Growing Rod versus Posterior Spinal Fusion Treatment of Juvenile Idiopathic Scoliosis: Unique Characteristics and Surgical Outcomes.

Progressive spinal curvature in juvenile idiopathic scoliosis (JIS) is challenging to treat. When conservative management fails, treatments include growing rods (GRs) or posterior spinal fusion (PSF). The purpose of this study is to compare the patient characteristics and outcomes of GR and PSF treatment of JIS. We performed a retrospective review of demographic, radiographic, and surgical data for all JIS patients requiring surgical treatment between 2012 and 2020. Patients who underwent any GR treatment were compared to PSF patients. A total of 36 patients (13 GR, 23 PSF) were reviewed. PSF patients had a larger pre-operative spinal height (p = 0.002), but similar pre-operative major curve magnitudes (p = 0.558). PSF treatment resulted in similar change in the T1-S1 length (p = 0.002), but a greater correction of the curve magnitude (p < 0.055) compared to GR patients. Eight patients initially treated with GRs later underwent definitive PSF treatment. This subset of patients had a greater spinal height before PSF (p = 0.006), but similar immediate post-PSF T1-S1 lengths (p = 0.437) and smaller changes in spinal height from PSF (p = 0.020) than primary PSF patients. At final follow-up, patients who underwent primary PSF versus PSF after GR had similar spinal heights (p = 0.842). The surgical intervention chosen to manage progressive JIS often differs based on patient characteristics. While this choice may impact immediate outcomes, the outcomes at final follow up are similar.

Common Pediatric Fractures for Community Orthopaedic Specialists: Fix Them or Ship Them?

It is important to focus on common pediatric fractures seen in community emergency rooms, including supracondylar humerus, elbow, forearm, distal radius, and femoral shaft fractures, along with periarticular fractures around the knee and ankle in children. The principles of surgical and nonsurgical management of these fractures are based on the fracture type and age of the patient. The orthopaedic surgeon should be aware of important tips and tricks to help manage these injuries and be familiar with common complications that may occur when these injuries are encountered during trauma call.

Does Implant Density Impact Three-Dimensional Deformity Correction in Adolescent Idiopathic Scoliosis with Lenke 1 and 2 Curves Treated by Posterior Spinal Fusion without Ponte Osteotomies?

STUDY DESIGN: Retrospective cohort study. PURPOSE: To determine whether implant density impact three-dimensional deformity correction in posterior spinal fusion (PSF) without Ponte osteotomies (POs) for patients with Lenke 1 and 2 adolescent idiopathic scoliosis (AIS). OVERVIEW OF LITERATURE: Currently, the optimal pedicle screw (PS) density for flexible moderate-sized thoracic AIS curve correction is still controversial. There are limited data regarding the impact of implant density on three-dimensional correction in PSF without the use of PO for thoracic AIS surgery. METHODS: A database of patients with AIS with Lenke 1 and 2 curves treated with PSF without PO and instrumented with PSs and ≥2-year follow-up was reviewed. The preoperative, immediate, and final follow-up postoperative radiographs were analyzed. The correlation between PS density and the following factors were determined: major curve correction (MCC), correction index (CI; MCC/curve flexibility), kyphosis angle change, and rib index (RI) correction. Then, patients were divided into low-density (LD) and high-density (HD) groups according to mean PS density for the entire cohort (1.5 PS per level). Demographics and radiographic and clinical outcomes were compared between groups. RESULTS: The study included 99 patients with Lenke 1 and 23 patients with Lenke 2 AIS. The average MCC was 67.2%. There was no correlation between screw density and these parameters: MCC (r=0.10, p=0.26), CI (r=0.16, p=0.07), change in T2-T12 kyphosis angle (r=-0.13, p=0.14), and RI correction (r=-0.09, p=0.37). Demographic and preoperative radiographic parameters were similar between the LD and HD groups. At the latest follow-up, there were no differences between the two groups in regard to MCC, CI, change in T2-T12 kyphosis angle, RI correction, and Scoliosis Research Society-30 scores (all p>0.05). CONCLUSIONS: This study revealed no significant correlation between screw density and curve correction in any planes. HD construct may not provide better deformity correction in patients with flexible and moderate thoracic AIS undergoing PSF without PO.

