In-office Maximal Voluntary Ventilation Testing Demonstrates Pulmonary Improvement Following Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis.

OBJECTIVE: Pulmonary function can be impaired in patients with adolescent idiopathic scoliosis (AIS). Maximal voluntary ventilation (MVV) has been shown to be more strongly correlated with major coronal curve, and a more easily obtained measurement of pulmonary function, than forced vital capacity (FVC). We evaluated changes in pulmonary function using these 2 measures in patients with AIS in relation to changes in major coronal curves over time. METHODS: Forty-seven patients with AIS with thoracic curves ≥10 degrees performed pulmonary function tests using the Carefusion MicroLoop Spirometer at enrollment and 1 year later. Major coronal curve worsening >5 degrees was considered curve progression. RESULTS: At enrollment, 47 patients had a mean major coronal curve of 38 degrees (range: 10 to 76 degrees). One year later, 17 patients had undergone posterior spinal fusion, 9 had curve progression >5 degrees, and 21 had no progression. MVV and major coronal curve were negatively correlated (r = -0.36, P = 0.01) at enrollment. After fusion, the major coronal curve improved by a mean of 41 degrees, and MVV improved by 23% (P < 0.01), but FVC did not improve significantly (6%, P = 0.29). In stable curves, MVV improved 12% (P = 0.01) and FVC improved 9% (P = 0.007). In patients without surgery whose curves progressed an average of 11 degrees, there was no significant change in MVV or FVC (P > 0.44). CONCLUSION: This is the first study using office-based spirometry in an orthopaedic clinic showing improved pulmonary function with posterior spinal fusion and growth in patients with AIS. It is notable that MVV improved after spinal fusion, but FVC did not, as MVV appears to be a more sensitive measurement for the assessment of pulmonary function in these patients. LEVEL OF EVIDENCE: Level II.

Prospective Study on Tension Band Plating: Most Patients are Not Returning to Normal Activities 1 Month Following Surgery.

BACKGROUND: Tension band plating for temporary hemiepiphysiodesis has been reported by several authors as simple and effective for treating angular deformities of the lower limb. Anecdotally, patients have reported higher pain levels than expected given the small size of incision and relatively minimal amount of dissection, and we sought to investigate this further. METHODS: Patients 16 years old or less with lower extremity angular deformities or limb length inequality were prospectively enrolled before tension band plating from 2 pediatric institutions from July 2016 to December 2018. Participants completed postoperative questionnaires regarding their pain and activity level. Pain was assessed using the FACES Pain Scale. Patients were included if they completed the 1 month survey. RESULTS: Of the 48 patients that met inclusion criteria (mean age at surgery: 13.1 y; range: 7 to 16 y), 39 patients completed the survey at 3 months postoperatively. There was a significant change in pain level between 1 week and 1 month postoperatively (P<0.001). Eighty-three percent (34/41) of patients were still taking pain medication at 1 week, which decreased to 38% (18/48) at 1 month. At 3 months, 21% (8/39) patients reported they were still using pain medication. At 1 month, 65% of patients (31/48) had not returned to their prior activity level. Of the 39 patients who played sports, 59% (23/39) still had not fully returned to sports at 1 month. CONCLUSION: At 1 month following tension band plating, 65% of patients had not returned to their preoperative activity level, and 38% were taking pain medications. Although the tension band plate and surgical incision is small in size, patients and parents should be counseled that there are significant activity limitations and pain levels for a month or longer in many patients. LEVEL OF EVIDENCE: Level II.

Adolescent idiopathic scoliosis patients treated with bracing, surgery, or observation showed no difference in behavioral and emotional function over a 2-year period.

