Does Obesity Affect Preoperative Shoulder Balance in Adolescent Idiopathic Scoliosis?

BACKGROUND: Obese patients with adolescent idiopathic scoliosis (AIS) have been shown to present with larger curve magnitudes preoperatively. However, the effect of obesity on shoulder balance in AIS remains unknown. The purpose of our study was to determine if overweight and obese patients with AIS have worse radiographic shoulder balance on initial presentation when compared with normal weight patients. METHODS: AIS patients <18 years old, with Lenke 1 or 2 curves, who underwent a posterior spinal fusion between March 2013 and December 2018 were retrospectively evaluated. BMI-for-age percentiles as defined by the Center for Disease Control and Prevention were used: obese (≥95th percentile), overweight (85th to <95th percentile), and normal weight (5th to <85th percentile). Shoulder height was measured via the radiographic shoulder height (RSH) method, with an RSH ≤ 1 cm considered balanced. The primary outcome was preoperative shoulder balance. Secondary outcomes included postoperative shoulder balance, major curve correction, and UIV selection. RESULTS: One hundred eighty-four patients (116 [63%] normal weight and 68 [37%] overweight/obese) were included. The mean age at surgery was 13.1 ± 2 years, and mean follow-up was 17.4 ± 13 months. Preoperative shoulder imbalance was significantly greater in the overweight/obese group compared to the normal weight group (1.9 ± 1 cm vs. 1.5 ± 1 cm, p = 0.04). The odds ratio of presenting with unbalanced shoulders was 2.0 (95% CI: 1.02-3.83, p = 0.04) for the overweight/obese group. No significant differences were found for postoperative shoulder balance, UIV selection, or major curve correction. CONCLUSIONS: Overweight and obese patients with AIS are twice as likely to present with unbalanced shoulders preoperatively; however, this difference is not clinically relevant with a mean difference of 0.4 cm between cohorts. Finally, the preoperative BMI percentile did not show a significant effect on the chosen UIV or curve magnitude correction. LEVEL OF EVIDENCE: Level III: this is a retrospective case-control study.

Surgical Outcomes of Obese Patients With Adolescent Idiopathic Scoliosis From Endemic Areas of Obesity in the United States.

BACKGROUND: Obesity rates continue to rise among children and adolescents across the globe. A multicenter research consortium composed of institutions in the Southern US, located in states endemic for childhood obesity, was formed to evaluate the effect of obesity on pediatric musculoskeletal disorders. This study evaluates the effect of body mass index (BMI) percentile and socioeconomic status (SES) on surgical site infections (SSIs) and perioperative complications in patients with adolescent idiopathic scoliosis (AIS) treated with posterior spinal fusion (PSF). METHODS: Eleven centers in the Southern US retrospectively reviewed postoperative AIS patients after PSF between 2011 and 2017. Each center contributed data to a centralized database from patients in the following BMI-for-age groups: normal weight (NW, 5th to <85th percentile), overweight (OW, 85th to <95th percentile), and obese (OB, ≥95th percentile). The primary outcome variable was the occurrence of an SSI. SES was measured by the Area Deprivation Index (ADI), with higher scores indicating a lower SES. RESULTS: Seven hundred fifty-one patients were included in this study (256 NW, 235 OW, and 260 OB). OB and OW patients presented with significantly higher ADIs indicating a lower SES (P<0.001). In addition, SSI rates were significantly different between BMI groups (0.8% NW, 4.3% OW, and 5.4% OB, P=0.012). Further analysis showed that superficial and not deep SSIs were significantly different between BMI groups. These differences in SSI rates persisted even while controlling for ADI. Wound dehiscence and readmission rates were significantly different between groups (P=0.004 and 0.03, respectively), with OB patients demonstrating the highest rates. EBL and cell saver return were significantly higher in overweight patients (P=0.007 and 0.002, respectively). CONCLUSION: OB and OW AIS patients have significantly greater superficial SSI rates than NW patients, even after controlling for SES. LEVEL OF EVIDENCE: Level III.

Outcomes of Vertical Expandable Prosthetic Titanium Ribs in Children With Early-Onset Scoliosis Secondary to Cerebral Palsy.