How much does depth matter? Magnetically controlled growing rod distraction directly influenced by rod tissue depth.

PURPOSE: Magnetically controlled growing rod (MCGR) for the treatment of early-onset scoliosis (EOS) is a relatively innovative technique. MCGR benefits over traditional growing rods are known but limitations and complications are being revealed. The purpose of this study was to examine the importance of tissue depth on rod lengthening. METHODS: A single-institution retrospective review of 72 MCGR patients was performed. Ultrasound measured rod distraction. Differences in programmed and actual distraction, and complications were recorded. Tissue depths and achieved length were averaged and used to construct a regression to account for variability. RESULTS: Percentage of std and offset orientation rod lengthening relative to the programmed distraction was inversely proportional to rod depth (std R = 0.50, p = 0.002) (offset R = 0.60, p < 0.001). Expected std rod lengthening achieved decreased by 1.46%/mm depth. Expected offset rod lengthening achieved decreased by 1.68%/mm depth. 28 pts (38.9%) sustained complications. Age, sex, BMI, standard tissue depth, and/or offset tissue depth had no predictive ability with respect to complications sustained (overall model R = 0.31, p = 0.36). CONCLUSION: In a series of EOS surgical patients treated with MCGRs, the relationship between percentage of programmed lengthening achieved as well as total lengthening was inversely proportional to tissue depth of the rod. There was a trend towards increasing frequency of complications recorded with decreasing tissue depth though this was not significant. These data can help with surgical planning during MCGR placement.

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.

Long-term experience with simultaneous prone video-assisted thoracoscopic anterior spinal release and posterior spinal fusion in severe rigid pediatric spinal deformities.

PURPOSE: While posterior-alone techniques have been successful for most pediatric spinal deformities, anterior spinal release may be useful for severe rigid deformities. Traditional lateral-positioned video-assisted thoracoscopic surgical release (VATSR) followed by prone posterior spinal fusion (PSF) has been criticized for adding extensive operative morbidity. We aimed to reduce its disadvantages by performing prone VATSR and PSF simultaneously and evaluate its long-term outcomes. METHODS: All consecutive patients from 1991 to 2012 undergoing VATSR and PSF at one institution were retrospectively reviewed. The inclusion criteria comprised severe rigid thoracic scoliosis (> 70°, bending correction > 45°) or kyphosis (> 75°, bolster correction > 45°), and a minimum 2 year follow-up. Demographics, operative data, hospital stay, and radiographic correction data were compared between patients who had undergone sequential VATSR followed by PSF and those who had undergone these procedures simultaneously. RESULTS: Of 153 patients who had undergone VATSR and PSF, 53 met the inclusion criteria (31 sequential, 22 simultaneous; average follow-up, 50 [range, 24-86] months). Age, preoperative measurements and flexibility, and perioperative complications did not differ significantly. The simultaneous group showed significantly lower operative time (449 vs. 618 min), blood loss (1039 vs. 1906 cc), and hospital stay (6.3 vs. 8.5 days) (all, p < 0.05). Postoperative radiographic correction and maintenance at the final follow-up showed a non-significant trend favoring the simultaneous group. CONCLUSION: Our simultaneous prone VATSR and PSF technique showed significantly lower operative time, blood loss, and hospital stay compared with the traditional sequential VATSR and PSF method, suggesting its value in treating rigid deformities.

Spine Growth Modulation in Early Adolescent Idiopathic Scoliosis: Prospective US FDA IDE Pilot Study of Titanium Clip-Screw Implant at Two to Five Years.

