A Comparative Analysis of Revision Surgery Before or After 2 Years After Graduation From Growth-friendly Surgery for Early Onset Scoliosis.

INTRODUCTION: After discontinuation of growth-friendly (GF) surgery for early onset scoliosis, patients are termed graduates: they undergo a spinal fusion, are observed after final lengthening with GF implant maintenance, or are observed after GF implant removal. The purpose of this study was to compare the rates of and reasons for revision surgery in two cohorts of GF graduates: before or after 2 years of follow-up from graduation. METHODS: A pediatric spine registry was queried for patients who underwent GF spine surgery with a minimum of 2 years of follow-ups after graduation by clinical and/or radiographic evidence. Scoliosis etiology, graduation strategy, number of, and reasons for revision surgery were queried. RESULTS: There were 834 patients with a minimum of 2-year follow-up after graduation who were analyzed. There were 241 (29%) congenital, 271 (33%) neuromuscular, 168 (20%) syndromic, and 154 (18%) idiopathic. 803 (96%) had traditional growing rod/vertical expandable titanium rib as their GF construct and 31 (4%) had magnetically controlled growing rod. Five hundred ninety-six patients (71%) underwent spinal fusion at graduation, 208 (25%) had GF implants retained, and 30 (4%) had GF implants removed.In the entire cohort, there were 108/834 (13%) patients who underwent revision surgery. Of the revisions, 71/108 (66%) occurred as acute revisions (ARs) between 0 and 2 years from graduation (mean 0.6 y), and the most common AR indication was infection (26/71, 37%). The remaining 37/108 (34%) patients underwent delayed revision (DR) surgery >2 years (mean 3.8 y) from graduation, and the most common DR indication was implant issues (17/37, 46%).Graduation strategy affected revision rates. Of the 596 patients with spinal fusion as a graduation strategy, 98/596 (16%) underwent revision, compared with only 8/208 (4%) patients who had their GF implants retained, and 2/30 (7%) that had their GF implants removed ( P ≤ 0.001).A significantly higher percentage of the ARs had a spinal fusion as the graduation strategy (68/71, 96%) compared with 30/37 DRs, (81%, P = 0.015). In addition, the 71 patients who underwent AR undergo more revision surgeries (mean: 2, range: 1 to 7) than 37 patients who underwent DR (mean: 1, range: 1 to 2) ( P = 0.001). CONCLUSION: In this largest reported series of GF graduates to date, the overall risk of revision was 13%. Patients who undergo a revision at any time, as well as ARs in particular, are more likely to have a spinal fusion as their graduation strategy. Patients who underwent AR, on average, undergo more revision surgeries than patients who underwent DR. LEVEL OF EVIDENCE: Level III, comparative.

Providence Bracing: Predicting the Progression to Surgery in Patients With Braced Idiopathic Scoliosis.

BACKGROUND: Idiopathic scoliosis (IS) is a common spinal abnormality, in which orthotic management can reduce progression to surgery. However, predictors of bracing success are still not fully understood. We studied a large patient population treated with the nighttime Providence orthosis, utilizing multivariable logistic regression to assess results and predict future spine surgery. METHODS: We retrospectively reviewed patients with IS meeting Scoliosis Research Society inclusion and assessment criteria presenting from April 1994 to June 2020 at a single institution and treated with a Providence orthosis. A predictive logistic regression model was developed utilizing the following candidate features: age, sex, body mass index, Risser classification, Lenke classification, curve magnitude at brace initiation, percentage correction in a brace, and total months of brace use. Model performance was assessed using the area under the receiver operating characteristic curve, accuracy, sensitivity, and specificity. The importance of individual features was assessed using the variable importance score. RESULTS: There were 329 consecutive patients with IS with a mean age of 12.8 ± 1.4 years that met inclusion and assessment criteria. Of these, 113 patients (34%) ultimately required surgery. The model's area under the curve (AUC) was 0.72 on the testing set, demonstrating good discrimination. The initial curve magnitude (Importance score: 100.0) and duration of bracing (Importance score: 82.4) were the 2 most predictive features for curve progression leading to surgery. With respect to skeletal maturity, Risser 1 (Importance score: 53.9) had the most predictive importance for future surgery. For the curve pattern, Lenke 6 (Importance score: 52.0) had the most predictive importance for future surgery. CONCLUSION: Out of 329 patients with IS treated with a Providence nighttime orthosis, 34% required surgery. This is similar to the findings of the BrAist study of the Boston orthosis, in which 28% of monitored braced patients required surgery. In addition, we found that predictive logistic regression can evaluate the likelihood of future spine surgery in patients treated with the Providence orthosis. The severity of the initial curve magnitude and total months of bracing were the 2 most important variables when assessing the probability of future surgery. Surgeons can use this model to counsel families on the potential benefits of bracing and risk factors for curve progression.

