The fate of the malrotated elbow supracondylar fractures in children: is varus really a problem?

PURPOSE: To evaluate the functional and cosmetic effects of elbow supracondylar fractures (SCF) in children with residual rotational deformity. METHODS: Retrospective review cohort of patients with evidence of malrotation after treatment for SCF. An analysis of the postoperative X-ray of 305 consecutive SCF type 3 treated surgically during five years identified 46 elbows with rotational deformity that fulfilled the selection criteria and were recalled for review; only 27 patients agreed to participate. Patients were evaluated clinically and radiographically. Clinically, the elbow and shoulder ROM were assessed. The postoperative fracture rotation (PFR) was radiologically measured using the Berdis method. Results were categorized according to Flynn criteria, and functional outcomes were evaluated with the QuickDASH questionnaire. On final assessment, a radiograph of both elbows was obtained, and measures were compared. Descriptive analysis was made calculating median, range, proportions, and confidence intervals. Non-parametric tests were used to test the association between variables. RESULTS: The group had a median age of four years and a median follow-up of 52 months. Shoulder rotation was asymmetrical in 13 patients; six patients presented a change on carrying angle > 5° (4 varus/2 valgus). The higher the residual rotation, the higher the chances of an altered shoulder rotation (for each degree of PFR, the shoulder rotation was changed to 0.4°). However, there was a low correlation between the amount of rotation and the final carrying angle (r = 0.37). According to Flynn's criteria, over 95% had excellent or good results. CONCLUSION: There was a weak correlation between varus and rotational malalignment. Patients with moderate residual malrotation could be expected to have a good outcome even if some shoulder rotation changes persist.

Elevated blood metal ion levels in patients undergoing instrumented spinal surgery: a systematic review and meta-analysis.

BACKGROUND CONTEXT: Elevated blood metal levels have been reported in patients after spinal surgery using metallic implants. Although some studies have suggested an association between heightened blood metal concentrations and potential adverse effects, estimates of the incidence of abnormal metal levels after spinal surgery have been inconsistent. PURPOSE: The aims of this systematic review and meta-analysis were to assess: (1) mean differences in blood metal ion levels between patients undergoing spinal fusion surgery and healthy controls, (2) odds of elevated blood metal ion levels after surgery compared to pre-surgery levels, and (3) pooled incidence of elevated blood metal ions overall and by metal type. STUDY DESIGN: Systematic review and meta-analysis. PATIENTS SAMPLE: The patient sample included 613 patients from 11 studies who underwent spinal surgery instrumentation. OUTCOME MEASURES: Blood metal ion concentrations and the incidence of patients with elevated metal levels compared with in those the control group. METHODS: A comprehensive search was conducted in PubMed, EMBASE, Scopus, and Cochrane Library to identify studies reporting blood metal ion levels after spinal fusion surgery. Mean differences (MD), odds ratios (OR), and incidence rates were pooled using random effects models. Heterogeneity was assessed using I2 statistics, and fixed-effects models were used if no heterogeneity was detected. Detailed statistical analysis was performed using the Review Manager version 5.4 software. RESULTS: The analysis included 11 studies, with a total of 613 patients. Mean blood metal ion levels were significantly higher after spinal fusion surgery (MD 0.56, 95% CI 0.17-0.96; I2=86%). Specifically, titanium levels were significantly elevated (MD 0.81, 95% CI 0.32-1.30; I2=47%). The odds of elevated blood metal ions were higher after surgery (OR 8.17, 95% CI 3.38-19.72; I2=41%), primarily driven by chromium (OR 23.50, 95% CI 5.56-99.31; I2=30%). The incidence of elevated chromium levels was found to be 66.98% (95% CI 42.31-91.65). CONCLUSION: In conclusion, blood metal ion levels, particularly titanium and chromium, were significantly increased after spinal fusion surgery compared to pre-surgery levels and healthy controls. Approximately 70% of the patients exhibited elevated blood levels of chromium and titanium.