STUDY DESIGN: Prospective longitudinal study of growth modulation system for early adolescent idiopathic scoliosis (AIS), consecutive case series from first human use to skeletal maturity, fusion, or five years postoperation. OBJECTIVES: Determine adverse events and curvature changes to end of study; examine factors most likely to explain variability in curve changes. SUMMARY OF BACKGROUND: Pilot clinical safety study was performed under US Food and Drug Administration (FDA) Investigational Device Exemption (IDE). Safety and radiographic results were previously reported to 24 months postoperation. METHODS: Subjects with early AIS underwent thoracoscopic placement of titanium clip-screw devices designed to modify growth asymmetrically. Eligibility was based on high risk of progression to 50°: single major thoracic curve 25°-40°, Risser 0, open triradiate cartilages, and premenarchal if female. Six subjects, the maximum allowed, enrolled. Adverse events (AEs), clinical outcomes, and curvatures were systematically collected. Disc heights, vertebral heights, and implant-bone contact areas were assessed. RESULTS: Consecutive subjects enrolled, aged 12.1 years (±1.7), three were female. AEs from two to five years postoperation included deformity changes leading to a second surgery in three patients: two for posterior spinal fusion, and one for thoracoscopic removal of half the implants for overcorrection. In the latter case, overcorrection appeared halted for duration of study. One patient, whose curve exceeded 50° at age 18 years, did not choose fusion. Major thoracic curves were 34° (±3°) preoperatively and 42° (±20°) at end of study. CONCLUSIONS: In a study of spine growth modulation in patients with early AIS with high risk of progression, at skeletal maturity or five years postoperation, major thoracic curves of half progressed to >50°, whereas curves of the other half remained <40°, below fusion indications. Removal of selected implants may halt overcorrection. The next, pivotal, study phase was approved by FDA. LEVEL OF EVIDENCE: Level IV, prospective case series under stringent regulatory controls.

Periapical-dropout Screws Strategy For 3-Dimensional Correction of Lenke 1 Adolescent Idiopathic Scoliosis in Patients Treated by Posterior Spinal Fusion.

STUDY DESIGN: This was a single-center, retrospective study. OBJECTIVE: The objective of this study was to compare periapical-dropout screws strategy (PDSS) with traditional-multilevel pedicle screws strategy (TMSS) for 3-plane correction of Lenke 1 adolescent idiopathic scoliosis deformity. SUMMARY OF BACKGROUND DATA: There are limited data in 3-plane correction and the optimal pedicle screw (PS) configuration for Lenke 1 adolescent idiopathic scoliosis surgery. MATERIALS AND METHODS: Sixty-one consecutive patients with Lenke 1 curves (range: 50-80 degrees), undergoing single-stage posterior spinal fusion with PS fixation, were included. Patients with a minimum follow-up of 1 year were divided into 2 groups according to PS strategy. The PDSS group included 33 patients with PS placement bilaterally at both ends and apex of the construct. The TMSS group included 28 patients with conventional PS placement. Baseline, immediate, and last follow-up demographic, radiographic, and clinical outcomes were analyzed. Radiographic outcomes were assessed in axial (using rib index and apical vertebral rotation using Raimondi ruler and Upasani methods), coronal, and sagittal planes. The implant costs were also evaluated. RESULTS: There were no differences in demographic, preoperative radiographic parameters and levels fused. The number of PSs per level fused was significantly lower in the PDSS group (1.3 vs. 1.4; P=0.0002). At last follow-up, major Cobb correction averaged 79% for the PDSS group and 69.5% for the TMSS group (P=0.001). T2-T12 kyphosis angle changes were 1 degree in the PDSS group and -2.5 degrees in the TMSS group (P=0.35). Rib index correction was 28.2% for the PDSS group and 17.7% for the TMSS group (P=0.02). Upasani grade apical vertebral rotation was significantly better in the PDSS group (0.7 vs. 1.4; P=0.0001). Clinical outcomes evaluated by Scoliosis Research Society-30 scores were similar in both groups. Total implant costs were significantly lower in the PDSS group ($16,852 vs. $18,926; P<0.001). CONCLUSION: The PDSS construct provides better deformity correction in all 3 planes and helps decrease implant costs compared with the TMSS construct. Thus, the PDSS construct can be considered as a rational strategy and cost-effective technique when treating moderate Lenke 1 curves with posterior spinal fusion.