Baclofen Pump Use: Complications After Growth-friendly Instrumentation for Early-onset Scoliosis.

BACKGROUND: Patients with early-onset scoliosis (EOS) and spasticity may receive treatment with an intrathecal baclofen pump. We assessed how baclofen pumps are associated with the odds of complications and secondary interventions after growth-friendly (GF) spine surgery for EOS and analyzed infectious complications within the pump cohort. METHODS: Using a prospectively maintained, international multicenter database, we studied patients with neuromuscular EOS with baclofen pumps who underwent GF spine surgery from 2002 through 2019 (n=25). Baclofen pumps were implanted before GF instrumentation in 18 patients, during in 2 patients, and after in 5 patients. Patients with existing pumps at initial GF spine surgery were matched 1:3 with 54 patients (control group) without pumps according to treatment center, year of surgery, diagnosis, surgery type, and preoperative curve magnitude. Univariate analysis and multivariate logistic regression were performed to compare complications and secondary interventions between the 2 cohorts. RESULTS: Patients with baclofen pumps had 4.8 times the odds [95% confidence interval (CI): 1.5-16] of experiencing any complication within 1 year after initial GF spine surgery compared with controls. During mean follow-up of 6.9±4.3 years, they had 4.7 times the odds (95% CI: 1.3-16) of deep surgical site infection and 5.6 times the odds (95% CI: 1.2-26) of spinal rod removal after any complication. Differences in rates of mechanical complication, such as rod migration and breakage, were nonsignificant between the 2 groups. For the 9 patients (50%) with pumps who experienced infections, the most common microorganisms were Staphylococcus aureus (4 patients) and Pseudomonas aeruginosa (2). The pump/catheter was revised or removed, in addition to antibiotic therapy or surgical irrigation and debridement, in 2 patients. CONCLUSIONS: Among patients with neuromuscular EOS, those with baclofen pumps are much more likely to experience complications within 1 year after GF spine surgery. They are also more likely to have deep surgical site infections, with S. aureus and P. aeruginosa being the most common causative organisms, and to require spinal rod removal. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

No Difference in the Rates of Unplanned Return to the Operating Room Between Magnetically Controlled Growing Rods and Traditional Growth Friendly Surgery for Children With Cerebral Palsy.

BACKGROUND: Early-onset scoliosis (EOS) is common in children with cerebral palsy (CP). The effectiveness of magnetically controlled growing rods (MCGR) and the risk for unplanned return to the operating room (UPROR) remain to be studied in this patient population. The primary outcome of this study was to examine the frequency of UPROR between MCGRs as compared with traditional growth friendly (TGF) surgeries for children with EOS secondary to CP. METHODS: Patients with EOS secondary to CP were prospectively identified from an international database, with data retrospectively analyzed. Scoliosis, kyphosis, T1-S1, and T1-T12 height were measured preoperation, immediate postoperation, and at minimum 2-year follow-up. The risk and etiology of UPRORs were compared between MCGR and TGF. RESULTS: Of the 120 patients that met inclusion criteria, 86 received TGF (age 7.5±0. 1.8 y; mean follow-up 7.0±2.9 y) and 34 received MCGR (age 7.1±2.2 y, mean follow-up 2.8±0.0.5 y). Compared with TGF, MCGR resulted in significant improvements in maintenance of scoliosis (P=0.007). At final follow-up, UPRORs were 8 of 34 patients (24%) for MCGR and 37 of 86 patients (43%) for TGF (P=0.05). To minimize the influence of follow-up period, UPRORs within the first 2 years postoperation were evaluated: MCGR (7 of 34 patients, 21%) versus TGF (20 of 86 patients, 23%; P=0.75). Within the first 2 years, etiology of UPROR as a percentage of all patients per group were deep infection (13% TGF, 6% MCGR), implant failure/migration (12% TGF, 9% MCGR), dehiscence (4% TGF, 3% MCGR), and superficial infection (4% TGF, 3% MCGR). The most common etiology of UPROR for TGF was deep infection and for MCGR was implant failure/migration. CONCLUSION: For patients with EOS secondary to CP, there was no difference in the risk of UPROR within the first 2 years postoperatively whether treated with TGF surgery or with MCGRs (23% TGF, 21% MCGR). LEVEL OF EVIDENCE: Level III-retrospective cohort, therapeutic study.

The Impact of Unplanned Return to the Operating Room on Health-related Quality of Life at the End of Growth-friendly Surgical Treatment for Early-onset Scoliosis.