Incidence and risk factors of distal adjacent disc degeneration in adolescent idiopathic scoliosis patients undergoing fusion surgery: a systematic review and meta-analysis.

PURPOSE: The objective of this meta-analysis was to determine the incidence of disc degeneration in patients with surgically treated adolescent idiopathic scoliosis (AIS) and identify the associated risk factors. METHODS: PubMed, EMBASE, Scopus, and Cochrane Collaboration Library databases were searched. The outcomes of interest were the incidence of disc degeneration, SRS-22, and radiological risk factors. The lower instrumented vertebra (LIV) was also evaluated. Fixed effects were used if there was no evidence of heterogeneity. Statistical analysis was performed using Review Manager. RESULTS: A meta-analysis was conducted including nine studies with a total of 565 patients. The analysis revealed that the global incidence of intervertebral disc degeneration in patients with surgically treated AIS patients was 24.78% (95% CI 16.59-32.98%) 10 years after surgery, which significantly increased to 32.32% (95% CI 21.16-43.47% at an average of 13.8 years after surgery. Among patients with significant degenerative disc changes, the SRS-22 functional, self-image, and satisfaction domains showed significantly worse results (MD - 0.25, 95% CI - 0.44 to - 0.05; MD - 0.50, 95% CI - 0.75 to - 0.25; and MD - 0.34, 95% CI - 0.66 to - 0.03, respectively). Furthermore, instrumentation at or above the L3 level was associated with a lower incidence of intervertebral disc degeneration compared to instrumentation below the L3 level (OR 0.25, 95% CI 0.10-0.64). It was also found that the preoperative and final follow-up lumbar curve magnitudes (MD 8.11, 95% CI 3.82-12.41) as well as preoperative and final follow-up lumbar lordosis (MD 0.42, 95% CI - 3.81 to 4.65) were associated with adjacent disc degeneration. CONCLUSIONS: This meta-analysis demonstrated that the incidence of intervertebral disc degeneration significantly increased with long-term follow-up using fusion techniques, reaching up to 32% when patients were 28 years of age. Incomplete correction of deformity and fusion of levels below L3, were identified as negative prognostic factors. Furthermore, patients with disc degeneration showed worse functional outcomes.

Reply to Lemans et al. Comment on "Burgos et al. Fusionless All-Pedicle Screws for Posterior Deformity Correction in AIS Immature Patients Permit the Restoration of Normal Vertebral Morphology and Removal of the Instrumentation Once Bone Maturity Is Reached. J. Clin. Med. 2023, 12, 2408".

We thank Dr. Lemans and coworkers for their interest and knowledgeable comments [...].

Fusionless All-Pedicle Screws for Posterior Deformity Correction in AIS Immature Patients Permit the Restoration of Normal Vertebral Morphology and Removal of the Instrumentation Once Bone Maturity Is Reached.

The aim of this study was to report the restoration of normal vertebral morphology and the absence of curve progression after the removal of instrumentation in AIS patients that underwent posterior correction of the deformity by a common all-screws construct without fusion. A series of 36 AIS immature patients (Risser 3 or less) were included in the study. Instrumentation was removed once the maturity stage was complete (Risser 5). The curve correction was assessed pre- and postoperatively, before instrumentation removal, directly post-removal, and more than two years after instrumentation was removed. Epiphyseal vertebral growth modulation was assessed by the coronal wedging ratio (WR) at the apical level of the main curve (MC). The mean preoperative coronal Cobb was corrected from 53.7° ± 7.5 to 5.5° ± 7.5° (89.7%) at the immediate postop. After implant removal (31.0 ± 5.8 months), the MC was 13.1°. T5-T12 kyphosis showed significant improvement from 19.0° before curve correction to 27.1° after implant removal (p < 0.05). Before surgery, the WR was 0.71 ± 0.06, and after removal, 0.98 ± 0.08 (p < 0.001). At the end of the follow-up, the mean sagittal range of motion (ROM) of the T12-S1 segment was 51.2 ± 21.0°. The SRS-22 scores improved from 3.31 ± 0.25 preoperatively to 3.68 ± 0.25 at the final assessment (p < 0.001). In conclusion, a fusionless posterior approach using common all-pedicle screws correctly constructed satisfactory scoliotic main curves and permitted the removal of instrumentation once bone maturity was reached. The final correction was highly satisfactory, and an acceptable ROM of the previously lower instrumented segments was observed.