Extensor Tendon Injury Associated With Dorsal Entry Flexible Nailing of Radial Shaft Fractures in Children: A Report of 5 New Cases and Review of the Literature.

BACKGROUND: Extensor pollicis longus (EPL) tendon injury following the dorsal approach to elastic stable intramedullary nailing (ESIN) of the radius has been reported in a growing number of cases in the literature. This study includes 5 new cases from our institution as well as a comprehensive review of previously reported cases from the literature. METHODS: We conducted a retrospective chart review of all patients undergoing ESIN between January 1, 2004 and December 31, 2013 at our institution. Those patients with an EPL injury or rupture were identified and clinical data collected included operative technique, diagnosis, treatment, and outcomes data. In addition, we performed a systematic review of the literature using Pubmed MEDLINE database, the Chochrane database, Scopus, Web of Science, and Embase. A total of 28 cases of EPL injury following ESIN of the radius were identified in the literature and the relevant data were extracted from those studies. RESULTS: All 33 pediatric cases of EPL tendon injury occurred after entry to the radial canal was obtained by the dorsal approach to ESIN. EPL injury was diagnosed an average of 10 weeks following the index procedure. Extensor indicis pollicis to EPL transfer was performed in 13 patients, tendon release/lysis of adhesions in 5, EPL repair in 2, EPL graft reconstruction from palmaris longus tendon in 1, 3 patients refused further intervention, and treatment was unreported in 7 cases. By 12-month follow-up, all operatively treated patients had a good functional outcome with near anatomic extension at the thumb interphalangeal joint, no pain, and no further complication. CONCLUSIONS: EPL tendon injury was found to be a complication unique to the dorsal entry approach for ESIN of the radius. The lateral approach appears to offer a safer alternative with regard to the EPL tendon. We suggest that physicians consider the risk of EPL tendon injury when planning for ESIN of the radius, and make an effort to avoid direct injury when using a dorsal approach. LEVEL OF EVIDENCE: Level III-therapeutic.

Observed Length Increases of Magnetically Controlled Growing Rods are Lower Than Programmed.

BACKGROUND: Magnetically controlled growing rods (MCGRs) are increasingly used in the treatment of early onset scoliosis (EOS). Few studies have reported whether desired lengthening can reliably be achieved, or if prior spine instrumentation and large tissue depths affect lengthening. In this clinical study of EOS patients, it was hypothesized that increases in rod length would equal programmed increases, patients with prior spine instrumentation would lengthen less than patients without prior surgery, and larger tissue depths would decrease lengthening success. METHODS: A retrospective chart review was conducted on EOS patients with single and dual MCGRs placed between April 2014 to September 2015 and distracted at a single institution. Rod distraction was measured at each visit using ultrasound. Differences between programmed and actual distraction for each patient, and between groups with and without prior spine instrumentation, were determined by 2-tailed t tests. Regression and correlation were used to determine the relationship between tissue depth and length increases. RESULTS: Thirty-one patients were included, 18 males, 13 females, age 8.1 (±2.5) years, with major curves measuring 60 (±14.6) degrees at time of MCGR insertion. In the 12 patients with prior instrumentation, time from initial growing rod placement to MCGR insertion was 23.1 (±10.6) months. The number of surgical procedures before MCGR insertion was 2.8 (±2.0). Total length increase relative to the programmed distraction was 86% (±21) (P<0.001). Length increases for patients with and without prior surgery were 87% (±23) and 86% (±19), respectively (P>0.9). Total lengthening was inversely proportional to tissue depth (r=0.38, P<0.01); the decrease in lengthening achieved was 2.1%/mm of tissue depth. CONCLUSIONS: Increases in rod length were 14% lower than the programmed distraction. Prior instrumentation did not impact the amount of rod distraction. Greater distance between the rod and the skin surface negatively affected the magnitude of distraction.