BACKGROUND: Limiting complications, especially unplanned return to the operating room (UPROR), is a major focus in the surgical management of early-onset scoliosis (EOS). Although UPROR remains common in this population, its effect on long-term health-related quality of life (HRQoL) remains unclear. The purpose of this study was to investigate the association between UPROR and end-of-treatment HRQoL in EOS patients treated with growth-friendly instrumentation. METHODS: Patients with EOS who underwent growth-friendly instrumentation at age less than 10 years from 1993 to 2018, and completed treatment, were identified in a multicenter EOS registry. UPROR events were recorded, and end-of-treatment (defined as skeletal maturity and/or definitive spinal fusion) HRQoL was assessed via the 24-item Early-Onset Scoliosis Questionnaire (EOSQ-24). RESULTS: A total of 825 patients were identified, and 325 patients (age at surgery: 6.4 y, follow-up: 8.1 y) had end-of-treatment HRQoL data necessary for our investigation. Overall, 129/325 (39.7%) patients experienced 264 UPROR events; the majority (54.2%) were implant-related. Aside from age and etiology, no other variables were determined to be confounders or effect modifiers. Congenital patients with UPROR had worse pain/discomfort by 10.4 points (P=0.057) and worse pulmonary function by 7.8 points (P=0.102) compared with non-UPROR patients adjusting for age. Neuromuscular patients with UPROR had worse pulmonary function by 10.1 points compared with non-UPROR patients adjusting for age (P=0.037). Idiopathic and syndromic patients with UPROR reported consistently worse domain scores than their non-UPROR counterparts, but smaller (<5-point) differences were seen. CONCLUSIONS: UPROR during growth-friendly surgical treatment for EOS is associated with worse HRQoL in all patients, but particularly in those with neuromuscular or congenital etiologies. Ongoing efforts to avoid UPROR are critical. LEVEL OF EVIDENCE: Level II. This is a multicenter retrospective cohort study investigating the effect of UPROR on HRQoL (prognostic study).

Treatment of Early-onset Scoliosis: Similar Outcomes Despite Different Etiologic Subtypes in Traditional Growing Rod Graduates.

BACKGROUND: It is unclear whether traditional growing rod (TGR) treatment outcomes vary by early-onset scoliosis (EOS) subtype. The goal of this study was to compare radiographic outcomes and complications of TGR treatment by EOS subtype. METHODS: We queried an international database of EOS patients from 20 centers to identify "graduates" who had (1) undergone primary TGR treatment from 1993 to 2014; (2) completed TGR treatment; and (3) had an uneventful clinical examination within 6 months after completion of TGR treatment with no anticipated further intervention. We included 202 patients in 4 etiologic subgroups: neuromuscular (n=65), syndromic (n=57), idiopathic (n=52), and congenital (n=28). Mean age at surgery was 7.1 years (range, 1.6 to 14.9 y); mean duration of follow-up was 8 years (range, 2 to 18.6 y). The groups did not differ by mean age, body mass index, sex, number of lengthenings, or duration of follow-up. The following preoperative differences were significant: (1) greater mean major curve in the neuromuscular versus idiopathic subgroup; (2) shorter spinal height (T1-S1) in the congenital versus idiopathic subgroup; and (3) smaller proportion of ambulatory patients in the neuromuscular subgroup versus all other subgroups. RESULTS: We found no significant differences among subgroups in mean major curve correction or changes in thoracic height (T1-T12), spinal height, or global kyphosis at any point. Rates of deep surgical site infection, implant-related complications, and neurological complications were not different among subgroups. The medical complication rate was significantly lower in the idiopathic group compared with the other groups. CONCLUSIONS: Major curve correction and spinal and thoracic height increases did not differ significantly at any point by EOS subtype. Rates of deep surgical site infection, implant-related complications, and neurological complications did not differ by subtype. Except for the lower rate of medical complications in the idiopathic group, our findings suggest that, after TGR treatment, patients can expect similar outcomes regardless of their EOS subtype. LEVEL OF EVIDENCE: Level III, therapeutic.

Prevalence of junctional kyphosis in early-onset scoliosis: can it be corrected at final fusion?

