Rib-on-Pelvis Deformity and Reported Pain in Neuromuscular Early-Onset Scoliosis.

BACKGROUND: Neuromuscular early-onset scoliosis (N-EOS) often presents with a long sweeping thoracolumbar scoliosis and pelvic obliquity. With severe pelvic obliquity, the ribs come into contact with the high side of the pelvis, termed rib-on-pelvis deformity (ROP). The goal of this study is to evaluate whether ROP is associated with reported pain and other health-related quality of life (HRQOL) measures. We hypothesize that ROP is associated with increased pain and negative HRQOL. METHODS: A multicenter international registry was queried for all nonambulatory patients with N-EOS from 2012 to 2022. Both surgical and nonsurgical patients were included. ROP was classified as a binary radiographic assessment of preoperative (surgical patients) and most recent follow-up (nonsurgical patients) upright radiographs. Reported pain and other HRQOL measures were assessed through the 24-Item Early Onset Scoliosis Questionnaire (EOSQ-24). Patients with nonupright radiographs or EOSQ-24 questionnaires and corresponding radiographs >4 months apart were excluded. RESULTS: Totally, 225 patients (8.4±3.1 y, 55% female) were included. The median major curve was 63.3 (IQR: 40.6 to 81.2) degrees and median pelvic obliquity was 15.5 degrees (IQR: 8.8 to 26.4). Eighty-three patients (37%) had ROP. ROP was associated with both frequency (P<0.001) and severity (P<0.001) of pain. ROP was associated with worse general health (P=0.01), increased difficulty with vocalization (P=0.02), increased frequency of shortness of breath (P=0.002), and increased difficulty sitting upright (P=0.04). Regarding overall EOSQ-24 domains, ROP was associated with worse general health, pain/discomfort, pulmonary function, and physical function (P<0.01). In a subanalysis of 76 patients who underwent surgical intervention with at least 2 years of follow-up, patients with preoperative ROP experienced significantly greater improvements in both frequency (P=0.004) and severity (P=0.001) of pain than the patients without preoperative ROP at 2 years postoperatively. CONCLUSIONS: The overall incidence of ROP in N-EOS is about 37%. ROP is associated with greater pain and worse HRQOL through the EOSQ-24 questionnaire. Furthermore, these patients experienced a greater reduction in pain after surgery. Clinicians and parents must be aware that ROP is possibly a pain generator, but responds positively to surgical intervention. LEVEL OF EVIDENCE: Level III.

Representation and Race in Adolescent Idiopathic Scoliosis Research: Disparities in Curve Magnitude and Follow-Up.

STUDY DESIGN: Prospective Cohort Study. OBJECTIVE: The present study aims to determine if the racial representation of patients enrolled in a large prospective scoliosis registry is reflective of the general United States population. Further, we studied whether there was an association between race, pre-operative parameters, outcomes and loss to follow-up. METHODS: Prospectively collected data for patients who underwent spinal fusion for adolescent idiopathic scoliosis (AIS) was reviewed, including self-reported race/ethnicity. The U.S. pediatric population and U.S. patients enrolled in the prospective registry were compared. The data obtained was analyzed for variations between races, for pre-operative variables and follow-up. RESULTS: Of the 2210 included patients in the registry 66% of patients reported as White, while 52% of the 2018 U.S. pediatric population reported as White. 15% of the registry reported as Hispanic/Latino compared to 22% of the U.S. pediatric population, 13% Black compared to 14% of the U.S. pediatric population, and 4% Asian compared to 5% of the U.S. pediatric population. Asian and White patients had statistically significant higher 2-year follow-up in all but one of six enrollment sites (P < 0.001). Native American, Other, and Hispanic/Latino patients had the highest BMIs. Native American and Black patients had the highest pre-op thoracic Cobb angles. Pre-op ages of Black, Hispanic, and Native American patients were statistically lower (P < 0.01). CONCLUSION: This study demonstrates the association between race and patient follow-up and pre-operative factors in patients who underwent surgery for AIS. Black, Native American, and Hispanic populations were underrepresented both at pre-op and follow-up when compared to their relative proportion in the U.S. pediatric population.

What is the role of plastic surgery for incisional closures in pediatric spine surgery? Results from a pediatric spine study group survey.