Spine Growth Modulation in Early Adolescent Idiopathic Scoliosis: Two-Year Results of Prospective US FDA IDE Pilot Clinical Safety Study of Titanium Clip-Screw Implant.

STUDY DESIGN: Prospective pilot clinical safety study of novel treatment, consecutive case series from first human use in patients with early adolescent idiopathic scoliosis (AIS). OBJECTIVE: The primary purpose was to determine the initial safety of a titanium clip-screw implant system for spine growth modulation. The secondary aim was to document curvatures to 2 years postoperatively. SUMMARY OF BACKGROUND DATA: Spinal growth modulation was documented in preclinical studies. A prospective pilot clinical safety study was then performed under a Food and Drug Administration (FDA) Investigational Device Exemption (IDE) (www.clinicaltrials.gov Identifier: NCT01465295). METHODS: Six subjects with early AIS underwent thoracoscopic placement of titanium clip-screw devices. Eligibility criteria included only patients at high risk for progression to 50°: single major thoracic curve 25°-40°, age ≥10 years, skeletally immature (Risser 0 plus open triradiate cartilages), and if female, premenarchal. Adverse events (AEs), clinical outcomes, and radiographic measures were documented using Good Clinical Practices. RESULTS: Six consecutive subjects were enrolled, three females and three males aged 12.1 years (±1.7). AEs included one that was device related-mild device migration at 18 months in the most rapidly progressive curve. Procedure-related AEs were mostly pulmonary. A chylous effusion that met the clinical protocol definition of a serious AE resolved after minimally invasive interventions. Major thoracic curves were 34° (±3°) preoperatively and 38° (±18°) at two years (intrasubject change, 4° ± 18°). At 24 months, curves in 3 patients were >45° and 3 were <40°. CONCLUSIONS: A spine growth modulation system undergoing study under an FDA IDE was determined to be safe. Variability in curve response to the implant was high, ranging from progression to correction. Investigational approval was granted by the US FDA for the next cohort of 30 subjects.

Growing Rods Are an Effective Fusionless Method of Controlling Early-Onset Scoliosis Associated With Neurofibromatosis Type 1 (NF1): A Multicenter Retrospective Case Series.

BACKGROUND: Spinal deformities associated with neurofibromatosis type 1 (NF1) often have an early onset. These curves frequently develop dysplastic features. Rapid progression is common, and is often difficult to control with casting or bracing. Spinal fusion at a young age can potentially interfere with chest and trunk growth. Growing rods (GRs) have been used in early-onset scoliosis (EOS) effectively. The purpose of this study was to evaluate GR use in NF1. METHODS: Retrospective data collection was performed from a multicenter EOS database with additional patients from our own institute. Each patient had a genetic diagnosis of NF1 and was treated with GR. Results were compared with reported results of GR in EOS in the literature. RESULTS: Fourteen patients from 5 centers underwent a total of 71 procedures with an average follow-up of 54 months. Mean age at surgery was 6.8 years. Means of initial and final curves were 74 and 36 degrees, respectively (51% correction). Spine grew at an average of 39 mm (11.2 mm per year). Implant-related complications were the most common (8/14, 57%), including failure of proximal construct (5/14), rod breakage (2/14), and prominent implants (1/14). There was no significant difference between screws and hooks as proximal anchors (Fischer test). Two patients had deep infection that needed debridement. CONCLUSIONS: This retrospective pooled data study is the first report on the treatment of early-onset NF1 scoliosis with GRs. The use of GRs in these patients effectively controls the spinal deformity and facilitates growth of the spine. The complications were no greater than those seen in other conditions causing EOS. Failure of proximal anchors was found to be the most common complication. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Rereduction for Redisplacement of Both-Bone Forearm Shaft Fractures in Children.