PURPOSE: To investigate the risk and predictive factors of junctional issues after conversion from Traditional growing rod (TGR) to definitive spinal fusion in Early-onset scoliosis (EOS). METHODS: Retrospective review of a multicenter EOS database. TGR patients who received final fusion with at least two-year follow-up were included. Proximal (PJA) and Distal junctional angles (DJA) on pre-final fusion, post-final fusion (within one year of surgery), and at latest follow-up were measured on lateral upright spinal radiographs. Differences in values among designated time points and predictive factors of junctional issues were evaluated statistically. RESULTS: Forty-six of 251 patients (28 females, 18 males and mean age at final fusion: 12 ± 2 [9-17] years) met the inclusion criteria. Mean follow-up between first postoperative measurement and latest follow-up was 49 ± 22 (24-112) months. No statistical differences in PJA and DJA values were available at pre-fusion, first post-fusion, or latest follow-up (p = 0.827, p = 0.076). Fifty percent of patients had extension of TGR instrumentation at fusion, either proximal or distal. No factor including sex and etiology, lumbar lordosis, thoracic kyphosis, major curve magnitude, PJA, and DJA at pre-fusion was found to be a predictive issue for extension of index TGR instrumentation, except the history of at least one implant-related complication during the period from index surgery to the definitive fusion. CONCLUSION: PJA and DJA remained stable when transitioning from TGR to final posterior spinal fusion. But 50% of patients had extension of construction at fusion, either proximal or distal.

Is There Value in Venous Thromboembolism Chemoprophylaxis After Pediatric Scoliosis Surgery? A 28-Year Single Center Study.

BACKGROUND: With a recognized increase in the incidence of venous thromboembolism (VTE) in children, especially in those with complex, chronic conditions, it is important for patient safety and risk management to identify subgroups that would benefit from prophylactic treatment. The aim of our study was to assess whether scoliosis surgery in children was associated with an increased incidence of VTE, including deep venous thrombosis (DVT) and pulmonary embolism, and if chemoprophylaxis is warranted. METHODS: We reviewed our institution's Pediatric Orthopaedic Spine Database (1992-2019) to identify patients who had a symptomatic VTE postoperatively. RESULTS: There were 1471 patients (1035 female, 436 male) with a mean age at surgery of 12.1±3.2 years (range, 1 to 18 y) underwent posterior spinal fusion and instrumentation (2131 procedures). No patients were given pharmacological VTE prophylaxis, and no routine screening for VTE was performed. Two patients had a lower extremity DVT (0.13%) within 6 months following surgery, (range, 55 to 161 d). Neither patient had a subsequent pulmonary embolism. They were 9 and 17 years of age with a diagnosis of neuromuscular scoliosis (1 each postpolio and myelodysplasia). One affected patient had a central venous line inserted perioperatively, a known risk factor for thromboembolism. All DVTs were treated with appropriately dosed anticoagulants. None had a family history of hypercoagulation. CONCLUSIONS: The risk of symptomatic VTE is extraordinarily low after pediatric spinal deformity surgery. Mechanical prophylaxis is sufficient in most cases. Further multi-center studies may help identify patient specific risk factors.

Postoperative Correction in Idiopathic Scoliosis: Which Preoperative Imaging Technique Is Most Predictive?

INTRODUCTION: Preoperative radiographic assessment of curve flexibility in patients with idiopathic scoliosis is important to determine Lenke classification, operative levels, and potential postoperative correction. However, no consensus exists regarding the optimal technique. We compared measurements from supine side bending (SB) and intraoperative traction radiographs under general anesthesia (TUGA) with actual postoperative correction followed for 1 year. METHODS: We identified 235 patients with idiopathic scoliosis who underwent posterior spinal fusion with pedicle screw instrumentation between 2010 and 2018 who had preoperative and postoperative radiographs including standing posterior-anterior (PA) and lateral radiographs, preoperative SB radiographs, and TUGA radiographs. Curves were categorized into proximal thoracic, main thoracic/thoracolumbar (MT), and distal thoracolumbar/lumbar (TL/L) curves. Flexibility was calculated from SB and TUGA radiographs. Correction rates were calculated from 1 month and 1 year radiographs postoperatively. Bending radiographs that correlated significantly with postoperative correction with P<0.10 were eligible for inclusion. Preoperative demographics, etiology, deformity details, and surgical details were included in the multivariate models. RESULTS: On univariate analysis, TUGA radiographs correlated with postoperative correction at 1 month and 1 year on MT curves (r=0.214, P=0.001; r=0.209, P=0.001) and TL/L curves (r=0.280, P<0.001; r=0.181, P=0.006). Supine SB radiographs did not correlate with postoperative correction on either MT or T/TL curves. On multivariate analysis, major curve TUGA radiographs were independently associated with postoperative MT curve correction at 1 month (beta: 0.158, 95% confidence interval: 0.035-0.280, P=0.012) and 1 year (beta: 0.195, 95% confidence interval: 0.049-0.340, P=0.009). MT curve SB radiographs were not associated with postoperative major curve correction at 1 month (P=0.088). CONCLUSIONS: TUGA radiographs independently correlated with postoperative main thoracic and distal thoracolumbar/lumbar curve correction at 1 month and 1 year postoperatively. SB radiographs independently correlated only with TL/L curve correction at 1 year postoperatively. However, this correlation was not as strong as TUGA correction (beta of 0.280 vs. beta of 0.092). TUGA radiographs appear superior to SB radiographs at predicting curve correction after surgery. LEVEL OF EVIDENCE: Level III.

