The Reliability of the Modified Fels Knee Skeletal Maturity System.

BACKGROUND: The recently described Modified Fels knee skeletal maturity system (mFels) has proven utility in prediction of ultimate lower extremity length in modern pediatric patients. mFels users evaluate chronological age, sex, and 7 anteroposterior knee radiographic parameters to produce a skeletal age estimate. We developed a free mobile application to minimize the learning curve of mFels radiographic parameter evaluation. We sought to identify the reliability of mFels for new users. METHODS: Five pediatric orthopaedic surgeons, 5 orthopaedic surgery residents, 3 pediatric orthopaedic nurse practitioners, and 5 medical students completely naïve to mFels each evaluated a set of 20 pediatric anteroposterior knee radiographs with the assistance of the (What's the Skeletal Maturity?) mobile application. They were not provided any guidance beyond the instructions and examples embedded in the app. The results of their radiographic evaluations and skeletal age estimates were compared with those of the mFels app developers. RESULTS: Averaging across participant groups, inter-rater reliability for each mFels parameter ranged from 0.73 to 0.91. Inter-rater reliability of skeletal age estimates was 0.98. Regardless of group, steady proficiency was reached by the seventh radiograph measured. CONCLUSIONS: mFels is a reliable means of skeletal maturity evaluation. No special instruction is necessary for first time users at any level to utilize the (What's the Skeletal Maturity?) mobile application, and proficiency in skeletal age estimation is obtained by the seventh radiograph. LEVEL OF EVIDENCE: Level II.

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

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

Safety and efficacy of intrathecal morphine in early onset scoliosis surgery.

Intrathecal morphine (IM) is a popular adjunct for pain management in spinal deformity surgery for idiopathic scoliosis. It has not been studied in patients with early onset scoliosis (EOS). We retrospectively reviewed EOS patients undergoing growth-friendly surgery who received IM or did not receive IM (non-IM). Data from initial insertion and final fusion procedures were studied. IM was not used for lengthening procedures, short procedures (<3 h), patients with significant underlying respiratory issues, paraplegia, unsuccessful access and anesthesiologist discretion. We assessed pediatric ICU (PICU) admission and IM complications (respiratory depression, pruritus and nausea/vomiting), time to first postoperative opiate, and pain scores. There were 97 patients including 97 initial insertions (26 IM and 71 non-IM) and 74 patients with final fusions (17 IM and 57 non-IM). The first dose of opioids following insertion and final fusion occurred at 16.8 ± 3.8 and 16.8 ± 3.1 h postoperatively in the IM group compared to 5.5 ± 2.8 and 8.3 ± 3.2 h in the non-IM group, respectively ( P < 0.001). Postoperative pain scores were lower in the IM groups ( P = 0.001). Two patients with IM developed mild respiratory depression following initial insertion ( P = 0.01) but did not require PICU admission. The rate of respiratory depression was not different between the final fusion groups. There was no difference between pruritus and nausea/vomiting at the final fusion. Preincision IM can provide well-tolerated and effective initial postoperative analgesia in select children with EOS undergoing spinal deformity surgery.

The safety and efficacy of intrathecal morphine in pediatric spinal deformity surgery: a 25-year single-center experience.

PURPOSE: Pre-incision intrathecal morphine (IM) is a popular adjunct in adolescent idiopathic spinal deformity surgery. This study represents our 25-year experience with IM in all diagnostic groups undergoing posterior spinal fusion (PSF) and segmental instrumentation (SI). METHODS: Our prospective Pediatric Orthopaedic Spine Database (1992-2018) identified all patients undergoing PSF and SI. We included patients 21 years of age or less, had a PSF with SSI, and received the recommended IM dose of 9-19 mcg/kg (up to 1 mg) or no IM. We assessed demographics, pain scores, duration of surgery, time to first dose of narcotics, pediatric intensive care unit (PICU) admission, length of hospital stay, and IM complications (respiratory depression, pruritus, nausea/vomiting). RESULTS: There were 984 patients who met inclusion criteria: 760 patients received IM, 224 did not (non-IM). They were divided into 5 diagnostic groups: idiopathic, neuromuscular, syndromic, and congenital scoliosis and kyphosis. The mean first post-operative opioid following IM administration was at 16.1 h in the IM group compared to 8.7 h in the non-IM group (p = < 0.001). The post-operative pain scores in the IM groups were significantly lower (p = < 0.001). Sixteen patients (2%) in the IM group were admitted to the PICU for observation secondary to respiratory depression, none requiring re-intubation. There were no other complications related to IM. CONCLUSION: Pre-incision IM is a safe adjunct for pain management in select children in all diagnostic groups undergoing spinal deformity surgery. There were no serious complications. LEVEL OF EVIDENCE: III.