BACKGROUND: There is a high rate of redisplacement after closed reduction and cast treatment of displaced both-bone forearm shaft fractures in children. Little evidence is available on the efficacy of rereduction of these redisplaced fractures. This study evaluates the impact of rereduction on radiographic outcomes and compares the cost to surgical stabilization. METHODS: This retrospective study included 31 children (mean age, 6.3 y; 18 boys) treated with rereduction for redisplacement of a displaced both-bone forearm shaft fracture between 2008 and 2013. Angulation was measured on anteroposterior and lateral radiographs of the radius and ulna at injury, after reduction, at redisplacement, after rereduction, and at fracture union. Average procedure costs for rereduction and surgical stabilization were calculated. RESULTS: Initial reduction decreased apex volar angulation (initially >20 degrees) of both bones to a median of ≤2 degrees. After an average of 15 days (range, 4 to 35 d), apex volar angulation of the radius worsened to 9 degrees, and apex ulnar angulation worsened to >10 degrees for both bones. For every 5 days after initial reduction, apex ulnar angulation of the radius worsened by 4 degrees. Rereduction reduced apex ulnar and volar angulation of both bones to <5 degrees, which was maintained after cast removal. There were no complications. The average procedure cost for rereduction was $2056 compared with $4589 for surgical stabilization with or without implant removal. CONCLUSION: Rereduction of both-bone forearm shaft fractures after redisplacement following initial closed reduction had satisfactory radiographic outcomes and is a safe, effective, and less expensive option than surgical stabilization. LEVEL OF EVIDENCE: Level IV-therapeutic.

Dural ectasia in a child with Larsen syndrome.

INTRODUCTION: We present a case of an incidental finding of dural ectasia in a child diagnosed with Larsen syndrome. Larsen syndrome is a rare inherited disorder of connective tissue characterized by facial dysmorphism, congenital joint dislocations of the hips, knees and elbows, and deformities of the hands and feet. Dural ectasia is as an abnormal expansion of the dural sac surrounding the spinal cord and may result in spinal morphologic changes, instability, and spontaneous dislocation. To the best of our knowledge, the presence of dural ectasia in Larsen syndrome has not previously been reported. CASE STUDY: A 6-year-old boy diagnosed with Larsen syndrome presented with an upper thoracic curve measuring 74 degrees, a right thoracic curve measuring 65 degrees, and significant cervicothoracic kyphosis with 50% anterior subluxation of C6 on C7 and C7 on T1. Advanced imaging studies showed dural ectasia (evidenced by spinal canal and dural sac expansion), thinning of pedicles and lamina, and C4 and C6 pars defects with cervical foramen enlargement. The patient received growing rod instrumentation (attached to cervical spine fixation) by a combined anterior/posterior surgical approach using intraoperative halo. Complications included intraoperative medial breach (fully resolved), wound dehiscence, 2 instances of bilateral broken rods, and a broken cervical rod. Following 7 lengthening procedures, the patient underwent definitive fusion. DISCUSSION: Surgeons should be aware of the potential for dural ectasia in patients with Larsen syndrome. Its presence will cause difficulties in the surgical intervention for spinal deformity. Multiple factors must be considered, and surgical approach and technique will require modification to avoid complications. Although dural ectasia confounds surgical intervention in these patients, surgery still appears to outweigh the risks associated with delayed intervention. The presence of dural ectasia should not preclude surgical decompression and stabilization. This report adds to the body of knowledge on the treatment of Larsen syndrome by demonstrating the potential existence of dural ectasia and highlights the importance of careful and thorough preoperative evaluation and diagnostic imaging.

Complications of surgical treatment of pediatric spinal deformities.

Surgery in a child with spinal deformity is challenging. Although current orthopedic practice ensures good long-term surgical results, complications occur. Idiopathic scoliosis represents the most extensively investigated deformity of the pediatric spine. Nonidiopathic deformities of the spine are at higher risk for perioperative and long-term complications, mainly because of underlying comorbidities. A multidisciplinary treatment strategy is helpful to assure optimization of medical conditions before surgery. Awareness of complications that occur during or after spine surgery is essential to avoid a poor outcome and for future surgical decision making. This article summarizes the complications of surgical treatment of the growing spine.

Intrafocal pinning for distal radius metaphyseal fractures in children.