Maximizing length with precice nail: a novel technique.

Intramedullary magnetic lengthening nails represents a marked advance in the process of limb lengthening, reducing the complications associated with other methods, and improving patient's comfort. However, one important limitation is its lengthening ability, especially when it comes to short bones. Previous reports have shown techniques that may allow further lengthening but at a cost of having to carry out repeated procedures, requiring the use of other devices, and submitting the patient to long-winded surgical procedures. This report presents a novel technique to achieve lengthening beyond the initial reach of the nail, in a simple and quick procedure, without the need of implanting any additional devices.

Diagnosis and staging of malignant bone tumours in children: what is due and what is new?

PURPOSE: Although malignant bone tumours in children are infrequent, it is important to know how to properly diagnose and stage them, in order to establish an adequate treatment. METHODS: We present a review of the diagnostic workflow of malignant bone tumours in children, including history and clinical examination, imaging, laboratory tests and biopsy techniques. Moreover, the two most commonly used staging systems are reviewed. RESULTS: History, clinical examination and laboratory tests are nonspecific for diagnosing malignant bone tumours in children. Radiographs remain the mainstay for initial diagnosis, with MRI the modality of choice for local assessment and staging. Fluorine-18 labelled fluoro-deoxy-glucose-positron emission tomography scans provide a noninvasive method to assess the aggressiveness of the tumour and to rule out metastasis and is replacing the use of the bone scintigraphy. Biopsy must be always performed under the direction of the surgeon who is to perform the surgical treatment and after all diagnostic evaluation has been done. Staging systems are useful to study the extent of the tumour and its prognosis. They are expected to evolve as we better understand new molecular and genetic findings. CONCLUSION: When a malignant bone tumour is suspected in a child, it is essential to make a correct diagnosis and referral to an experienced centre. Following an appropriate workflow for diagnosis and staging facilitates, prompt access to treatment improves outcomes. LEVEL OF EVIDENCE: Level V Expert opinion.

How to manage pes cavus in children and adolescents?

Pes cavus in its different forms is not a pathological entity, but rather the manifestation of multiple diseases.Cavovarus, a form of cavus foot, should never be considered a physiological deformity. A neurological condition should always be excluded.The evolution of pes cavovarus is unpredictable because of the large number of conditions involved in its aetiology, as well as their variable degree of expression. About 66% of cavovarus feet are the result of subtle neurological diseases, which only become evident later in life.Although surgery may not change quality of life, recent studies suggest that it may improve foot posture and reduce walking instability.The aim of treatment is to preserve a painless, plantigrade, mobile foot. Management consists of correcting bone deformity while preserving movement, and the wise use of rebalancing techniques. Arthrodesis should only be a salvage procedure. Cite this article: EFORT Open Rev 2021;6:510-517. DOI: 10.1302/2058-5241.6.210021.

Intra-articular Radial Head Fractures: A Deceptive Type of Injury.