Seromas Following Pediatric Spinal Deformity Surgery: Is Operative Management Necessary?

BACKGROUND: Seromas are known complications after pediatric spinal deformity surgery. Although many surgeons perform an early debridement to prevent deep surgical site infections (SSIs), a less invasive approach to seroma management has not been studied. We hypothesized that a conservative approach to seroma management would be safe and yield equivalent outcomes. METHODS: We performed a retrospective review of patients who developed a postoperative seroma with or without nonpurulent drainage. Inclusion criteria were patients below 21 years who underwent primary posterior spinal fusion from 1996 to 2016 and developed a postoperative wound seroma. Seromas were clinically defined as an afebrile patient with a fluid collection that was soft and nontender to palpation and without induration or erythema. Growing spine surgeries and revision procedures were excluded from this study. RESULTS: Twenty-five of 790 total patients with a mean follow-up of 57.8 months (±48.5 mo) developed a seroma. Seromas were identified at a mean of 13.6 days postoperatively and resolved after a mean of 12.2 days following the presentation. Seromas occurred in 12 patients with idiopathic scoliosis, 12 with neuromuscular scoliosis, and 1 patient with Scheuermann kyphosis. All cases were managed conservatively with monitoring of the incision without an operative procedure. In cases of spontaneous drainage, a sterile dressing was applied to the wound and changed as needed until drainage ceased. Two patients underwent bedside needle aspiration and 5 patients received prophylactic antibiotics at the treating surgeon's discretion. All cases resolved spontaneously without development of an acute SSI. Three cases subsequently developed a late SSI (range, 18 to 38 mo postoperatively). Two had idiopathic scoliosis and 1 had neuromuscular scoliosis. None of these seromas drained spontaneously. CONCLUSIONS: Conservative management of postoperative seromas after pediatric spinal deformity surgery is appropriate. It is unclear if seromas contributed to the development of the 3 late infections. Further studies are needed regarding the relationship of late infections in seroma patients. LEVEL OF EVIDENCE: Level IV-case series.

Intrathecal Morphine in the Presence of a Syrinx in Pediatric Spinal Deformity Surgery.

BACKGROUND: Intrathecal morphine (IM) is a popular adjunct for pain relief during pediatric spinal deformity surgery. There is no literature regarding its usefulness and safety in the presence of a spinal cord syrinx for patients undergoing spinal instrumentation. Anesthesiologists have previously been reluctant to use IM in the presence of any syrinx. METHODS: We retrospectively reviewed all patients with a preoperatively diagnosed spinal cord syrinx undergoing spinal deformity surgery who received IM and did not receive IM (non-IM). We recorded location of the syrinx, surgical time, length of stay, unexpected pediatric intensive care unit (PICU) admission, IM related complications (neurological, respiratory depression, or pruritus, nausea/vomiting), and reason for no IM administration. Patients with a syrinx and myelodysplasia (8), tethered spinal cord (4), paraplegia (1), holocord (1), neuroblastoma (1), and spinal cord glioma (1) were not given IM. Other reasons included a failed attempt (1), expectedly short surgical time (1), and anesthesiologist declined (2). RESULTS: There were 42 patients who met the inclusion criteria. Twenty-two patients received IM, while 20 patients did not. Patients receiving IM had 4 cervical, 5 cervicothoracic, 12 thoracic syrinxes, and 1 holocord syrinx. The non-IM group had 8 cervicothoracic, 6 thoracic, 4 holocord syrinxes, and 2 had unclassified locations. There were no neurological complications in the IM group, and 1 patient experienced respiratory depression following a shorter than expected surgery and was observed overnight in the PICU. One patient in the non-IM group with a holocord syrinx had temporary lower extremity weakness postoperatively that completely resolved and 4 patients were unexpectedly admitted to the PICU. Pruritus and nausea/vomiting was mild and similar in both groups. CONCLUSIONS: Our study demonstrates that with careful preoperative evaluation, most patients with a spinal cord syrinx can safely be given IM. Certain patients, such as those with a spinal holocord syrinx may have anatomic reasons to avoid IM, but those who are deemed appropriate for IM can receive it safely. LEVEL OF EVIDENCE: Level III-therapeutic study; retrospective comparative study.