The purpose of this retrospective case control study was to evaluate the results of intrafocal pinning for distal radius metaphyseal fractures in children and to compare these results with conventional pinning. Data were collected from medical records and radiographs from patients who underwent closed reduction and percutaneous pinning for distal radius fracture in a Level I trauma center at the authors' institution between 2008 and 2010. Inclusion criteria included a dorsally angulated metaphyseal fracture without physeal involvement, an open distal radius physis, and a follow-up to radiographic union. A total of 10 patients with intrafocal pinning were compared to 26 patients with conventional pinning. Preoperatively, angulation was greater in patients who received intrafocal pinning than conventional pinning based on anteroposterior radiographs. Postoperatively, the 2 groups did not differ in angulation on either anteroposterior or lateral radiographs. One malunion and 2 pin-related complications occurred in the conventional pinning group, and 1 pin-related complication occurred in the intrafocal pinning group. The 2 groups did not differ by age, sex, side of injury, days to surgery, or initial shortening. This study affirms that the intrafocal pinning technique is an alternative to the conventional pinning technique for the stabilization of displaced metaphyseal distal radius fractures in children. Intrafocal pinning can also be used as a reduction tool for fractures that cannot be reduced by closed manipulation. The complications are comparable between the 2 techniques.

Does the presence of dystrophic features in patients with type 1 neurofibromatosis and spinal deformities increase the risk of surgery?

STUDY DESIGN: Retrospective chart and radiographical review. OBJECTIVE: To present the demographics of patients with scoliosis and neurofibromatosis type 1 (NF-1), to record the incidence of dystrophic features, and to determine whether the presence of dystrophic features increase the risk of surgery in patients with NF-1 and associated spinal pathology. SUMMARY OF BACKGROUND DATA: The most common of the osseous complications of NF-1 is spinal deformity, occurring in 10% to 30% of individuals with NF-1. Many of these patients will eventually require surgery for curve progression, which makes study of demographics and identification of features predicting the need for surgery essential in this patient population. METHODS: A retrospective review was performed in patients with NF-1 and spinal deformities, followed in a multidisciplinary neurofibromatosis center. A subset of 56 patients with complete radiographical evaluation was reviewed for identification of risk factors for spine surgery. RESULTS: One hundred thirty-one patients from a population of 694 patients with NF-1 (19%) had scoliosis. Mean age at diagnosis of scoliosis was 9 years (range; 1-17 yr). Scoliosis and need for surgery were equally distributed between males and females. In the group of 56 patients, 63% had 3 or more dystrophic features. The presence of 3 or more dystrophic features was the strongest predictor of the need for surgery (odds ratio = 14.34; P < 0.001). Individual features most predictive of need for surgery were the presence of vertebral scalloping (odds ratio = 13.19; P < 0.001) followed by the presence of dural ectasia (odds ratio = 6.38; P = 0.005). Patients with no dystrophic features were unlikely to progress to need for surgery. CONCLUSION: Scoliosis and need for surgery were equally distributed between males and females. The presence of 3 or more dystrophic features was highly predictive of the need for surgery, with the most significant individual predictors being vertebral scalloping and dural ectasia. A combination of radiographical and MRI features can be used to predict need for spinal surgery. LEVEL OF EVIDENCE: 3.

Guided growth for the treatment of limb length discrepancy: a comparative study of the three most commonly used surgical techniques.

The purpose of this study was to compare the safety and effectiveness of three mechanical devices (percutaneous transphyseal screws, tension band plates, and staples) for the correction of limb length discrepancies in growing children and adolescents. Thirty-nine consecutive patients treated with epiphysiodesis for limb length discrepancy were retrospectively reviewed. No significant difference was recorded between the three devices in postoperative limb length discrepancy or the rate of correction between the plating and stapling groups and between plating and percutaneous transphyseal screws groups. Epiphysiodesis for length discrepancies can be performed effectively using staples, tension band plates, or percutaneous transphyseal screws.

Mid- to long-term outcomes in adolescent idiopathic scoliosis after instrumented posterior spinal fusion: a meta-analysis.

