue depth. Given the high rate of MCGR stalling, we proposed to investigate the impact of preoperative soft tissue depth on the rate of MCGR stalling at a minimum of 2 years following implantation. Methods: A single-center, retrospective review of prospectively enrolled children with EOS treated with MCGR was performed. Children were included if they had a minimum of 2-years follow-up after implantation and underwent advanced spinal imaging (MRI or CT) preoperatively within a year of implantation. The primary outcome was the development of MCGR stall. Additional measures included radiographic deformity parameters and gain in MCGR actuator length. Results: About 55 patients were identified with 18 having preoperative advanced imaging allowing tissue depth measurement (Mean 5.99 ± 1.9 years, 83.3% female, mean Cobb 68.6 ± 13.8°). At a mean follow-up of 46.1 ± 11.9 months, 7 patients (38.9%) experienced stalling. MCGR stalling was associated with increased preoperative soft tissue depth (21.5 ± 4.4 mm vs. 16.5 ± 4.1 mm; p = .025) and increased BMI (16.3 ± 1.6 vs. 14.5 ± 0.9; p = .007). Conclusions: Greater preoperative soft tissue depth and BMI were associated with the development of MCGR stalling. This data supports previous studies showing that the distraction capacity of MCGR diminishes with increased soft tissue depth. Further research is needed to validate these findings and their implications on the indications for MCGR implantation.

The evolving stall rate of magnetically controlled growing rods beyond 2 years follow-up.

PURPOSE: Magnetically controlled growing rods (MCGR) have become the dominant distraction-based implant for the treatment of early onset scoliosis (EOS). Recent studies, however, have demonstrated rising rates of implant failure beyond short-term follow-up. We sought to evaluate a single-center experience with MCGR for the treatment of EOS to define the rate of MCGR failure to lengthen, termed implant stall, over time. METHODS: A single-center, retrospective review was conducted identifying children with EOS undergoing primary MCGR implantation. The primary endpoint was the occurrence of implant stalling, defined as a failure of the MCGR to lengthen on three consecutive attempted lengthening sessions with minimum of 2 years follow-up. Clinical and radiographic variables were collected and compared between lengthening and stalled MCGRs. A Kaplan-Meier survival analysis was conducted to assess implant stalling over time. RESULTS: A total of 48 children met inclusion criteria (mean age 6.3 ± 1.8 years, 64.6% female). After a mean 56.9 months (range of 27 to 90 months) follow-up, 25 (48%) of children experienced implant stalling at a mean of 26.0 ± 14.1 months post-implantation. Kaplan-Meier survival analysis demonstrated that only 50% of MCGR continue to successfully lengthen at 2 years post-implantation, decreasing to < 20% at 4 years post-implantation. CONCLUSION: Only 50% of MCGR continue to successfully lengthen 2 years post-implantation, dropping dramatically to < 20% at 4 years, adding to the available knowledge regarding the long-term viability and cost-effectiveness of MCGR in the management of EOS. Further research is needed to validate these findings.

The Effect Immobilization Mechanisms Have on Radiographic Outcomes and Complication Rates in the Conservative Treatment of Distal Radius Fractures: A Systematic Review.

Distal radius fractures (DRFs) are among the most common fractures in the United States. Despite their high incidence, there is no consensus on the optimal type of cast or splint to treat these fractures. The purpose of this systematic review is to evaluate the available literature pertaining to the outcomes for different constructs used to conservatively treat DRFs. A literature search of PubMed, Medline, and Embase was conducted to identify research comparing the outcomes of various immobilization mechanisms. In particular, endpoints included complications (eg, loss of reduction, pain), radiographic outcomes, and Disabilities of the Arm, Shoulder, and Hand (DASH) scores. A total of 1655 articles were identified during the literature search, and 22 ultimately fulfilled inclusion criteria. These 22 studies included 1826 conservatively treated DRFs. The different immobilization mechanisms were divided into 8 groupings: above-elbow casts, above-elbow splints, below-elbow casts, below-elbow splints, gutter or spica casts, gutter or spica splints, dorsal-volar splints, and dorsal splints. Qualitative review of the studies determined that below-elbow constructs result in equal or better functional and radiologic outcomes when compared with above-elbow constructs. Meta-analysis demonstrated that a statistically significant difference (P = .04) existed in the incidence of loss of reduction between the immobilization constructs, although post hoc analysis did not detect significant differences between 2 particular constructs.

The Effect of Immobilization Position on Functional Outcomes and Complications Associated With the Conservative Treatment of Distal Radius Fractures: A Systematic Review.