Serial Casting in Neuromuscular and Syndromic Early-onset Scoliosis (EOS) Can Delay Surgery Over 2 Years.

BACKGROUND: The primary goal in managing early-onset scoliosis (EOS) is delaying/preventing surgical intervention while allowing improved spinal growth and chest wall and lung development to improve life expectancy. The effectiveness of serial casting for patients with neuromuscular and syndromic EOS is unclear. METHODS: Patients from 2 multicenter registries who underwent serial casting for nonidiopathic scoliosis (NIS) were reviewed retrospectively. Comparisons were made between precasting and postcasting major and compensatory curves and spine height. The need for surgical intervention and any treatment complications were documented. Risk factors for major curve progression from baseline to casting cessation were evaluated via univariate analysis. RESULTS: Forty-four patients (23 females; 21 males) with NIS (26 syndromic, 18 neuromuscular) and a mean age of 3.2 years at baseline were included. Mean follow-up and casting duration was 3.9 and 2.0 years, respectively. There were no statistically significant differences between mean precasting and postcasting major curve (55 vs. 60 degrees; P=0.348), minor curve (31 vs. 33 degrees; P=0.510), or rib-vertebra angle difference (18 vs. 29 degrees; P=0.840). However, thoracic height (15.5 vs. 16.8 cm; P=0.031) and lumbar height (8.9 vs. 9.8 cm; P=0.013) were significantly greater upon casting cessation. Currently, 13 patients (30%) have had successful casting (improvement of major curve ≥10 degrees) while 24 patients (55%) experienced major curve progression (worsening), and 19 patients (43%) required surgical intervention. Mean time from first casting to surgery was 34.5±15.1 months. There were no statistically significant predictors for major curve progression on univariate analysis. CONCLUSIONS: Spinal deformity progression despite casting and the subsequent need for surgical intervention for NIS were significantly higher compared with those reported for idiopathic EOS. However, serial casting did afford a substantial delay in surgical intervention. Ultimately, serial casting for neuromuscular or syndromic EOS is an effective strategy for delaying surgical intervention, despite suboptimal radiographic outcomes. LEVEL OF EVIDENCE: Level III.

Idiopathic Early-onset Scoliosis: Growing Rods Versus Vertically Expandable Prosthetic Titanium Ribs at 5-year Follow-up.

BACKGROUND: Distraction-based techniques allow spinal growth until skeletal maturity while preventing curve progression. METHODS: Two multicenter early-onset scoliosis databases were used to identify patients with idiopathic spine abnormalities treated with traditional growing rods (TGR) or vertically expandable titanium ribs (VEPTR). Patients underwent at least 4 lengthenings and had at least 5-year follow-up. Significance was set at P<0.05. RESULTS: In total, 50 patients treated with TGR and 22 treated with VEPTR were included. Mean (±SD) age at surgery was 5.5 (±2.0) years for the TGR group versus 4.3 (±1.9) years for the VEPTR group (P=0.044); other demographic parameters were similar. VEPTR patients had more procedures (mean 15±4.2) than TGR patients (mean 10±4.0) (P=0.001). Unilateral constructs were present in 18% (4 of 22) of VEPTR and 16% (8 of 50) of TGR patients. Bilateral constructs spanned a mean 2.1 additional surgical levels and exposed patients to 1.6 fewer procedures than unilateral constructs. Curve correction was similar between bilateral and unilateral constructs. TGR patients experienced greater curve correction (50%) than VEPTR patients (27%) (P<0.001) and achieved a greater percentage of thoracic height gain (24%) than VEPTR patients (12%) (P=0.024). At latest follow-up, TGR patients had better maintenance of curve correction, less kyphosis, and 15% greater absolute gain in thoracic height versus VEPTR patients. TGR patients had a lower rate of wound complications (14%) than VEPTR patients (41%) (P=0.011). CONCLUSIONS: In patients with idiopathic early-onset scoliosis, TGRs produced greater initial curve correction, greater thoracic height gains, less kyphosis, and lower incidence of wound complications compared with VEPTR. LEVEL OF EVIDENCE: Level III.

Best Practice Guidelines for Surgical Site Infection Prevention With Surgical Treatment of Early Onset Scoliosis.