Current best practice guidelines recommend a plastics-style multilayer wound closure for high-risk pediatric spine surgery. However, plastic surgery closure of spinal incisions remains controversial. This study investigates surgeon perceptions and practice patterns regarding plastic surgery multilayered closure (PMC) in pediatric spine surgery. All surgeons in an international pediatric spine study group received a 30-question survey assessing incisional closure practices, frequency of plastic surgery collaboration, and drain management. Relationship to practice size, setting, geographic region, and individual diagnoses were analyzed. 87/178 (49%) surgeons responded from 79% of participating sites. Plastics utilization rates differed by diagnosis: neuromuscular scoliosis 16.9%, early onset scoliosis 7.8%, adolescent idiopathic scoliosis 2.8% (P < 0.0001). Plastics were used more for early onset scoliosis [odds ratio (OR) 18.5, 95% confidence interval (CI): 8.5, 40.2; P < 0.001] and neuromuscular scoliosis [OR 29.2 (12.2, 69.9); P < 0.001] than adolescent idiopathic scoliosis. Plastics use was unrelated to practice size, setting, or geographic region (P ≥ 0.09). Respondents used plastics more often for spina bifida and underweight patients compared to all other indications (P < 0.001). Compared to orthopaedic management, drains were utilized more often by plastic surgery (85 vs. 21%, P = 0.06) and for longer durations (P = 0.001). Eighty-nine percent of surgeons felt plastics increased operative time (58 ±â€…37 min), and 34% felt it increased length of hospitalization. Surgeons who routinely utilize plastics were more likely to believe PMC decreases wound complications (P = 0.007). The perceived benefit of plastic surgery varies, highlighting equipoise among pediatric spine surgeons. An evidence-based guideline is needed to optimize utilization of plastics in pediatric spine surgery.

Development of Consensus-Based Best Practice Guidelines for the Peri- and Post-operative Care of Pediatric Patients with Spinal Deformity and Programmable Implanted Devices.

STUDY DESIGN: Modified Delphi consensus study. OBJECTIVE: To develop consensus-based best practices for the care of pediatric patients who have implanted programmable devices (IPDs) and require spinal deformity surgery. SUMMARY OF BACKGROUND DATA: Implanted programmable devices (IPDs) are often present in patients with neuromuscular or syndromic scoliosis who require spine surgery. Guidelines for monitoring and interrogating these devices during the peri-operative period are not available. METHODS: A panel was assembled consisting of 25 experts (i.e., spinal deformity surgeons, neurosurgeons, neuro-electrophysiologists, cardiologists, and otolaryngologists). Initial postulates were based on literature review and results from a prior survey. Postulates addressed the following IPDs: vagal nerve stimulators (VNS), programmable ventriculo-peritoneal shunts (VPS), intrathecal baclofen pumps (ITBP), cardiac pacemakers and implantable cardioverter-defibrillators (ICD), deep brain stimulators (DBS), and cochlear implants. Cardiologist and otolaryngologists participants responded only to postulates on cardiac pacemakers or cochlear implants, respectively. Consensus was defined as ≥80% agreement, items that did not reach consensus were revised and included in subsequent rounds. A total of three survey rounds and one virtual meeting were conducted. RESULTS: Consensus was reached on 39 total postulates across six IPD types. Postulates addressed general spine surgery considerations, use of intraoperative monitoring and cautery, use of magnetically-controlled growing rods (MCGRs), and use of an external remote controller to lengthen MCGRs. Across IPD types, consensus for the final postulates ranged from 94.4-100%. Overall, experts agreed that MCGRs can be surgically inserted and lengthened in patients with a variety of IPDs and provided guidance for the use of intraoperative monitoring and cautery, which varied between IPD types. CONCLUSION: Spinal deformity correction surgery often benefits from the use of intraoperative monitoring, monopolar and bipolar cautery, and MCGRs. Final postulates from this study can inform the peri- and post-operative practices of spinal deformity surgeons who treat patients with both scoliosis and IPDs. LEVEL OF EVIDENCE: V- Expert opinion.

How do implants overlying the spine influence "The Law of Diminishing Returns" in early-onset scoliosis patients?