Purpose: We evaluated the literature on complications associated with different positions used for immobilizing the upper extremity during conservative treatment of distal radius fractures (DRF). Methods: A search of PubMed, Embase, and Medline was conducted to identify original research on the effects that upper extremity positioning during the treatment of DRFs has on complication rates. Treatment groups were categorized by wrist positioning in flexion, extension, or neutral, as well as forearm positioning in pronation, supination, or neutral. The primary endpoints examined included the loss of reduction, recasting/refabricating an orthosis, and functional limitations. Results: A total of 1,655 articles were identified through an initial database search. Ultimately, 8 studies, with 786 total patients, met the inclusion criteria for this systematic review. A qualitative analysis determined that immobilizing DRFs with the wrist in extension results in better functional and radiographic outcomes with lower rates of complications, such as pain, recasting, and the need for operation. The 2 studies that compared forearm pronation versus supination revealed contradictory results regarding which position was associated with superior outcomes. A meta-analysis comparing the various wrist and forearm positions failed to demonstrate statistically significant differences in the rates of loss of reduction or recasting/refabricating an orthosis between the groups. This analysis was limited by considerable heterogeneity in the data from the different studies. Conclusions: Despite the high incidence of DRFs, there is limited research on the optimal position of immobilization for conservative treatment of them. Available evidence suggests that the wrist should be immobilized in extension, as these patients had improved functional and radiographic outcomes. No conclusion can be drawn from the existing literature on ideal forearm position during immobilization. This review also suggests better data reporting practices for studies researching DRFs, so that future meta-analyses can be more comprehensive. Type of study/level of evidence: Therapeutic II.

Hypothalamic Neurons that Regulate Feeding Can Influence Sleep/Wake States Based on Homeostatic Need.

Eating and sleeping represent two mutually exclusive behaviors that satisfy distinct homeostatic needs. Because an animal cannot eat and sleep at the same time, brain systems that regulate energy homeostasis are likely to influence sleep/wake behavior. Indeed, previous studies indicate that animals adjust sleep cycles around periods of food need and availability. Furthermore, hormones that affect energy homeostasis also affect sleep/wake states: the orexigenic hormone ghrelin promotes wakefulness, and the anorexigenic hormones leptin and insulin increase the duration of slow-wave sleep. However, whether neural populations that regulate feeding can influence sleep/wake states is unknown. The hypothalamic arcuate nucleus contains two neuronal populations that exert opposing effects on energy homeostasis: agouti-related protein (AgRP)-expressing neurons detect caloric need and orchestrate food-seeking behavior, whereas activity in pro-opiomelanocortin (POMC)-expressing neurons induces satiety. We tested the hypotheses that AgRP neurons affect sleep homeostasis by promoting states of wakefulness, whereas POMC neurons promote states of sleep. Indeed, optogenetic or chemogenetic stimulation of AgRP neurons in mice promoted wakefulness while decreasing the quantity and integrity of sleep. Inhibition of AgRP neurons rescued sleep integrity in food-deprived mice, highlighting the physiological importance of AgRP neuron activity for the suppression of sleep by hunger. Conversely, stimulation of POMC neurons promoted sleep states and decreased sleep fragmentation in food-deprived mice. Interestingly, we also found that sleep deprivation attenuated the effects of AgRP neuron activity on food intake and wakefulness. These results indicate that homeostatic feeding neurons can hierarchically affect behavioral outcomes, depending on homeostatic need.

AgRP Neurons Can Increase Food Intake during Conditions of Appetite Suppression and Inhibit Anorexigenic Parabrachial Neurons.

To maintain energy homeostasis, orexigenic (appetite-inducing) and anorexigenic (appetite suppressing) brain systems functionally interact to regulate food intake. Within the hypothalamus, neurons that express agouti-related protein (AgRP) sense orexigenic factors and orchestrate an increase in food-seeking behavior. In contrast, calcitonin gene-related peptide (CGRP)-expressing neurons in the parabrachial nucleus (PBN) suppress feeding. PBN CGRP neurons become active in response to anorexigenic hormones released following a meal, including amylin, secreted by the pancreas, and cholecystokinin (CCK), secreted by the small intestine. Additionally, exogenous compounds, such as lithium chloride (LiCl), a salt that creates gastric discomfort, and lipopolysaccharide (LPS), a bacterial cell wall component that induces inflammation, exert appetite-suppressing effects and activate PBN CGRP neurons. The effects of increasing the homeostatic drive to eat on feeding behavior during appetite suppressing conditions are unknown. Here, we show in mice that food deprivation or optogenetic activation of AgRP neurons induces feeding to overcome the appetite suppressing effects of amylin, CCK, and LiCl, but not LPS. AgRP neuron photostimulation can also increase feeding during chemogenetic-mediated stimulation of PBN CGRP neurons. AgRP neuron stimulation reduces Fos expression in PBN CGRP neurons across all conditions. Finally, stimulation of projections from AgRP neurons to the PBN increases feeding following administration of amylin, CCK, and LiCl, but not LPS. These results demonstrate that AgRP neurons are sufficient to increase feeding during noninflammatory-based appetite suppression and to decrease activity in anorexigenic PBN CGRP neurons, thereby increasing food intake during homeostatic need.SIGNIFICANCE STATEMENT The motivation to eat depends on the relative balance of activity in distinct brain regions that induce or suppress appetite. An abnormal amount of activity in neurons that induce appetite can cause obesity, whereas an abnormal amount of activity in neurons that suppress appetite can cause malnutrition and a severe reduction in body weight. The purpose of this study was to determine whether a population of neurons known to induce appetite ("AgRP neurons") could induce food intake to overcome appetite-suppression following administration of various appetite-suppressing compounds. We found that stimulating AgRP neurons could overcome various forms of appetite suppression and decrease neural activity in a separate population of appetite-suppressing neurons, providing new insights into how the brain regulates food intake.