Purpose Patients who have neuromuscular scoliosis, such as cerebral palsy (CP), often develop spinal deformities that negatively impact quality of life. The vertical expandable prosthetic titanium rib (VEPTR) was designed for thoracic insufficiency syndrome (TIS), but it has also been utilized in patients with CP with restrictive lung disease and spine deformity. Few studies report on VEPTRs in neuromuscular scoliosis; however, none reports on their utilization specifically in patients with CP. Our purpose was to assess if VEPTRs can improve spinal deformity and TIS in these patients. Methods A retrospective chart review was performed of all patients with CP and scoliosis treated with a VEPTR between 2008 and 2017. Eight patients were eligible for this study. The mean follow-up was four years. Outcomes evaluated were Cobb angle, pelvic obliquity, space available for lung ratio (SAL), T1-S1 height, and complication rates. A p-value of less than 0.05 was used for statistical significance. Results There were significant postoperative improvements in Cobb angle, pelvic obliquity, and T1-S1 height, but no statistical difference in SAL. Prior to final fusion, the mean number of VEPTR lengthening procedures was 3. The mean time from index surgery to final fusion was 3.7 years. The most common complications were infection (62.5%) and wound dehiscence (25%). Only 25% of patients did not have a complication. Conclusion VEPTRs demonstrated significant improvement in almost all parameters and may be valuable in improving TIS in patients with CP. The complication and reoperation rates were similar to those of VEPTRs used for other pathological conditions.

The value-added benefit of utilizing two attending surgeons for patients with scoliosis secondary to cerebral palsy.

PURPOSE: The use of two attending surgeons during posterior spinal fusion (PSF) for cerebral palsy (CP) patients has been shown to improve perioperative outcomes. This study aims to determine if the use of two surgeons is associated with an increase in the number of subsequent surgeries that can be performed in the same operating room (OR) during business hours. METHODS: Patients with scoliosis and CP treated with PSF with minimum 90-day follow-up were included. Patients were grouped based on whether one or two attending surgeons performed the case. The primary outcome was the number of surgeries that followed in the same OR before 5 PM. Secondary outcomes included operative time, estimated blood loss (EBL), length of stay, rate of surgical site infection, and rate of unplanned return to the operating room. RESULTS: Thirty-six patients were included (10 with 1 surgeon and 26 with 2 surgeons). The two surgeon group had a significant increase in the average number of surgeries subsequently performed in the same OR during business hours (1.1 vs. 0.3, p = 0.01), as well as shorter mean operative time (159 vs. 307 min, p = 0.007) and EBL (554 vs. 840 cc, p = 0.01; 26 vs. 39%EBV, p = 0.03). CONCLUSION: The use of two attending surgeons was associated with a significant increase in the number of cases subsequently performed in the same OR during business hours, and significant decreases in operative time and EBL. Hospitals should consider the patient care and potential system-level improvements when considering implementation of two surgeon teams for PSF in CP patients. LEVEL OF EVIDENCE: Therapeutic Level III.

Screw Versus Hybrid Constructs for Flexible Thoracic Curves in Adolescent Idiopathic Scoliosis: A Prospective, Randomized Study.

STUDY DESIGN: Prospective, computer-randomized design. OBJECTIVE: Compare screw and hybrid constructs in flexible, thoracic curves for adolescent idiopathic scoliosis (AIS) in a prospective randomized fashion. SUMMARY OF BACKGROUND: The consensus in scientific literature is that all-screw constructs correct AIS better than hooks in the lumbar and in large, stiff thoracic curves. However, debate continues whether all-screw constructs outperform hybrid constructs in small, flexible thoracic AIS. To our knowledge, this is the first prospective, randomized scoliosis study that examines measures of correction and patient satisfaction with the Scoliosis Research Society-30 (SRS-30) questionnaire. METHODS: A total of 45 enrolled AIS patients with flexible, thoracic curves were given an identification number with an associated computer-generated randomization to the hybrid (n = 22) or screw group (n = 23). The treating surgeon received the randomization 2-3 days before surgery. Data including major Cobb (MC), truncal rotation (TR), rib index (RI), secondary curve (SC), and SRS-30 questionnaire were collected preoperatively and postoperatively at 4 weeks and 3, 6, 12, and 24 months. RESULTS: Thirty-seven patients in the hybrid (n = 18) and screw (n = 19) groups completed the study with a mean follow-up of 26 months (range, 24-49 months). Hybrid versus screw group means for preoperative, postoperative, and final follow-up were: MC 58° ± 8° versus 55° ± 6°, 18° ± 8° versus 15° ± 7°, and 23°± 8° versus 14° ± 6°; TR 14° ± 6° versus 16° ± 4°, 10° ± 5° versus 7° ± 3°, and 11° ± 5° versus 7° ± 4°; RI 3.0° ± 1.2° versus 3.4° ± 1.4°, 2.5° ± 0.7° versus 1.8° ± 0.6°, and 2.5° ± 0.8° versus 2.0° ± 0.5°; SC 35° ± 13° versus 31° ± 8°, 13° ± 11° versus 7° ± 9°, and 13° ± 12° versus 7° ± 7°; and SRS-30 3.9 ± 0.2 versus 3.9 ± 0.2, 4.1 ± 0.4 versus 4.0 ± 0.3, and 4.1 ± 0.3 versus 4.0 ± 0.2. CONCLUSIONS: Intergroup preoperative and early postoperative values were comparable (p > .05). At final follow-up, owing to loss of correction in the hybrid group, differences in MC (9°; p = .000), RI (0.54; p = .016), and TR (4°; p = .039) correction were statistically significant as SC trended toward significance (6°; p = .052). All-screw constructs outperformed hybrid constructs, especially over time. No differences in SRS-30 scores occurred between groups.