BACKGROUND: Postoperative surgical site infection (SSI) is unfortunately a commonly encountered complication in the surgical treatment of children with Early Onset Scoliosis (EOS). There is documented variation in the treatment of this patient population. Previous work building consensus for the approach to high risk patients (eg, neuromuscular etiology) has been promising. The goal of the current study is to apply similar principles to develop consensus-based guidelines for the treatment of patients with EOS. METHODS: A focus group from 2 multicenter pediatric spine deformity study groups developed a list of statements to be distributed to a larger group of EOS experts. Using the Delphi process, participants were presented with a systematic review of the literature as well as a review of current practices in growth friendly surgery. The first round was conducted using an electronic survey. Results of this survey were then discussed face-to-face and the statements were further refined. A final round was conducted using the Audience Response System, allowing participants to vote for each statement (strongly agree or agree). Agreement >80% or disagreement <20% was considered consensus. RESULTS: A total of 29 of 57 statements reached consensus. Negative statements (statements of disagreement) were excluded, so the final consensus guidelines included 22 statements. The number of statements from the previously published Best Practice Guidelines (BPG) approved for insertion and lengthening growth friendly procedures were 12 of 14 and 11 of 14, respectively. The high risk BPG therefore does not cover all of the issues specific to the EOS population, and explains why 22 statements reached consensus in the current guideline. Upon completion of the surveys, 100% of the participants agreed to support its publication. CONCLUSIONS: Using the Delphi process several "best practices" were developed for growth friendly surgical treatment of EOS. LEVEL OF EVIDENCE: Level V.

Early MRI Detection and Closed Bone Graft Epiphysiodesis May Alter the Course of Avascular Necrosis Following Unstable Slipped Capital Femoral Epiphysis.

BACKGROUND: Unstable slipped capital femoral epiphysis (SCFE) has an increased incidence of avascular necrosis (AVN). Early identification and surgical intervention for AVN may help preserve the femoral head. METHODS: We retrospectively reviewed 48 patients (50 hips) with unstable SCFE managed between 2000 and 2014. AVN was diagnosed based on 2 different postoperative protocols. Seventeen patients (17 hips) had a scheduled magnetic resonance imaging (MRI) between 1 and 6 months from initial surgery, and the remaining 31 patients (33 hips) were evaluated by plain radiographs alone. If AVN was diagnosed, we offered core decompression and closed bone graft epiphysiodesis (CBGE) to mitigate its affects. At final follow-up, we assessed progression of AVN using the Steinberg classification. RESULTS: Overall 13 hips (26%) with unstable SCFEs developed AVN. MRI revealed AVN in 7 of 17 hips (41%) at a mean of 2.5 months postoperatively (range, 1.0 to 5.2 mo). Six hips diagnosed by MRI received surgical intervention (4 CBGE, 1 free vascularized fibula graft, and 1 repinning due to screw cutout) at a mean of 4.1 months (range, 1.3 to 7.2 mo) postoperatively. None of the 4 patients treated with CBGE within 2 months postoperatively progressed to stage IVC AVN. The 2 patients treated after 4 months postoperatively both progressed to stage VC AVN.Plain radiographs demonstrated AVN in 6 of 33 hips (18%) at a mean of 6.8 months postoperatively (range, 2.1 to 21.1 mo). One patient diagnosed with stage IVB AVN at 2.4 months had screw cutout and received CBGE at 2.5 months from initial pinning. The remaining 5 were not offered surgical intervention. Five of the 6 radiographically diagnosed AVN, including the 1 treated with CBGE, progressed to stage IVC AVN or greater. CONCLUSIONS: Although all patients with positive MRI scans developed radiographic AVN, none of the 4 patients treated with CBGE within 2 months after pinning developed grade IVC or greater AVN. Early MRI detection and CBGE may mitigate the effects of AVN after SCFE. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Bipolar Sealer Devices Used in Posterior Spinal Fusion for Neuromuscular Scoliosis Reduce Blood Loss and Transfusion Requirements.