Surgical site infection prevention protocol for pediatric spinal deformity surgery: does it make a difference?

STUDY DESIGN: Retrospective. OBJECTIVE: Can a standardized, hospital-wide care bundle decrease surgical site infection (SSI) rate in pediatric spinal deformity surgery? SSI is a major concern in pediatric spinal deformity surgery. METHODS: We performed a retrospective review of our primary scoliosis surgeries between 1999 and 2017. In 2008, we implemented a standardized infection reduction bundle. Interventions included preoperative nares screening for methicillin-resistant staphylococcus aureus or methicillin-sensitive Staphylococcus aureus 2 weeks preoperatively, and treatment with intranasal mupirocin when positive, a bath or shower the night before surgery, a preoperative chlorohexidine scrub, timing of standardized antibiotic administration, standardized intraoperative re-dosing of antibiotics, limiting operating room traffic, and standardized postoperative wound care. In 2011, we added intrawound vancomycin powder at wound closure. Our inclusion criteria were patients 21 years of age or less with idiopathic, neuromuscular, syndromic, or congenital scoliosis who had a primary spinal fusion or a same day anterior and posterior spine fusion with segmental spinal instrumentation of six levels or more. We compared the incidence of early (within 90 days of surgery) and late (> 91 days) SSI during the first postoperative year. RESULTS: There were 804 patients who met inclusion criteria: 404 in the non-bundle group (NBG) for cases prior to protocol change and 400 in the bundle group (BG) for cases after the protocol change. Postoperatively, there were 29 infections (7.2% of total cases) in the NBG: 9 early (2.2%) and 20 late (5.0%) while in the BG there were only 10 infection (2.5%): 6 early (1.5%) and 4 late (1.0%). The reduction in overall SSIs was statistically significant (p = 0.01). There was a trend toward decreased early infections in the BG, without reaching statistical significance (p = 0.14). CONCLUSION: Standardized care bundles appear effective in reducing the incidence of postoperative pediatric spine SSIs. LEVEL OF EVIDENCE: Level III.

One stage or two? A cohort analysis of anterior-posterior spinal fusions for severe pediatric scoliosis.

STUDY DESIGN: Retrospective case-series study of prospectively collected data. OBJECTIVE: We sought to identify the differences in outcomes between one-stage (single surgical episode) and two-stage (separate day) anterior and posterior spinal fusion and segmental spinal instrumentation surgeries in severe non-idiopathic and idiopathic scoliosis cases. BACKGROUND: Patients with severe pediatric spine deformity may require combined anterior and posterior fusion procedures. Given their increased complexity and morbidity, surgeons may consider staging these procedures on separate days. METHODS: A retrospective cohort study was performed on a prospective Pediatric Spine Database. Patients 21 years of age or under with pediatric scoliosis who underwent primary anterior and posterior spinal deformity correction surgery either through a one-stage or planned two-stage sequence with greater than 2-year follow-up were included. Differences in demographics, comorbidities, surgical details, perioperative morbidity, complications, and outcomes were assessed based on scoliosis etiology. Multivariate models were utilized to control for confounders. RESULTS: There were 70 non-idiopathic (14 two-stage vs. 56 one-stage) and 65 idiopathic scoliosis (8 two-stage vs. 57 one-stage) patients. Mean follow-up was 90.1 ± 54.7 months. In non-idiopathic scoliosis patients, two-stage surgery was independently associated with a 140-min increased surgical time (95% confidence interval: 52-229 min, p = 0.002) and an 8.2-day (95% confidence interval: 2.3-14.1 days, p = 0.007) increased hospital length of stay. In idiopathic scoliosis patients, two-stage surgery was independently associated with a 2108 ml increase in crystalloid use (95% confidence interval: 834-3381 ml p = 0.002) and a 5.3-day increased hospital length of stay (95% confidence interval: 4.0-6.5 days, p < 0.001). There were no significant differences in blood loss, transfusions, complications, or post-operative curves on multivariate analysis between one-stage and two-stage surgery cohorts in either non-idiopathic or idiopathic scoliosis patient groups. CONCLUSION: Two-stage surgery was associated with increased crystalloid use in idiopathic scoliosis patients and longer operative times in non-idiopathic scoliosis patients, and longer hospital length of stay in both populations, without significant difference in complications or deformity correction. In the appropriate patient, one-stage anterior-posterior scoliosis surgery may be preferable to two-stage surgery. LEVEL OF EVIDENCE: Level III Retrospective Comparative Study.