BACKGROUND: Isolated intra-articular radial head (IARH) fractures in skeletally immature patients represent a rare injury. Despite their initial benign radiologic appearance, these fractures are at risk for progressive radial head subluxation and may end with degenerative irreversible changes of the radiocapitellar joint. The aim of this study is to highlight the seriousness of these injuries and the importance of early diagnosis and a proper follow-up to achieve optimal outcomes. METHODS: We retrospectively reviewed 6 patients with IARH fractures treated at our institution between 2011 and 2016. All patients presented with Salter-Harris types III or IV fracture. Five of 6 fractures were initially undisplaced. Treatment, clinical, and radiographic results were analyzed. Patients were divided into 2 groups according to treatment: patients included in group A were treated conservatively, whereas patients of group B were treated with early surgery. The final functional outcome was assessed using the Oxford Elbow Score (OES). The Broberg-Morrey classification was used for the radiographic results. RESULTS: Group A included 3 patients (average age, 11±2 y). They developed an initially missed posterior subluxation of the radiocapitellar joint that caused to all of them a painful elbow and limited range of motion (ROM). Despite rescue surgery, they all presented with limited ROM at the final follow-up, although no functional limitations (OES, 46.3±2.9). The radiographs showed early degenerative changes. Group B included 3 patients (average age, 11±1 y) all treated surgically within 1 week from the injury. They showed no limitation of ROM and good functional (OES, 47.7) and radiologic outcomes. CONCLUSIONS: IARH fractures in skeletally immature children are deceptive injuries which are often underestimated. Surgeons should be aware of these fractures, especially when a discrepancy between the clinical signs and symptoms, and the radiologic appearance exists, as this may be the only red flag that allows their identification in the acute setting. An early and accurate diagnosis followed by prompt and more aggressive treatment when necessary is mandatory for successful results. LEVEL OF EVIDENCE: Level IV-case series.

Innovative treatment for pes cavovarus: a pilot study of 13 children.

Background and purpose - Pes cavovarus (PCV) is a complex deformity, frequently related to neurological conditions and associated with foot pain, callosities, and walking instability. The deformity has the tendency to increase during growth. Orthotic treatment is ineffective and surgery may be troublesome. We present the preliminary results of a new mini-invasive surgical technique for correction of this foot deformity. Patients and methods - We operated on 13 children (24 feet), age 7-13 years. In 7 children the deformity was neurological in origin. The surgical technique included a dorsal hemiepiphysiodesis of the 1st metatarsal, and a plantar fascia release. The clinical deformity, hindfoot flexibility, and foot callosities, together with a radiological assessment (Meary angle, calcaneal pitch, and talo-calcaneal angle), was done pre- and postoperatively. At final check-up, after a median of 28 months (12-40), the Oxford Ankle Foot Questionnaire for children (OXAFQ-C) was used to assess patient satisfaction. The primary outcome was the hindfoot varus correction. Results - All the operated feet improved clinically and radiologically. Heel varus improved from a mean 6° preoperatively to 5° valgus postoperatively. In those children where treatment was initiated at a younger age, full correction was achieved. Footwear always improved. Interpretation - This treatment may offer a less aggressive alternative in the treatment of PCV in young children and may eventually reduce the amount of surgery needed in the future.

Calcifying aponeurotic fibroma in children: our experience and a literature review.

Calcified aponeurotic fibroma is a rare benign fibrous tumour with characteristic histopathological features commonly observed in children and adolescents. It usually involves the most distal part of the extremities. Despite being a benign tumour, it has a high risk of local recurrence. We report our experience treating four children with calcifying aponeurotic fibroma who underwent surgical excision of the tumour. Two of them developed a local recurrence: one required a surgical revision, whereas the other currently continues to be under observation. The incidence found over a 5-year period (2010-2015) may lead us to consider that this condition is not as rare as reported and may often be misdiagnosed.

Retrograde Percutaneous Drilling for Osteochondritis Dissecans of the Head of the Talus: Case Report and Review of the Literature.

Osteochondral lesions of the talus might be a more common cause of pain than previously recognized, especially among those involved in athletic activities. However, the location of an osteochondral lesion on the talar head is much less common than such lesions localized to the dome of the talus and can pose diagnostic difficulties. We present the case of a 14-year-old soccer player who complained of longstanding pain in his left foot. After unsuccessful conservative treatment consisting of rest and bracing, he was ultimately treated with retrograde percutaneous drilling of the talar head performed by a medial approach. This was followed by casting and non-weightbearing for 6 weeks, after which physical therapy was undertaken. He was able to return to full activity and remained asymptomatic during a 5-year observation period. Although rare, osteochondritis dissecans of the talar head should be considered in young athletes with persistent foot pain that is unresponsive to reasonable therapy.