The purpose of this study was to assess if behavior and emotional function, as measured by the Pearson Behavioral Assessment Survey for Children, Second Edition (BASC-2) in patients and parents, changes with differing treatment protocols in patients with adolescent idiopathic scoliosis (AIS). One previous study showed abnormal BASC-2 scores in a substantial number of patients diagnosed with AIS; however, no study has assessed how these scores change over the course of treatment. AIS patients aged 12 to 21 years completed the BASC-2. The 176-item questionnaire was administered to subjects at enrollment, assessing behavioral and emotional problems across 16 subscales of 5 domains: school problems, internalizing problems, inattention/hyperactivity, emotional symptoms index, and personal adjustment. Parents were given an equivalent assessment survey. Surveys were administered again after 2 years. Subject treatment groups (bracing, surgery, and observation) were established at enrollment. Patients were excluded if they did not complete the BASC-2 at both time points. Forty-six patients met the inclusion criteria, with 13 patients in the surgical, 20 in the bracing, and 13 in the observation treatment groups. At enrollment, 26% (12/46) of subjects with AIS had a clinically significant score in 1 or more subscales, and after 2 years 24% (11/46) of subjects reported a clinically significant score in at least 1 subscale (P = .8). There were no significant differences in scores between enrollment and follow-up in any treatment group. Similar to what was reported in a previous study, only 36% (4/11) of patients had clinically significant scores reported by both patient and parent, conversely 64% (7/11) of parents were unaware of their child's clinically significant behavioral and emotional problems. Common patient-reported subscales for clinically significant and at-risk scores at enrollment included anxiety (24%; 11/46), hyperactivity (24%; 11/46), attention problems (17%; 8/46), and self-esteem (17%; 8/46). At 2-year follow-up, the most commonly reported subscales were anxiety (28%; 13/46), somatization (20%; 9/46), and self-esteem (30%; 14/46). Patients with AIS, whether observed, braced or treated surgically, showed no significant change in behavior and emotional distress over the course of their treatment, or compared with each other at 2-year follow-up.

Primary Lymphoma of the Distal Femur Presenting as Spontaneous Deep Vein Thrombosis and Knee Monoarthritis: A Case Report.

CASE: A 68-year-old man with a history of unprovoked deep vein thrombosis (DVT) presented with recurrent knee effusions after the initiation of anticoagulation. Radiographs showed soft-tissue swelling without a distinct skeletal lesion. Magnetic resonance imaging, however, showed a marrow-replacing process in the distal femur. Subsequent biopsy demonstrated B-cell lymphoma. CONCLUSION: This is a rare case of a primary lymphoma of bone mimicking synovial disease. It also highlights the fact that an unprovoked DVT may be a harbinger of an undiagnosed underlying malignancy.

Intralaminar Screw Fixation of Spondylolysis.

Spondylolysis, defined as injury to the pars interarticularis, is the most common identifiable cause of back pain in children. Historically, treatment has primarily been nonoperative, including physical therapy, activity modification, and occasionally bracing1. In instances in which the condition is refractory to nonoperative management, however, surgical treatment may be an efficacious alternative. Persistent pain following nonoperative management is described as occurring in 6% of the general population, but is reported to be as high as 15% to 47% in the pediatric population who participate in sports2,3. There have been several proposed methods of surgical intervention, such as screws, hooks, wires, and combinations of the aforementioned, none of which have garnered unanimous support as being most effective. The report by Buck3 served to popularize the use of intralaminar screwing for fixation, and the 93% success rate reported in that study has since been corroborated, with several studies reporting rates from 82% to 100%1,3,4. This technique offers a low-profile solution that is motion-sparing with demonstrable stability and mechanical advantage compared with other techniques5 and has been shown to be a more stable method of fixation that can correct relatively large defects, showing efficacy with defects 4 mm and larger5. This procedure is performed by (1) placing the patient in a prone position with minimization of lordosis on the operating table and use of fluoroscopy to localize the defect. (2) A midline incision (approximately 5 cm) is made just lateral to the corresponding spinous process in order to expose the lamina and the defect. (3) A curet is used to clean the defect. (4) Under fluoroscopy, and alternating between anteroposterior and lateral views, a percutaneous stab is made if needed using a 4.5-mm cannulated screw guidewire, and the wire is drilled through the caudal laminar surface, bisecting the pedicle to the superior cortex of the pedicle. (5) A 3.2-mm cannulated drill is then used to drill over the guidewire. (6) The wire is removed, and a ball-tip probe is used to feel the cortices. The screw length is measured and tapped. (7) The lamina is distally overdrilled if it is large enough. (8) A solid (rather than cannulated) screw of appropriate size (usually 4.5-mm diameter) is inserted with compression as needed. (9) If necessary, autologous posterior iliac crest bone graft is obtained from the same incision, and cancellous graft is placed in the defect. (10) A corticocancellous strip is overlaid from the lamina to the transverse process.