STUDY DESIGN: Meta-analysis on mid- to long-term outcomes in adolescent idiopathic scoliosis after instrumented posterior spinal fusion. OBJECTIVE: To compare mid- to long-term outcomes and complications of the most commonly used instrumentation systems in adolescent idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: A meta-analysis of mid- to long-term results of different methods of instrumentation, including the most currently used all-pedicle screw construct, is lacking. METHODS: A structured literature review was conducted for studies concerning management of patients with adolescent idiopathic scoliosis with instrumented posterior fusion. Pooled means, standard deviations, and sample sizes were either identified or calculated on the basis of the results of each study. RESULTS: Meta-analyses were performed on outcomes from 27 studies. Overall, 1613 patients who had been treated with Harrington rods, 361 patients who had undergone Cotrel-Dubousset instrumentation, and 298 patients who managed with all-pedicle screw constructs were reviewed. The mean follow-up was 14.9 years. Cotrel-Dubousset and pedicle screw instrumentations achieved a significantly greater degree of correction of the thoracic curve than Harrington rods (40.3° vs. 14.7°; P < 0.001 and 21.9° vs. 14.7°; P = 0.005, respectively). Cotrel-Dubousset technique achieved a significantly higher degree of correction than all-pedicle screw construct in both the thoracic (40.3° vs. 21.9°, respectively; P < 0.001) and lumbar curves (37.2° vs. 16°, respectively; P < 0.001). Similarly, Cotrel-Dubousset construct achieved a greater correction of both thoracic kyphosis (33.5° vs. 23°, respectively; P < 0.001) and lumbar lordosis (46° vs. 50.7°, respectively; P = 0.002) than pedicle screws. All-pedicle screw fixation was associated with the lower risk of pseudarthrosis, infection, neurological deficit, and reoperation. CONCLUSION: This study confirms the negative effect of Harrington rods on sagittal alignment. We further found that the degree of correction in the coronal and sagittal planes was higher after Cotrel-Dubousset instrumentation than all-pedicle screw fixation. All-pedicle screw constructs offered the lower risk of mid- to long-term complications and revision surgery.

In vivo dynamic compressive stresses in the disc annulus: a pilot study of bilateral differences due to hemiepiphyseal implant in a quadruped model.

STUDY DESIGN: In vivo biomechanical study in quadruped model. OBJECTIVE: To develop in vivo model capable of determining physiological compressive stresses bilaterally in the intervertebral disc annulus and preliminarily assess effects of a hemiepiphyseal implant. SUMMARY OF BACKGROUND DATA: Spine growth modification alters stress distributions in vertebral growth plates and discs. Quantification of stresses is required to help assess implant efficacy and disc health. More generally, despite widespread and necessary use of animals in preclinical studies of spine instrumentation, limited quantitative information is available on mechanobiological conditions in quadruped spines for comparisons with those of humans. METHODS: Skeletally immature domestic pigs were instrumented with an implant and 4 stress sensors. Sensors were inserted into left and right sides of the annulus at 2 thoracic levels. A titanium staple-screw construct was implanted at 1 level. Signals were acquired intraoperatively, postoperatively during normal activities, and biweekly with the animal under anesthesia, for up to 8 weeks. RESULTS: Stresses varied by sensor location relative to implant, postoperative time, activity, and animal. Intraoperatively, the mean peak stress due to staple insertion was 1.6 MPa at the sensor nearest the staple. Mean stress at the end of surgery was 0.23 MPa. Mean stress standing the first day was 0.38 MPa. Dynamic stresses were recorded at all locations, including the location nearest the staple. Highest mean stresses were those nearest the implant. With the animal under anesthesia, the dynamic stress range in the resting prone position was 0.1 MPa, whereas this range was 0.9 MPa when the spine was manually flexed. CONCLUSION: Compressive stresses were dynamic at both control and stapled levels, which indicated that the disc was not immobilized by the implant. These pilot results suggested that mean disc compression was increased within the first postoperative week. Stresses ranged up to levels measured in humans.