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

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

Risk Factors for Early Infection in Pediatric Spinal Deformity Surgery: A Multivariate Analysis.

STUDY DESIGN: Retrospective case-control study. OBJECTIVES: To identify risk factors for early deep surgical site infections (SSIs; within three months of index procedure) following pediatric spinal deformity surgery. BACKGROUND: Deep surgical site infections (SSIs) following pediatric spinal deformity surgery are a source of significant morbidity. We sought to identify independent risk factors for early infection following primary, definitive single-stage pediatric posterior spinal fusion and instrumentation (PSFI). METHODS: A total of 616 consecutive patients (2001-2016) from an institutional prospectively maintained Pediatric Orthopaedic Spine database were identified that met inclusion criteria of definitive single-stage PSFI. Early deep SSI was defined as infection within three months of index procedure requiring surgical intervention. A multivariate analysis of demographics, comorbidities, and perioperative factors was performed and independent risk factors were identified. RESULTS: Eleven patients (1.6%) developed an early deep SSI. Independent risk factors for SSI identified were nonidiopathic (neuromuscular, syndromic, and congenital) etiologies of scoliosis (adjusted odds ratio [aOR]: 8.384, 95% confidence interval [CI]: 1.784-39.386, p = .007) and amount of intraoperative crystalloids (aOR: 1.547 per additional liter of fluid, 95% CI: 1.057-2.263, p = .025). Mean crystalloid administered in the SSI group was 3.3 ± 1.2 L versus 2.4 ± 1.0 L in the noninfected group (p = .019). On univariate analysis, there was no significant difference in weight of patients between cohorts (p = .869) or surgery time (p = .089). There was also no significant difference in infection rates from redosing of antibiotics intraoperatively after 3 hours of surgery (p = .231). CONCLUSIONS: Nonidiopathic scoliosis and amount of intraoperative crystalloids were independently associated with early postoperative SSI. Further investigation into intraoperative fluid management may identify modifiable risk factors for early postoperative SSI in primary pediatric spinal deformity posterior spinal fusion patients. LEVEL OF EVIDENCE: Level III, case-control study.

Incidence of complete spinal instrumentation removal following surgery for spinal deformity: a 22-year single institution study.

The aim of this study was to define the incidence of complete implant removal following surgical correction of spinal deformity in pediatric patients over a 22-year period and identify possible risk factors. A retrospective review of our Pediatric Orthopedic Spine Database between 1992 and 2016 was performed. We included patients undergoing complete implant removal following scoliosis correction surgery with a minimum of 2-year follow-up. Medical charts were reviewed to determine initial patient diagnosis and the indication for implant removal. Statistical analysis was carried out to determine the associations between sex and factors such as primary diagnosis and indication for removal. A review of 1117 procedures in 1114 patients identified complete instrument removal in 52 (4.7%) patients (34 females and 18 males). Mean time to removal following surgery was 2.3 years (range: 0-5.9 years). Removal occurred in 24 of 548 (4.4%) patients with adolescent idiopathic scoliosis, four of 117 (3.4%) patients with juvenile idiopathic scoliosis, 11 of 287 (3.8%) patients with neuromuscular scoliosis, and three of 79 (3.8%) patients with syndromic scoliosis. Infection was the most common indication for complete implant removal [24 (46%) patients], followed by persistent pain [8 (15%) patients], and metal intolerance [8 (15%) patients]. There were two cases of early infection (<1 year following surgery) and 22 late infections (≥1 year following surgery). The overall 22-year incidence of complete implant removal following spinal correction surgery for scoliosis was 4.7%. Infection continues to be the most common indication, followed by pain and metal intolerance.

Outcomes Following Operative Treatment of Adolescent Mallet Fractures.