PURPOSE: The "law of diminishing returns" (LODR) in early-onset scoliosis (EOS) is well-known. We hypothesized that previously observed variations between constructs may be related to the lateral distance that each construct lies from the spine. We therefore sought to determine whether the curve magnitude improvement and spinal length gains for distraction-based constructs in EOS are positively correlated with the collinearity of the spine and the convex-sided implant on posteroanterior radiographs. METHODS: A prospectively-collected, multicenter EOS registry was queried for all patients who underwent non-fusion, distraction-based instrumentation surgery. Post-index radiographs were graded from 1 to 5 based on amount of overlap between the convex-sided rod and the apical vertebra. Grade 1: convex rod is lateral to convex-sided pedicle; Grade 2: overlaps the convex-sided pedicle; Grade 3: lies between pedicles; Grade 4: overlaps concave-sided pedicle; Grade 5: medial to concave-sided pedicle. ANOVA assessed the correlations between post-index overlap grade and change in (a) curve magnitude and (b) T1-T12 height. Multivariable regression modeling further assessed these associations. RESULTS: 284 patients met all selection criteria and were included. On ANOVA, post-index grade was associated with curve magnitude (p <0.001) and T1-12 height (p = 0.028) change. Better curve correction and height change were associated with higher grade. On regression modeling, curve correction (R = 0.574) and T1-T12 height change (R = 0.339) remained significantly associated with grade when controlling for time, anchor locations, age, underlying diagnosis, and pre-index curve magnitude. CONCLUSION: More apical overlap by the convex rod was associated with better spinal deformity control and improved height gain. LEVEL OF EVIDENCE III: Therapeutic.

A multicenter evaluation of the time and travel burden on families with children treated for early-onset scoliosis.

PURPOSE: Patients who undergo growth-friendly (GF) treatment for early-onset scoliosis (EOS) undergo multiple clinical and surgical encounters. We sought to quantify the associated temporal and travel burden and estimate subsequent cost. METHODS: Four centers in an international study group combined data on EOS patients who underwent surgical GF treatment from 2006 to 2021. Data collected included demographics, scoliosis etiology, GF implant, encounter type, and driving distance. We applied 2022 IRS and BLS data or $0.625/mile and $208.2/day off work to calculate a relative financial burden. RESULTS: A total of 300 patients were analyzed (55% female). Etiologies were: congenital (33.3%), idiopathic (18.7%), neuromuscular (30.7%), and syndromic (17.3%). The average age at the index procedure was 5.5 years. For the 300 patients, 5899 encounters were recorded (average 18 encounters/patient). Aggregate encounter types were 2521 clinical office encounters (43%), 2045 surgical lengthening encounters (35%), 1157 magnetic lengthening encounters (20%), 149 spinal fusions (3%), and 27 spinal fusion revisions (0.5%). When comparing patients by scoliosis etiology or by GF implant type, no significant differences were noted in the total number of encounters or average travel distance. Patients traveled a median round trip distance of 158 miles/encounter between their homes and treating institutions (range 2.4-5654 miles), with a cumulative median distance of 2651 miles for the entirety of their treatment (range 29-90,552 miles), at an estimated median cost of $1656.63. The mean number of days off work was 18 (range 3-75), with an associated loss of $3643.50 in income. CONCLUSION: Patients with EOS averaged 18 encounters for GF surgical treatment. These patients and their families traveled a median distance of 158 miles/encounter, with an estimated combined mileage and loss of income of $5300.

Do Children With Medicaid Insurance Have Increased Revision Rates 5 Years After Posterior Spinal Fusions?

BACKGROUND: Socioeconomic disparities in musculoskeletal care are increasingly recognized, however, no studies to date have investigated the role of the insurance carrier on outcomes after posterior spinal fusion (PSF) with segmental spinal instrumentation for adolescent idiopathic scoliosis (AIS). METHODS: A US insurance dataset was queried using the PearlDiver Mariner software for all patients aged 10 to 18 undergoing PSF for a primary diagnosis of AIS between 2010 and 2020. Age, sex, geographic region, number of levels fused, and baseline medical comorbidities were queried. Complications occurring within 90 days of the index surgery were queried using the International Classification of Diseases, Ninth Revision (ICD-9) and International Classification of Diseases, 10th Revision (ICD-10) codes. Revision surgery was also queried up to 5 years after the index PSF. Categorical variables were compared using the Fisher χ 2 tests and continuous variables were compared using independent t tests. All-cause revision within 5 years was compared using the Kaplan-Meier analysis and a log-rank test. Significance was set at P -value <0.05. RESULTS: A total of 10,794 patients were identified with 9006 (83.4%) patients with private insurance and 1788 (16.6%) patients insured by Medicaid. The mean follow-up in the database was 5.36±3 years for patients with private insurance and 4.78±2.9 years for patients with Medicaid insurance ( P <0.001). Children with AIS and Medicaid insurance had a significantly higher prevalence of asthma, hypertension, and obesity. A larger percentage of children with Medicaid insurance (41.3%) underwent a ≥13-level PSF compared with privately insured children (34.5%) ( P <0.001). Medicaid patients did not experience higher odds of postoperative complications; in addition, revision surgeries occurred in 1.1% and 1.8% of patients with private insurance and Medicaid insurance, respectively at 5 years postoperatively ( P =0.223). CONCLUSION: Despite worse baseline comorbidities and longer fusion constructs, AIS patients insured with Medicaid did not have higher rates of complications or revisions at 5-year follow-up versus privately insured patients. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

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.