Histological differences between various methods of hemiepiphysiodesis: is guided growth really different?

Traditional systems of hemiepiphysiodesis are based on the application of asymmetrical compression to the physis to correct angular deformities. The guided growth method claims to act as a tension plate avoiding compression. The aim of this study was to confirm or refute this claim. Twenty-four White New Zealand rabbits were subjected to a proximal tibial hemiepiphysiodesis using either staples or a plate and two-screws method. Both methods succeeded in producing deformity. The initial existent histological differences between systems became less apparent after 6 weeks of hemiepiphysiodesis, when histological results were very similar. The findings suggest that the eight-plate system produces, like staples, compression of the physis, but the forces are applied more gradually.

Resultado a largo plazo de las fusiones largas espinopelvicas en escoliosis: importancia de la edad, la capacidad de marcha y el tipo de fijación ilíaca / Resultado a longo prazo das grandes artrodeses espinopélvicas em escoliose: importância da idade, da capacidade de marcha e do tipo de fixação ilíaca / Long-term result of major spinopelvic arthrodeses in scoliosis: importance of age, walking ability and type of iliac fixation

OBJETIVO: Conocer los factores que influyen en los fracasos instrumentales lumbosacros después de fusiones espinopélvicas largas. MÉTODO: Estudio retrospectivo de pacientes diagnosticados con escoliosis, tratados quirúrgicamente por vía posterior, realizándo se fusión espinopélvica de T2 o T3 a ilíaco, utilizando tornillos pediculares e ilíacos. Se analizaron los fracasos instrumentales y su asociación con diferentes parámetros clínicos y radiológicos. RESULTADOS: Se presentan 44 pacientes con edad promedio de 24 años, con diferentes etiologías. El valor promedio preoperatorio de la curva mayor era de 74,2º, y en la revisión final la corrección promedio fue 67%. El desequilibrio anteroposterior y la inclinación pélvica, la cifosis torácica, la lordosis lumbar y el desequilibrio lateral mejoraron significativamente en la revisión final. Hubo 41% de fracasos de instrumentación, todos a nivel lumbosacro. Se encontró asociación significativa con más fracasos instrumentales en mayores de 17 años y en los que tenían deambulación autónoma. En 24 pacientes, se utilizó un solo tornillo ilíaco bilateralmente y en 20 pacientes, dos o más. Los dos grupos tuvieron una incidencia similar de fracasos. En el grupo de dos o más tornillos solo existieron roturas de barras sin desanclajes, ni lisis. El uso de implantes intersomáticos de L3 a S1 o cerclajes sublaminares con una tercera barra disminuyó la incidencia de fracasos. CONCLUSIONES: En esta serie se presentaron un 41% de fracasos instrumentales, todos localizados a nivel lumbosacro. Los pacientes con capacidad de deambulación autónoma y mayores de 17 años presentaron significativamente más fallas instrumentales. En los que se realizó fusión intersomática L3-S1 o una tercera barra con cerclajes sublaminares, disminuyó la incidencia.

OBJETIVO: Compreender os fatores que influenciam as falhas instrumentais lombossacrais depois de fusões espinopélvicas grandes. MÉTODOS: Estudo retrospectivo de pacientes com diagnóstico de escoliose, tratados cirurgicamente com fusão espinopélvica por via posterior, realizada de T2 ou T3 até o ilíaco, com parafusos pediculares e ilíacos. As falhas instrumentais foram analisadas, além de sua associação com diferentes parâmetros clínicos e radiológicos. RESULTADOS: Apresentamos 44 pacientes com média de idade de 24 anos, com diferentes etiologias. O valor médio da curva pré-operatória maior foi 74,2 graus, e na revisão final foi de 67%. O desequilíbrio anteroposterior e a inclinação pélvica, a cifose torácica, a lordose lombar e o desequilíbrio lateral melhoraram significantemente na revisão final. Houve falhas de instrumentação de 41%, todas na região lombossacral. Verificou-se associação significante com mais falhas instrumentais em pacientes com mais de 17 anos e nos que tinham deambulação independente. Em 24 pacientes, utilizou-se um único parafuso ilíaco bilateral e em 20 pacientes, foram usados dois ou mais. Os dois grupos tiveram incidência de falhas semelhante. No grupo de dois ou mais parafusos ocorreram apenas quebra de hastes, sem perda da ancoragem ou lise. Os implantes intersomáticos de L3 a S1 ou amarrias sublaminares com uma terceira haste diminuíram a incidência de fracassos. CONCLUSÕES: Nesta série ocorreram 41% de falhas instrumentais, todas localizadas na região lombossacral. Os pacientes com capacidade de marcha independente e com mais de 17 anos tiveram significantemente mais falhas instrumentais. Nos pacientes submetidos à fusão intersomática de L3-S1 ou com uma terceira haste com amarrias sublaminares, a incidência foi reduzida.