BACKGROUND: Many surgeons advocate for surgical intervention of adult mallet fractures that involve either subluxation of the distal interphalangeal (DIP) joint or those that involve more than one-third of the articular surface. However, the efficacy of operative treatment and complication rates are unclear regarding the adolescent population. QUESTIONS/PURPOSES: The goal of this study is to evaluate the clinical outcomes following operative fixation of bony mallet fractures in the adolescent population. METHODS: Seventeen patients with bony mallet fractures treated surgically were retrospectively reviewed. Twelve patients were treated by closed reduction with extension block pinning. The other patients underwent an open reduction and pin fixation. The average age was 15.2 years (13-18). Most injuries were sport related. The average time from injury to presentation was 17 days and from injury to surgery was 24.5 days. Nine patients had subluxation at the DIP joint and all involved at least one-third of the articular surface. RESULTS: The average time from surgery to pin removal was 28 days (19-46). All distal phalanx physis were closed or nearly closed. One patient reported pain at the final follow-up. Two patients (11.8%) had major complications. One had an extension contracture postoperatively, did not attend therapy, and re-fractured 5 months later requiring reoperation. The second was treated delayed (32 days) and lost fixation, requiring revision surgery and antibiotics for a superficial infection. Two patients with delayed treatment (32 and 44 days) had an extensor lag (11.8%). CONCLUSIONS: Operative treatment of mallet fractures with subluxation or involving more than one-third of the articular surface appears effective. Pin removal 4 weeks postoperatively appears adequate. Complications occurred with delayed presentation and non-compliance.

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

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

The frequency of nonaccidental trauma in children under the age of 3 years with femur fractures: is there a better cutoff point for universal workups?

The purpose of this study was to evaluate narrower age groups in children aged 0-4 years to determine whether guidelines should be refined when investigating femur fractures for nonaccidental trauma (NAT). This was a retrospective review of the pediatric trauma database at our level 1 pediatric trauma center. The database was examined from 2009 to present. We examined rates of NAT in the less than or equal to 12-month, 13-24-month, 25-36-month, and 37-48-month age groups. χ was used to compare rates of NAT between these groups, and P less than 0.05 was considered to be significant. Over the indicated time period, there were 138 femur fractures in children aged 0-4 years, of which 30 were determined to be NAT. The rate of NAT in the less than or equal to 12-month age group was 74.1%, accounting for 20 of the 30 NAT femur fractures. A significant difference in rates of NAT was found between the less than or equal to 12-month age group and all other age groups (P<0.00001). No significant difference in rates of NAT was found between the 13-24-month, 25-36-month, and 37-48-month age groups. Although our institution has generally felt that NAT should be universally evaluated in patients below 36 months of age with femur fractures, our data suggest that there is little justification for universally evaluating 13-36-month-old patients with femur fractures for NAT when the rates do not differ for 37-48-month-old patients. NAT does exist in femur fractures in children above 12 months of age, but it is most worrisomely high in patients of less than or equal to 12 months of age.

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

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

Low Pelvic Incidence Is Associated With Proximal Junctional Kyphosis in Patients Treated With Growing Rods.

STUDY DESIGN: Retrospective review of a prospectively collected pediatric orthopedic spine database. OBJECTIVE: To investigate whether pelvic incidence (PI) changes during growing rod treatment and to report the effects of PI, if any, on complications during treatment. SUMMARY OF BACKGROUND DATA: Growing rods have been demonstrated to correct spinal deformity in early onset scoliosis while allowing for spinal growth. There has been little investigation into the potential effects, if any, of abnormal PI on complications, especially proximal junctional kyphosis (PJK). METHODS: We retrospectively reviewed clinical and surgical data from our prospectively collected pediatric orthopedic spine database. Our final cohort of 48 patients had at least one lateral radiograph throughout the course of treatment containing the femoral heads and sacral endplate, and a minimum follow-up of 2 years. Defined failures were identified prospectively. Radiographs were measured for PI and development of PJK. RESULTS: Mean age at initial treatment was 6.9 years (range 2.8-10.8 yr), with 35 females and 13 males. The mean length of follow-up was 8.1 years (range 2.0-22.1 yr). No statistical change in PI was observed throughout this study (P = 0.655). Development of any failure as well as total number of failures was associated with younger age at initial treatment (P < 0.0005 for both). Development of PJK was associated with younger age at initial treatment (P = 0.030), female sex (P = 0.002), and lower mean PI (P = 0.042). CONCLUSION: PI remains constant throughout growth and the course of treatment with growing rods. Low PI was associated with increased PJK. When using growing rods in early onset scoliosis patients with decreased PI, increased attention should be paid to sagittal plane balance in an attempt to avoid PJK. LEVEL OF EVIDENCE: 4.