Rib-to-spine and rib-to-pelvis magnetically controlled growing rods: does the law of diminishing returns still apply?

PURPOSE: The Law Of Diminishing Returns (LODR) has been demonstrated for traditional growing rods, but there is conflicting data regarding the lengthening behavior of Magnetically Controlled Growing Rods (MCGR). This study examines a cohort of patients with early-onset scoliosis (EOS) with rib-to-spine or rib-to-pelvis-based MCGR implants to determine if they demonstrate the LODR, and if there are differences in lengthening behaviors between the groups. METHODS: A prospectively collected multicenter EOS registry was queried for patients with MCGR with a minimum 2-year follow-up. Patients with rib-based proximal anchors and either spine- or pelvis-based distal anchors were included. Patients with non-MCGR, unilateral constructs, < 3 lengthenings, or missing > 25% datapoints were excluded. Patients were further divided into Primary-MCGR (pMCGR) and Secondary-MCGR (sMCGR). RESULTS: 43 rib-to-spine and 31 rib-to-pelvis MCGR patients were included. There was no difference in pre-implantation, post-implantation and pre-definitive procedure T1-T12 height, T1-S1 height, and major Cobb angles between the groups (p > 0.05). Sub-analysis was performed on 41 pMCGR and 19 sMCGR rib-to-spine patients, and 31 pMCGR and 17 sMCGR rib-to-pelvis patients. There is a decrease in rod lengthenings achieved at subsequent lengthenings for each group: rib-to-spine pMCGR (rho = 0.979, p < 0.001), rib-to-spine sMCGR (rho = 0.855, p = 0.002), rib-to-pelvis pMCGR (rho = 0.568, p = 0.027), and rib-to-pelvis sMCGR (rho = 0.817, p = 0.007). Rib-to-spine pMCGR had diminished lengthening over time for idiopathic, neuromuscular, and syndromic patients (p < 0.05), with no differences between the groups (p > 0.05). Rib-to-pelvis pMCGR neuromuscular patients had decreased lengthening over time (p = 0.01), but syndromic patients had preserved lengthening over time (p = 0.65). CONCLUSION: Rib-to-spine and rib-to-pelvis pMCGR and sMCGR demonstrate diminished ability to lengthen over subsequent lengthenings.

The Sanders Classification and Obesity: Do Obese Kids With AIS Present With More Advanced Skeletal Maturity?

INTRODUCTION: Obese and overweight (OOW) patients with adolescent idiopathic scoliosis (AIS) have been shown to initially present with a more advanced Risser score compared to normal weight (NW) patients. The Sanders Maturity Scale (SMS) is now more commonly used by surgeons to assist with treatment decisions because it more reliably predicts skeletal maturity. However, the relationship between SMS and obesity has not been described. We hypothesize that in patients with AIS, OOW patients will have a higher SMS score on initial presentation when compared to NW patients. METHODS: Billing data from 2 different institutions were used to identify patients with AIS presenting to a pediatric orthopaedic spine surgeon for an initial visit between July 2012 and March 2020. We excluded those without height/weight data, spine radiographs, or left-hand radiographs for measuring SMS stage. Body mass index-for-age percentiles were calculated and used to group patients into NW (<85th percentile) or OOW (85th percentile and above) per Centers for Disease Control guidelines. After collecting preliminary data, a power analysis was performed using average SMS scores between NW and OOW patients with an alpha of 0.5, determining a needed sample size of approximately 300 male and 300 female subjects. RESULTS: Five hundred ninety patients (296 female, 294 male) were identified. The SMS stage at presentation was significantly greater in OOW compared to NW patients for both females (5.9±1.8 vs. 5.2±1.7; P =0.003) and males (4.9±1.9 vs. 4.1±1.8; P =0.002). The major curve magnitude for OOW females was significantly different from NW females (36±16 degrees vs. 30±16 degrees; P =0.004). The major curve magnitude was not different for OOW and NW males ( P =0.3). CONCLUSION: At initial presentation, OOW patients present at a greater skeletal maturity as measured by the SMS compared with NW patients. OOW female patients present with a greater major curve magnitudes than NW female patients. These results highlight negative implications of the pediatric obesity epidemic as it relates to the AIS population. These findings can be used to counsel families and provide anticipatory guidance for the AIS treatment plan. LEVEL OF EVIDENCE: Level III-cross-sectional study.