OBJECTIVE: To determine the factors that influence lumbosacral instrumentation failures following spino-pelvic fusions. METHODS: A retrospective study of patients diagnosed with scoliosis who underwent spinopelvic fusion via posterior, from T2 or T3 proximally to iliac crest, using pedicle and iliac screws. Instrumentation failures were analyzed, and the association of this complication with different parameters was studied. RESULTS: We present 44 patients, with an average age of 24 years, with different etiologies. The mean value of the largest preoperative major curve was 74.2°, and in the final review, it was 67%. The anterior-posterior imbalance, pelvic tilt, thoracic kyphosis, lumbar lordosis and lateral imbalance were significantly improved in the final review. There were instrumentation failures in 41% cases, all at the lumbosacral level. A significant association was found between increased instrumentation failures in patients over 17 years and in patients with independent walking ability. In 24 patients, a bilateral single iliac screw was used and in 20 patients, two or more screws were used. Both groups had a similar incidence of failures. In the group with two or more screws, only rod breakages occurred, without detachment or screw lysis. There was lower instrumentation failure incidence in the patients who underwent L3-S1 interbody fusion or a third rod attached with sublaminar compression hooks. CONCLUSIONS: This series had 41% instrumentation failures, all located at lumbosacral level. There were significant more instrumentation failures in patients with independent walking ability and those aged over 17 years. There was lower instrumentation failure incidence in the patients who underwent L3-S1 interbody fusion or a third rod attached with sublaminar compression hooks.

Resultados postoperatorios inmediatos y a largo plazo de un abordaje mini-invasivo para la corrección de escoliosis idiopática del adolescente / Resultados pós-operatórios imediatos e a longo prazo de abordagem mini-invasiva para correção de escoliose idiopática do adolescente / Immediate postoperative and long-term results of a minimally invasive approach for the correction of adolescent idiopathic scoliosis

OBJETIVO: Analizar los resultados de una nueva técnica quirúrgica mínimamente invasiva (MIS, por el inglés "minimally invasive surgery") por vía posterior aislada para la corrección quirúrgica de la escoliosis idiopática del adolescente (EIA). MÉTODOS: Se comparan dos grupos de pacientes con EIA tipo 1A de Lenke, similares en cuanto a edad, género, ángulo de Cobb, ápex de la curva, rotación vertebral, cifosis torácica, niveles de fusión, tipo de instrumentación y seguimiento. El Grupo 1 fue tratado con la técnica mínimamente invasiva que describiremos y el Grupo 2, de forma convencional. Se analizaron el tiempo quirúrgico, la pérdida sanguínea intraoperatoria, los requerimientos analgésicos en el postoperatorio inmediato, la estancia hospitalaria, la tasa de mal posición de los tornillos, la pérdida de corrección, la tasa de pseudoartrosis y la movilización de implantes. RESULTADOS: En el Grupo 1 (MIS) la cirugía disminuyó significativamente el sangrado y presentó menor número de casos de tornillos mal posicionados en la concavidad que el grupo tratado de forma convencional; sin embargo la cirugía tuvo mayor duración. Ambos grupos tuvieron requerimientos analgésicos similares y la estancia hospitalaria no presentó diferencias. A largo plazo en ninguno de los dos grupos se encontraron casos de no-unión, pérdidas de corrección, ni movilización de los implantes. CONCLUSIONES: La técnica MIS demostró prolongación del tiempo quirúrgico y menores pérdidas hemáticas, sin disminuir los requerimientos analgésicos ni la estancia hospitalaria. La corrección inicial de la escoliosis por la convexidad disminuyó la incidencia de tornillos mal posicionados en la concavidad, no dio lugar a pérdidas de corrección, movilización de implantes y no-unión.