Intrathecal morphine attenuates acute opioid tolerance secondary to remifentanil infusions during spinal surgery in adolescents.

INTRODUCTION: The unique pharmacokinetic properties of remifentanil with a context-sensitive half-life unaffected by length of infusion contribute to its frequent use during anesthetic management during posterior spinal fusion in children and adolescents. However, its intraoperative administration can lead to increased postoperative analgesic requirements, which is postulated to be the result of acute opioid tolerance with enhancement of spinal N-methyl-D-aspartate receptor function. Although strategies to prevent or reduce tolerance have included the coadministration of longer acting opioids or ketamine, the majority of these studies have demonstrated little to no benefit. The current study retrospectively evaluates the efficacy of intrathecal morphine (ITM) in preventing hyperalgesia following a remifentanil infusion. METHODS: We retrospectively analyzed 54 patients undergoing posterior spinal fusion with segmental spinal instrumentation, to evaluate the effects of ITM on hyperalgesia from remifentanil. Patients were divided into two groups based on whether they did or did not receive remifentanil during the surgery: no remifentanil (control group) (n=27) and remifentanil (study group) (n=27). Data included demographics, remifentanil dose and duration, Wong-Baker visual analog scale postoperative pain scores, and postoperative intravenous morphine consumption in the first 48 postoperative hours. RESULTS: The demographics of the two study groups were similar. There were no differences in the Wong-Baker visual analog scale pain scores in the postanesthesia care unit and on postoperative days 1 and 3. Pain scores were higher in the remifentanil group on postoperative day 2 (2.9 vs 3.8). Postoperative morphine requirements were similar between the two groups (0.029 vs 0.017 mg/kg/48 h for the control group and the study group, respectively). CONCLUSION: In patients receiving preincisional ITM during spinal surgery, intraoperative remifentanil does not increase postoperative analgesic requirements.

Early onset scoliosis: the value of serial risser casts.

BACKGROUND: Treatment of early onset scoliosis (EOS) is challenging. In many cases, bracing will not be effective and growing rod surgery may be inappropriate. Serial, Risser casts may be an effective intermediate method of treatment. METHODS: We studied 20 consecutive patients with EOS who received serial Risser casts under general anesthesia between 1999 and 2011. Analyses included diagnosis, sex, age at initial cast application, major curve severity, initial curve correction, curve magnitude at the time of treatment change or latest follow-up for those still in casts, number of casts per patient, the type of subsequent treatment, and any complications. RESULTS: There were 8 patients with idiopathic scoliosis, 6 patients with neuromuscular scoliosis, 5 patients with syndromic scoliosis, and 1 patient with skeletal dysplasia. Fifteen patients were female and 5 were male. The mean age at first cast was 3.8±2.3 years (range, 1 to 8 y), and the mean major curve magnitude was 74±18 degrees (range, 40 to 118 degrees). After initial cast application, the major curve measured 46±14 degrees (range, 25 to 79 degrees). At treatment change or latest follow-up for those still in casts, the major curve measured 53±24 degrees (range, 13 to 112 degrees). The mean time in casts was 16.9±9.1 months (range, 4 to 35 mo). The mean number of casts per patient was 4.7±2.2 casts (range, 1 to 9 casts). At the time of this study, 7 patients had undergone growing rod surgery, 6 patients were still undergoing casting, 5 returned to bracing, and 2 have been lost to follow-up. Four patients had minor complications: 2 patients each with superficial skin irritation and cast intolerance. CONCLUSIONS: Serial Risser casting is a safe and effective intermediate treatment for EOS. It can stabilize relatively large curves in young children and allows the child to reach a more suitable age for other forms of treatment, such as growing rods. LEVEL OF EVIDENCE: Level IV; case series.

Bipolar sealer device reduces blood loss and transfusion requirements in posterior spinal fusion for adolescent idiopathic scoliosis.