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.

Comparison of Distal Spine Anchors and Distal Pelvic Anchors in Children With Hypotonic Neuromuscular Scoliosis Treated With Growth-friendly Instrumentation.

BACKGROUND: Lower preoperative pelvic obliquity (PO) and L5 tilt have been associated with good radiographic outcomes when the fusion ended short of the pelvis in children with neuromuscular scoliosis (NMS). Our purpose was to identify indications to exclude the pelvis in children with hypotonic NMS treated with growth-friendly instrumentation. METHODS: This was a multicenter retrospective review. Children with spinal muscular atrophy and muscular dystrophy treated with dual traditional growing rod, magnetically controlled growing rod, or vertical expandable prosthetic titanium rib with minimum 2-year follow-up after the index surgery were identified. RESULTS: A total of 125 patients met the inclusion criteria. Thirty-eight patients had distal spine anchors (DSAs) and 87 patients had distal pelvic anchors (DPAs) placed at the index surgery. Demographics and length of follow-up were similar between the groups but there was a greater percentage of DPA patients who were nonambulatory [79 patients (91%) vs. 18 patients (47%), P <0.0001]. Preindex radiographic measures were similar except the DSA patients had a lower PO (11 vs. 19 degrees, P =0.0001) and L5 tilt (8 vs. 12 degrees, P =0.001). Postindex and most recent radiographic data were comparable between the groups. There was no difference in the complication and unplanned returns to the operating room rates.Subanalysis of the DSA group based on ambulatory status showed similar radiographic measures except the ambulatory patients had a lower PO at all time points (preindex: 5 vs. 16 degrees, P =0.011; postindex: 6 vs. 10 degrees, P =0.045; most recent follow-up: 5 vs. 14 degrees, P =0.028). Only 1 ambulatory DSA patient had a PO ≥10 degrees at most recent follow-up compared with 6 nonambulatory DSA patients. Three (8%) DSA patients, all nonambulatory, underwent extension of their instrumentation to the pelvis. CONCLUSIONS: Pelvic fixation should be strongly considered in nonambulatory children with hypotonic NMS treated with growth-friendly instrumentation. At intermediate-term follow-up, revision surgery to include the pelvis was rare but DSAs do not seem effective at maintaining control of PO in nonambulatory patients. DSA and DPA were equally effective at maintaining major curve control, and complication and unplanned returns to the operating room rates were similar. LEVEL OF EVIDENCE: Level III-therapeutic.

Definition of Tweener: Consensus Among Experts in Treating Early-onset Scoliosis.

BACKGROUND: The term "Tweener" is colloquially used to refer to early-onset scoliosis (EOS) patients whose age and development make them candidates for multiple surgical options. The purpose of this study was to establish expert consensus on a definition to formally characterize the Tweener population. METHODS: A 3-round survey of surgeons in an international EOS study group was conducted. Surgeons were provided with various patient characteristics and asked if each was part of their definition for Tweener patients. Responses were analyzed for consensus (≥70%), near-consensus (60% to 69%), and no consensus (<60%). RESULTS: Consensus was reached (89% of respondents) for including chronological age in the Tweener definition; 8 to 10 years for females and 9 to 11 years for males. Surgeons agreed for inclusion of Sanders score, particularly Sanders 2 (86.0%). Patients who have reached Sanders 4, postmenarche, or have closed triradiate cartilage should not be considered Tweeners. Bone age range of 8 years and 10 months to 10 years and 10 months for females (12 y for males) could be part of the Tweener definition. CONCLUSIONS: This study suggests that the Tweener definition could be the following: patients with open triradiate cartilage who are not postmenarche and have not reached Sanders 4, and if they have one of the following: Sanders 2 or chronological age 8 to 10 years for females (9 to 11 y for males) or bone age 8 years and 10 months to 10 years and 10 months for females (12 y for males). This definition will allow for more focused and comparative research on this population. LEVEL OF EVIDENCE: Level V-expert opinion.

The Majority of Black Orthopaedic Surgeons Report Experiencing Racial Microaggressions During Their Residency Training.