BACKGROUND: Reducing perioperative blood loss and the need for transfusions in patients undergoing spinal surgery is especially important for those with neuromuscular disorders. These patients require extensive spino-pelvic exposure and are often medically fragile. We have used Amicar to decrease blood loss since 2001. As an effort to further reduce blood loss and transfusions, we use a bipolar sealer device (Aquamantys) as an adjunct to electrocautery. We present the results of our first 64 neuromuscular patients to show the efficacy of the device. METHODS: Using a prospectively maintained database we reviewed the operative time, estimated perioperative blood loss, cell saver use, and intraoperative and postoperative transfusion rate in patients who underwent posterior spinal fusion for neuromuscular scoliosis. Sixty-four patients were identified who fit these criteria since the use of the bipolar sealer device was instituted.We compared these patients with a control group of the preceding 65 patients in whom this device was not used for hemostasis. All patients, including those in the study group, received Amicar (infusion of 100 mg/kg over 15 to 20 min, then 10 mg/kg/h throughout the remainder of the procedure). The surgical technique did not differ between the 2 groups. RESULTS: Baseline characteristics between the 2 groups were similar except for the number of patients having an all-screw construct which was larger in the investigational group (25% vs. 8%, P=0.03). There were no significant differences in operative time or duration of hospital stay. Intraoperative blood loss was lower in the study group (741 mL) as compared with the control group (1052 mL, P=0.003). Total perioperative blood loss, however, showed no significant difference. Thirty-five (55%) patients in the study group and 50 (77%) patients in the control group required additional intraoperative or postoperative transfusions (P=0.01). The number of packed red cell units transfused per patient was 0.81 in the study group and 1.57 in the control group (P=0.001). Although the intraoperative cell saver transfusion was same, the total blood volume transfused, which includes cell saver and any other transfusions, was significantly lower in the study group, 425 mL versus 671 mL (P=0.002). CONCLUSIONS: Use of a bipolar sealer device in posterior spinal fusion for neuromuscular scoliosis significantly reduced intraoperative blood loss and transfusion rate when compared with a control group in this retrospective review. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Rod fracture and lengthening intervals in traditional growing rods: is there a relationship?

PURPOSE: Is there any relationship between lengthening intervals and rod fracture in traditional growing rod (TGR) surgery? METHODS: A multicenter EOS database was queried for patients who had: (1) dual growing rods for EOS; (2) minimum 2-year follow-up; (3) a minimum of 2 lengthenings; and (4) revision surgery due to rod fracture. Of 138 patients who met the criteria: 56 patients experienced at least one-rod fracture (RF group) and 82 patients had no rod fractures (NRF group). In addition to each patient's lengthening intervals, demographics, construct details, and radiographic parameters were compared. RESULTS: RF and NRF patients had a mean pre-op age of 5.7 years (range 1.3-10.7) and 7.3 years (range 1.6-12.8), respectively (p < 0.001). There was no significant association between etiologies and rod fracture or between BMI and rod fracture (p = 0.979). There was no significant difference between lengthening intervals between the RF and NRF groups (p > 0.05). RF and NRF patients had statistically similar mean pre-op major curve size and max kyphosis (p = 0.279; p = 0.619, respectively). Stainless steel rods fractured more frequently compared with Titanium rods (SS 49.2 % vs. Ti 38 %; p = 0.004). Rod fracture occurred more in rods smaller than 4 mm (p = 0.011). CONCLUSIONS: Lengthening intervals were not statistically different in RF and NRF groups and there was no association between lengthening interval and rod fracture in TGR cases. It was shown that patients who had rod fracture were younger and were more likely to have SS rods with smaller than 4 mm diameter.

Classification of Early Onset Scoliosis has Excellent Interobserver and Intraobserver Reliability.

BACKGROUND: Classification systems can be useful tools for clinical care and research but must be proven as reliable. The purpose of this study was to evaluate the interobserver and intraobserver reliability of the Classification of Early Onset Scoliosis (C-EOS) scheme. METHODS: After IRB approval, 50 cases were drawn from a prospectively collected database of patients with EOS. Cases were selected using a stratified randomization scheme based on etiology. These cases were used to create an internet survey that was sent to pediatric orthopaedic faculty, research coordinators, and fellows involved in EOS care and research. Participants were asked to classify each case and were provided with a written C-EOS scheme that could be referenced while they completed the survey. Surveys were sent to participants twice, 3 weeks apart, to assess both intraobserver and interobserver reliability. Fleiss κ and Cohen κ were used to assess interobserver and intraobserver reliability, respectively. RESULTS: There were 36 total participants, 29 who completed the survey twice (21 faculty, 13 research coordinators, and 2 fellows). Overall Fleiss κ coefficient for interobserver reliability was excellent across the major categories of etiology (0.84), major curve (0.93), and kyphosis (0.96). Overall intraobserver reliability was excellent with Cohen κ values for etiology (0.92), major curve (0.96), and kyphosis (0.98). Faculty members had excellent agreement for etiology (0.90), major curve (0.91), and kyphosis (0.96). Research coordinators had high levels of agreement for etiology (0.78), and excellent for major curve (0.95) and kyphosis (0.96). Intraobserver reliability was excellent across all major categories for all groups: faculty, research coordinators, and fellows. CONCLUSIONS: The study shows high levels of interobserver and intraobserver agreement of the C-EOS scheme. The C-EOS scheme can be used as a reliable tool for classifying EOS patients for clinical communication and research. LEVEL OF EVIDENCE: Level II-diagnostic study.