OBJETIVO: Analisar os resultados de uma nova técnica cirúrgica minimamente invasiva (MIS, de minimally invasive surgery) em abordagem posterior isolada para a correção cirúrgica de escoliose idiopática do adolescente (EIA). MÉTODOS: Foram comparados dois grupos de pacientes com EIA Lenke tipo 1A, semelhantes quanto a idade, sexo, ângulo de Cobb, ápice da curva, rotação vertebral, cifose torácica, níveis de fusão, tipo de instrumentação e acompanhamento. Os pacientes do Grupo 1 foram tratados com a técnica minimamente invasiva que será descrita e o Grupo 2, da maneira convencional. Foi analisado tempo de cirurgia, sangramento intraoperatório, necessidade de analgésicos no pós-operatório imediato, estadia hospitalar, taxa de mau posicionamento do parafuso, perda da correção, taxa de pseudoartrose e mobilidade dos implantes. RESULTADOS: No Grupo 1 (MIS),a cirurgia diminuiu significativamente o sangramento e houve menor incidência de parafusos mau posicionados no orifício do que no grupo de tratamento convencional, porém o tempo de cirurgia foi maior. Ambos os grupos tiveram necessidade de analgésicos semelhante e o tempo de internação não apresentou diferenças. A longo prazo, em nenhum dos dois grupos houve casos de não-união, perdas de correção nem mobilidade dos implantes. CONCLUSÕES: A técnica MIS mostrou tempo operatório prolongado e menos perda de sangue, sem reduzir a necessidade de analgésicos nem o tempo de permanência no hospital. A correção inicial da escoliose pela convexidade diminuiu a incidência de parafusos mau posicionados no orifício, não houve perda de correção, mobilidade dos implantes e não-união.

OBJECTIVE: To analyze the results obtained with a new surgical technique for minimally invasive (MIS) isolated posterior approach to the surgical correction of adolescent idiopathic scoliosis (AIS). METHODS: We compared two similar groups of patients with AIS of Lenke type 1A. The groups were similar in age, sex, Cobb angle, apex of the curve, vertebral rotation, thoracic kyphosis, fusion levels, type of instrumentation and follow-up. Group 1 was treated with a mini-invasive technique and Group 2 by the conventional method. We analyzed surgery time, intraoperative blood loss, analgesic requirements in the period immediately after surgery, hospitalization times, rate of screw malposition, loss of correction, rate of pseudoarthrosis, and implant mobilization. RESULTS: In Group 1 (MIS) the surgery significantly decreased bleeding and there was a lower incidence of malpositioned screws in the recess than in the conventionally-treated group, however the surgery lasted longer. Both groups had similar analgesic requirements, and hospitalization times did not differ significantly. In the long-term, neither group showed any cases of non-union, correction losses, or mobilization of the implants. CONCLUSIONS: The MIS technique demonstrated longer surgery time and less blood loss, but did not reduce the analgesic requirements or hospitalization times. Initial correction of scoliosis by convexity decreased the incidence of malpositioned screws in the concavity. There was no losses resulting in correction, mobilization of the implants, or non-union.

Guided growth: the importance of a single tether. An experimental study.