BACKGROUND: Orthopaedic surgery is the least-diverse surgical specialty based on race and ethnicity. To our knowledge, the impact of this lack of diversity on discriminatory or noninclusive experiences perceived by Black orthopaedic surgeons during their residency training has never been evaluated. Racial microaggressions were first defined in the 1970s as "subtle verbal, behavioral, and environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative racial slights and insults to the target person or group." Although the term "microaggression" has long been established, more recently, as more workplaces aim to improve diversity, equity, and inclusion, it has entered the medical profession's lexicon as a means of describing the spectrum of racial discrimination, bias, and exclusion in the healthcare environment. QUESTION/PURPOSES: (1) What is the extent of discrimination that is perceived by Black orthopaedic surgeons during residency? (2) What subtypes of racial microaggressions (which encompasses racial discrimination, bias, and exclusion) do Black orthopaedic surgeons experience during residency training, and who are the most common initiators of these microaggressions? (3) What feedback statements could be perceived as racially biased to Black orthopaedic surgeons in residency training? (4) Are there gender differences in the reported types of racial microaggressions recalled by Black respondents during residency training? METHODS: An anonymous survey was administered between July 1, 2020, and September 1, 2020, to practicing orthopaedic surgeons, residents, and fellows in the J. Robert Gladden Orthopaedic Society database who self-identify as Black. There were 455 Black orthopaedic surgeons in practice and 140 Black orthopaedic residents or fellows in the database who met these criteria. Fifty-two percent (310 of 595) of participants responded. Fifty-three percent (243 of 455) were practicing surgeons and 48% (67 of 140) were current residents or fellows. Respondents reported their perception of discrimination in the residency workplace using a modified version of the single-item Perceived Occupational Discrimination Scale and were asked to recall any specific examples of experiences with racial discrimination, bias, or exclusion during their training. Examples were later categorized as different subtypes of racial microaggressions and were quantified through a descriptive analysis and compared by gender. RESULTS: Among survey respondents, 34% (106 of 310) perceived a lot of residency workplace discrimination, 44% (137 of 310) perceived some residency workplace discrimination, 18% (55 of 310) perceived a little residency workplace discrimination, and 4% (12 of 310) perceived no residency workplace discrimination. Categorized examples of racial microaggressions experienced in residency were commonly reported, including being confused for a nonphysician medical staff (nurse or physician's assistant) by 87% (271 of 310) of respondents or nonmedical staff (janitorial or dietary services) by 81% (250 of 310) of respondents. Racially explicit statements received during residency training were reported by 61% (190 of 310) of respondents. Thirty-eight percent (117 of 310) of such statements were reportedly made by patients and 18% (55 of 310) were reportedly made by attending faculty. Fifty percent (155 of 310) of respondents reported receiving at least one of nine potentially exclusionary or devaluing feedback statements during their residency training. Among those respondents, 87% (135 of 155) perceived at least one of the statements to be racially biased in its context. The three feedback statements that, when received, were most frequently perceived as racially biased in their context was that the respondent "matched at their program to fulfill a diversity quota" (94% [34 of 36]), the respondent was unfriendly compared with their peers (92% [24 of 26]), or that the respondent was "intimidating or makes those around him/her uncomfortable" (88% [51 of 58]). When compared by gender, Black women more frequently reported being mistaken for janitors and dietary services at 97% (63 of 65), compared with Black men at 77% (187 of 244; p < 0.01). In addition, Black women more frequently reported being mistaken as nurses or physician assistants (100% [65 of 65]) than Black men did (84% [205 of 244]) during orthopaedic residency training (p < 0.01). Black women also more frequently reported receiving potentially devaluing or exclusionary feedback statements during residency training. CONCLUSION: Perception of workplace discrimination during orthopaedic residency training is high (96%) among Black orthopaedic surgeons in the United States. Most respondents reported experiencing discrimination, bias, and exclusion that could be categorized as specific subtypes of racial microaggressions. Several different examples of racial microaggressions were more commonly reported by Black women. Certain feedback statements were frequently perceived as racially biased by recipients. CLINICAL RELEVANCE: To better understand barriers to the successful recruitment and retention of Black physicians in orthopaedics, the extent of racial discrimination, bias, and exclusion in residency training must be quantified. This study demonstrates that racial discrimination, bias, and exclusion during residency, wholly categorized as racial microaggressions, are frequently recalled by Black orthopaedic surgeons. A better understanding of the context of these experiences of Black trainees is a necessary starting point for the development of a more inclusive workplace training environment in orthopaedic surgery.