Outcomes after salvage procedures for the painful dislocated hip in cerebral palsy.

BACKGROUND: The painful dislocated hip in the setting of cerebral palsy is a challenging problem. Many surgical procedures have been reported to treat this condition with varying success rates. The purpose of this study is to retrospectively evaluate and compare the outcomes of 3 different surgical procedures performed at our institution for pain relief in patients with spastic quadriplegic cerebral palsy and painful dislocated hips. METHODS: A retrospective chart review of the surgical procedures performed by 5 surgeons for spastic, painful dislocated hips from 1997 to 2010 was performed. The procedures identified were (1) proximal femoral resection arthroplasty (PFRA); (2) subtrochanteric valgus osteotomy (SVO) with femoral head resection; and (3) proximal femur prosthetic interposition arthroplasty (PFIA) using a humeral prosthesis. Outcomes based on pain and range of motion were determined to be excellent, good, fair, or poor by predetermined criteria. RESULTS: Forty-four index surgeries and 14 revision surgeries in 33 patients with an average follow-up of 49 months met the inclusion criteria. Of the index surgeries, 12 hips were treated with a PFRA, 21 with a SVO, and 11 with a PFIA. An excellent or good result was noted in 67% of PFRAs, 67% of SVOs, and 73% of PFIAs. No statistical significance between these procedures was achieved. The 14 revisions were performed because of a poor result from previous surgery, demonstrating a 24% reoperation rate overall. No patients classified as having a fair result underwent revision surgery. All patients receiving revision surgery were eventually classified as having an excellent or good result. CONCLUSIONS: Surgical treatment for the painful, dislocated hip in the setting of spastic quadriplegic cerebral palsy remains unsettled. There continue to be a large percentage of failures despite the variety of surgical techniques designed to treat this problem. These failures can be managed, however, and eventually resulted in a good outcome. We demonstrated a trend toward better outcomes with a PFIA, but further study should be conducted to prove statistical significance. LEVEL OF EVIDENCE: III.

Arthrogram-assisted fixation of slipped capital femoral epiphysis: a CT and radiographic study.

BACKGROUND: Intraoperative fluoroscopy does not always provide the operating surgeon with optimal visualization of a slipped capital femoral epiphysis (SCFE). Arthrography can be used to enhance fluoroscopic images of these patients. This study retrospectively compared the screw placement between patients who received conventional versus arthrographic-assisted in situ screw fixation for SCFE. METHODS: We reviewed the charts and radiographs of all patients diagnosed with a SCFE at our institution from 2005 to 2010. We isolated those who received postoperative computed tomography (CT) scans to confirm screw placement, and subdivided the patients into 2 groups: those who received arthrograms to facilitate screw placement and those who did not. The screw-tip-to-articular-surface distance was then measured on intraoperative fluoroscopic images and postoperative CT scans. RESULTS: Seventy-eight patients met inclusion criteria and 24 received an intraoperative arthrogram. Screw placement determined by intraoperative fluoroscopic images did not differ between the 2 groups. When measured on postoperative CT scans the screw-tip-to-articular-surface distance was significantly smaller in the arthrogram-assisted cohort (2.8 vs. 5.2 mm), and the difference between intraoperative and postoperative measurements was significantly greater in the arthrogram-assisted cohort (4.9 vs. 1.6 mm). No cases of intra-articular screw placement were found in either cohort, nor were there any cases demonstrating loss of fixation. CONCLUSIONS: Arthrogram-assisted fixation of SCFE is a safe and effective tool in patients whose body habitus makes diagnostic fluoroscopic images difficult to obtain. It is, however, not without technical challenges. After the dye is injected it becomes more difficult to visualize the subchondral bone on fluoroscopic images. Our screws were, on average, 4.9 mm closer to the joint space on CT scans than seen intraoperatively. The operating surgeon must be aware of this fact to avoid joint penetration. LEVEL OF EVIDENCE: Level III.