BACKGROUND: During the last few years, the use of the 8-plate as a technique for hemiepiphysiodesis has gained wide acceptance, as it has been shown that it works in a more physiological way than other methods such as staples or transphyseal screws. It has mechanically been compared with a tension band plate, and for this reason, only a single plate is needed. The following study was undertaken to test the 8-plate against the staples and assess factors that can influence the difference in results. METHODS: A prospective experimental study was designed to compare the ability of 2 hemiepiphysiodesis methods, the 8-plate and the double staple, to produce angular deformity in the rabbit's tibia (group I). The variable studied was the variations in the articular line-diaphysis angle at 6 weeks. As the results showed that the 8-plate produced a bigger deformity, a second group was designed (group II) comparing single against double staple, under the hypothesis that the differences observed in the first group could be related to the number of anchors put across the physis and consequently depend on the volume of physis involved by the staples. RESULTS: In group I, the 8-plate produced a bigger angulation at 6 weeks' time than the 2 staples (a difference of 6.5 degrees, P = 0.03). Similarly, in group II, the single staple produced a greater angulation than the 2 staples (difference 6 degrees, P = 0.08). When both groups were compared, no differences in the angulation produced by the 8-plate and the single staple with respect to the 2 staples were found. CONCLUSIONS: These results suggest that one of the reasons why the 8-plate may act in a more "physiological way" (vs. the traditional 2-staple or 3-staple hemiepiphysiodesis) could be the fact that the growth plate is tethered only at a single point. Therefore, the physis retains a major potential for growth and deformity. CLINICAL RELEVANCE: The 8-plate is superior in producing/correcting angular deformity when compared with the traditionally used staples (2 or more) but not when compared with a single staple.

Screw length in the guided growth method.

BACKGROUND: The appearance of the 8-plate as a method for hemiepiphysiodesis has renewed the interest for the use of this technique. However, many questions remain unanswered about the way of action of the guided growth method. Although screw length has been said to play no role, to our knowledge, no clinical or experimental evidence exists. METHODS: An experimental prospective randomized study with 40 WNZ Rabbits aged 8 weeks was conducted. Four experimental groups were established. Each tibia was randomly allocated to one of the following groups: Staples (group 1), 8-plate either using self-taping screws of 9 mm (group 2), or 5 mm lengths (groups 3) and control (group 4). Radiological assessment of the tibial deformity was done in a weekly fashion, and ALDA (articular line-diaphyseal angle) variations at 6 weeks were used as the control variable. RESULTS: The 8-plate as a whole produced a significant bigger deformity than the staples (10°). No significant differences between the two models of the 8-plate were found along the study (3.7°). CONCLUSIONS: The 8-plate has shown to be more efficient in producing angular deformity than staples. However, the length of the screw has showed no role in the 8-plate function.

Aortic abutment after direct vertebral rotation: plowing of pedicle screws.

STUDY DESIGN: Retrospective case series. OBJECTIVE: To report the occurrence of pedicle screw plow after individual-level direct vertebral rotation (DVR) that resulted in critical screw proximity to the aorta, from three institutions over a four-year period (2004-2008). SUMMARY OF BACKGROUND DATA: Thoracic pedicle screws are generally accepted as safe implants that possess sufficient strength to correct the coronal, sagittal, and now transverse plane deformities associated with scoliosis. Structural failure of the bone resulting in translation of the screw in the transverse plane, defined as plow, can occur with individual-level DVR. METHODS: We performed a retrospective review of all pediatric patients who underwent posterior spinal fusion with pedicle screws for neuromuscular and idiopathic scoliosis and underwent postoperative computed tomographic scan. We identified all patients who required a secondary procedure for implant removal because of malposition of the screw. RESULTS: Six patients with lateral screw direction after a DVR maneuver required screw removal because of proximity to the aorta. All patients had intraoperative confirmation of adequate screw placement before introducing the rod and performing derotation. CONCLUSIONS.: The biologic limitations of vertebrae are approached as we strive to achieve further correction of the spine. Surgeons' experience and methods to assess proper screw placement may give a false sense of adequate final implant position after DVR. Vigilance to ensure proper pedicle screw position can avoid potential iatrogenic catastrophes.