Reliability of radiographic assessment of growth modulation from anterior vertebral body tethering surgery in pediatric scoliosis.

PURPOSE: To assess the reliability of vertebral height and angular measurements for anterior vertebral body tethering (AVBT). METHODS: Eight observers measured PA radiographs of 15 idiopathic scoliosis patients treated with AVBT, pre-operative and 4-year follow-up. Vertebral wedging, disc wedging, convex vertebral body heights, and concave vertebral body heights of the 3 apical vertebrae were measured. For each observer, there were a total of 90 measurements for vertebral body height and 75 measurements for all wedging types At least 14 days elapsed between first and second round measurements. RESULTS: From the pre-operative to the 4-year follow-up time-point, the total wedging angle over the 3 peri-apical levels fell from 30 ± 7° to 16 ± 6° (p < 0.001) and the difference between the convex and concave vertebral heights decreased from 9 ± 4 to 6 ± 3 mm (p < 0.001). Interobserver agreement for pre-operative vertebral body heights was good [ICC = 0.80; 95% CI (0.74-0.85)]. At 4-year follow-up there was a moderate agreement [ICC = 0.67 (0.59-0.74)]. There was a poor interobserver agreement for pre-operative wedging angle measurements [ICC = 0.41 (0.32-0.52)] and 4-year follow-up [ICC = 0.45 (0.36-0.56)]. The Limits of Agreement with the Mean (LOAM) for pre-op heights was ± 2.4 mm, similar to the follow-up ± 2.6 mm. When raters are averaged in random groups of two the agreement limits decrease to ± 1.8 mm pre-op and ± 1.6 mm at follow-up. Similarly for wedging angles, LOAM values among the 8 observers of ± 4.6° pre-op and ± 4.2° dropped to ± 2.7° for both pre-op and follow-up when random groups of two raters were averaged together. Intraobserver agreement ranged from good to excellent per individual (ICC = 0.84-0.94) for pre-operative vertebral body heights, but this decreased at 4-year follow-up (ICC = 0.52-0.88). Intraobserver agreement was low overall for wedging (pre-operative ICC = 0.41-0.71; 4-year follow-up ICC = 0.41-0.76). CONCLUSION: Based on 8 individual observers, interobserver agreement ranged from good (pre-operative vertebral body heights) to moderate (4-year follow-up vertebral body heights) to poor (all wedging angles). To improve the reliability of the measurement of wedging angles, we recommend averaging the measurements of at least two observers.

Increasing Diversity in Orthopaedics: The Problem, Strategies, and Solutions.

It is important to educate and equip the orthopaedic community with tools to address health care disparities and improve orthopaedic specialty recruitment for racial minorities. How patients and providers are affected by systemic racism in healthcare and what that means in orthopaedic surgery, methods to identify bias and improve access to orthopaedic care for racial minorities, and how to structure a program and department environment to encourage and promote diversity are important topics of discussion.

An Organizational Approach to Addressing Racism in Orthopaedic Surgery: AOA Critical Issues Symposium.

ABSTRACT: This article highlights the key topics that were presented at a symposium of the American Orthopaedic Association in May 2021, with the primary objectives of acknowledging the existence of systemic racism within the field of orthopaedic surgery, developing a plan for combating racism before it manifests within orthopaedic departments and practices, and understanding the benefit of pipeline programs in diversifying the orthopaedic surgeon workforce. When the word racism is mentioned among a group of orthopaedic surgeons, it may have the immediate effect of stifling honest conversations. Therefore, the crippling effects of racism within orthopaedic surgery are not addressed, and there are downstream effects that influence patient care by perpetuating disparities in health care. If orthopaedic departments want to fix the lack of diversity within the specialty, the magnitude of the problem must first be measured. Fortunately, through the efforts of the J. Robert Gladden Orthopaedic Society, data sets are being created that better measure the diversity of individual orthopaedic residency programs. In addition to hiring diverse faculty, orthopaedic departments and practices should focus on the mentorship, sponsorship, retention, and promotion of these faculty. Finally, pipeline programs such as Nth Dimensions have a proven track record for improving the diversity of the orthopaedic workforce and can serve as the primary mechanism employed by departments and practices in making their orthopaedic surgeon workforce look more like the demographics of the United States.

The Insidious Effects of Childhood Obesity on Orthopedic Injuries and Deformities.