Radius crossover sign: an indication of malreduced radius shaft greenstick fractures.

BACKGROUND: Radius shaft greenstick fractures in children can be a challenging injury to treat because angulation and rotational alignment are difficult to assess. METHODS: In this report, we describe a simple method for analyzing the deformity and identifying rotational and angular malalignment. This technique involves analyzing the forearm radiographs as 2 segments, proximal and distal, and assuring that the rotational position of each matches the other. RESULTS: We present 3 cases of proximal radius greenstick fractures in malalignment to demonstrate the radius crossover sign. CONCLUSIONS: Identifying the radius crossover sign, and proceeding with further closed reduction may prevent deformity that could otherwise result in a significant loss of forearm motion. LEVEL OF EVIDENCE: Level V.

The properties of damaged and undamaged suture used in metal and bioabsorbable anchors: an in vitro study.

PURPOSE: The purpose of this study was to determine the mechanical properties of undamaged and damaged sutures in metal and bioabsorbable suture anchors. METHODS: Undamaged and damaged FiberWire (Arthrex, Naples, FL), Tevdek (Deknatel, Mansfield, MA), and PDS (Ethicon, Somerville, NJ) sutures were tested by a single pull to failure while being pulled parallel to the axis of either a metal or bioabsorbable suture anchor. Sutures were damaged by use of a razor blade incorporated into a custom-designed jig. The friction of the sutures through the anchor eyelets was also tested. RESULTS: For both anchor types, FiberWire was the strongest suture studied. Undamaged PDS had a significantly greater load to failure than Tevdek. Although all sutures lost significant strength when damaged, PDS lost the most, with damaged PDS becoming significantly weaker than damaged Tevdek. Damaged FiberWire was significantly stronger in metal anchors compared with bioabsorbable anchors, with failure of the bioabsorbable suture eyelet preventing testing of undamaged FiberWire. Neither undamaged nor damaged PDS or Tevdek had a significant difference in strength between metal and bioabsorbable anchors. However, in metal anchors the mechanical properties of undamaged Tevdek were inferior to those of the other undamaged sutures tested. For undamaged or damaged sutures through either anchor type, PDS suture had the highest coefficient of friction, significantly higher than FiberWire and Tevdek. All sutures, undamaged or damaged, had significantly less friction in bioabsorbable anchors compared with metal anchors. CONCLUSIONS: The FiberWire-anchor construct is significantly weaker when bioabsorbable anchors are used instead of metal anchors. For Tevdek and PDS sutures, the anchor type does not affect the strength of the construct, as the suture is the limiting factor. When used with suture anchors, PDS has the most friction of the sutures tested, potentially leading to suture damage, which disproportionately weakens PDS compared with the other sutures tested. For both undamaged and damaged sutures, bioabsorbable anchors lead to less friction than do metal anchors, which may lessen suture damage in vivo. CLINICAL RELEVANCE: The mechanical properties of damaged suture are important to all surgeons who use suture arthroscopically.

Strength of damaged suture: an in vitro study.

PURPOSE: To determine the mechanical properties of damaged suture. METHODS: Undamaged and damaged sutures were tested by a single pull to failure. Sutures were damaged with a razor blade incorporated into a custom-designed jig. Sutures were tested to failure by straight pull and by pulling at 180 degrees through a suture anchor eyelet. The friction of sutures through anchors was also tested. RESULTS: For the straight line pull test, undamaged FiberWire (Arthrex, Naples, FL) had the highest load to failure (LTF) and ultimate tensile strength (UTS) of all sutures tested. Undamaged Orthocord (Mitek, Somerville, NJ) ranked second in both properties. Uncut polydioxanone (PDS) suture (Ethicon, Somerville, NJ) had a higher LTF and a comparable UTS with respect to Tevdek (Deknatel, Mansfield, MA) and Ethibond (Ethicon). For cut sutures, FiberWire and Orthocord had a significantly higher LTF and UTS than the other sutures tested. Suture stiffness was not significantly affected when the suture was cut. For the suture anchor test, FiberWire and Orthocord had the highest LTF, whether undamaged or damaged. When cut, PDS had the greatest loss of LTF and UTS during both tests. CONCLUSIONS: The newer polyethylene core sutures (FiberWire and Orthocord) have superior mechanical properties compared with other sutures. Their superior properties are maintained even when cut. Although uncut PDS had equivalent or superior strength compared with Ethibond and Tevdek, once cut, PDS suture was weakened significantly more compared with all other sutures tested. CLINICAL RELEVANCE: The mechanical properties of damaged suture are important to all surgeons who use suture arthroscopically.