The current childhood obesity epidemic, affecting approximately 20% of American children and adolescents, is accompanied by unique orthopedic manifestations. The growing musculoskeletal system is susceptible to the endocrine effects of obesity, resulting in decreased bone mass and quality. As a result, obese children are at increased risk of musculoskeletal injury, fracture, and lower extremity deformities. The efficacy of nonoperative treatment such as casting or bracing may be limited by body habitus and surgical treatment is accompanied by increased risk of perioperative complications.

Effect of pelvic fixation on ambulation in children with neuromuscular scoliosis.

BACKGROUND: The effect of posterior spinal fusion (PSF) incorporating the pelvis on an ambulatory patient's ability to mobilize after the fusion is not well understood. AIM: To see whether a posterior spinal fusion with pelvic fixation using iliac or sacral alar iliac screws in ambulatory neuromuscular scoliosis (NMS) patients influences postoperative ambulatory ability. METHODS: A retrospective review of all patients with NMS that underwent PSF with fixation incorporating the pelvis between January 1, 2012 and February 29, 2019. A total of 118 patients were eligible, including 11 ambulatory patients. The primary outcome was the maintenance of ambulatory status postoperatively. Secondary outcomes included postoperative curve magnitude, pelvic obliquity, and complications, comprising infections, instrumentation failure, and any unplanned returns to the operative room. RESULTS: The ambulatory function was maintained in all 11 ambulatory NMS patients. One patient had an improvement in functional status with equipment-free ambulation postoperatively. An average postoperative follow-up was 19 mo. The overall complication rate was 19.4% (n = 23) with no significant differences between the groups in infection (P = 0.365), hardware failure (P = 0.505), and reoperation rate (P = 1.0). Ambulatory status did not affect complication rate (P = 0.967). CONCLUSION: Spinal fusion to the pelvis in ambulatory patients with NMS provides effective deformity correction without the reduction in ambulatory capabilities.

Contraindications to magnetically controlled growing rods: consensus among experts in treating early onset scoliosis.

PURPOSE: The purpose of this study was to describe contraindications to the magnetically controlled growing rod (MCGR) in patients with early onset scoliosis (EOS) by establishing consensus amongst expert surgeons who treat these patients frequently. METHODS: Nine pediatric spine surgeons from an international EOS study group participated in semi-structured interviews via email to identify factors that influence decision making in the use of MCGR. A 39-question survey was then developed to specify these factors as contraindications for MCGR-these included patient age and size, etiology, medical comorbidities, coronal and sagittal curve profiles, and skin and soft tissue characteristics. Pediatric spine surgeons from the EOS international study group were invited to complete the survey. A second 29-item survey was created to determine details and clarify results from the first survey. Responses were analyzed for consensus (> 70%), near consensus (60-69%), and no consensus/variability (< 60%) for MCGR contraindication. RESULTS: 56 surgeons of 173 invited (32%) completed the first survey, and 64 (37%) completed the second survey. Responders had a mean of over 15 years in practice (range 1-45) with over 6 years of experience with using MCGR (range 2-12). 71.4% of respondents agreed that patient size characteristics should be considered as contraindications, including BMI (81.3%) and spinal height (84.4%), although a specific BMI range or a specific minimum spinal height were not agreed upon. Among surgeons who agreed that skin and soft tissue problems were contraindications (78.6%), insufficient soft tissue (98%) and skin (89%) to cover MCGR were specified. Among surgeons who reported curve stiffness as a contraindication (85.9%), there was agreement that this curve stiffness should be defined by clinical evaluation (78.2%) and by traction films (72.3%). Among surgeons who reported sagittal curve characteristics as contraindications, hyperkyphosis (95.3%) and sagittal curve apex above T3 (70%) were specified. Surgeons who indicated the need for repetitive MRI as a contraindication (79.7%) agreed that image quality (72.9%) and not patient safety (13.6%) was the concern. In the entire cohort, consensus was not achieved on the following factors: patient age (57.4%), medical comorbidities (46.4%), etiology (53.6%), and coronal curve characteristics (58.9%). CONCLUSION: Surgeon consensus suggests that MCGR should be avoided in patients who have insufficient spinal height to accommodate the MCGR, have potential skin and soft tissue inadequacy, have too stiff a spinal curve, have too much kyphosis, and require repetitive MRI, particularly of the spine. Future data-driven studies using this framework are warranted to generate more specific criteria (e.g. specific degrees of kyphosis) to facilitate clinical decision making for EOS patients. LEVEL OF EVIDENCE: Level V-expert opinion.