BACKGROUND: Reducing perioperative blood loss and transfusion requirements is important in the operative treatment of idiopathic scoliosis. This can be achieved with special frames, cell saver systems, pharmacologic aspects, and other techniques. Recently there has been interest in bipolar sealer devices as an adjunct to traditional monopolar electrocautery. However, there is limited information on this device in pediatric spinal deformity surgery. We reviewed our experience with this device in a setting of a standard institutional operative carepath. METHODS: Perioperative blood loss and transfusion requirements of 50 consecutive patients with adolescent idiopathic scoliosis undergoing a posterior spinal fusion and segmental spinal instrumentation and who had a bipolar sealer device used during their surgery was compared with a control group of the 50 preceding consecutive patients who did not. Anesthesia, surgical technique, use of intraoperative epsilon aminocaproic acid (Amicar), postoperative protocol, and indications for transfusions (hemoglobin≤7.0 g/dL) were identical in both groups. RESULTS: The preoperative demographics for the patients in both groups were statistically the same. The bipolar sealer group demonstrated a significant reduction in intraoperative estimated blood loss, total perioperative blood loss, volume of blood products transfused, and overall transfusion rate when compared with the control group. When subgroups consisting of only hybrid or all-pedicle screw constructs were considered individually, these findings remained consistent. There were no complications associated with the use of this device. CONCLUSIONS: Using the bipolar sealer device is a significant adjunct in decreasing perioperative blood loss and transfusion requirements in patients undergoing surgery for adolescent idiopathic scoliosis. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Closed bone graft epiphysiodesis for avascular necrosis of the capital femoral epiphysis.

BACKGROUND: Avascular necrosis (AVN) of the capital femoral epiphysis (CFE) after an unstable slipped capital femoral epiphysis (SCFE), femoral neck fracture or traumatic hip dislocation can result in severe morbidity. Treatment options for immature patients with AVN are limited, including a closed bone graft epiphysiodesis (CBGE). However, it is unclear whether this procedure prevents AVN progression. QUESTIONS/PURPOSES: We investigated whether early MRI screening and CBGE prevented the development of advanced AVN changes in the CFE and the rates of complications with this approach. METHODS: We prospectively followed all 13 patients (seven boys, six girls) with unstable SCFEs (six patients), femoral neck fractures (five patients), and traumatic hip dislocations (two patients) and evidence of early AVN treated between 1984 and 2012. Mean age at initial injury was 12 years (range, 10-16 years). Nine of the 13 patients had followup of at least 2 years or until conversion to THA (mean, 4.5 years; range, 0.8-8.5 years), including two with unstable SCFEs, the five with femoral neck fractures, and the two with traumatic hip dislocations. All patients had technetium scans and/or MRI within 1 to 2 months of their initial injury (before CBGE) and all had evidence of early (Ficat 0) AVN. Patients were followed clinically and radiographically for AVN progression. RESULTS: Six of the nine hips did not develop typical clinical or radiographic evidence of AVN. These six patients have been followed 6.3 years (range, 4.3-9.1 years) from initial injury and 5.9 years (range, 3.8-8.5 years) from CBGE. The remaining three patients were diagnosed with AVN at periods ranging from 3 to 6 months after CBGE. CONCLUSIONS: Early recognition and treatment of AVN with a CBGE may alter the natural history of this complication. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Obesity negatively affects spinal surgery in idiopathic scoliosis.

BACKGROUND: Are obese patients with idiopathic scoliosis undergoing spinal surgery at higher risk for perioperative complications? This is not clearly understood. One previous study showed a greater preoperative thoracic kyphosis but no increase in perioperative complications. QUESTIONS/PURPOSES: We asked whether obese adolescents with idiopathic scoliosis have more perioperative complications and decreased curve correction. METHODS: We retrospectively reviewed 478 patients with idiopathic scoliosis operated on from 1998 to 2010. There were 236 (187 females, 49 males) with a mean age of 14 years (range, 11-22 years) who met the inclusion criteria. Demographic data, radiographic measurements, perioperative data, and major and minor complications were recorded. The BMI percentile (BMI%) defined two patient groups: healthy weight (BMI%<85) (n=181) and obese (BMI%≥85) (n=55). The preoperative curves were similar in the two groups. Minimum followup was 2 years (mean, 6 years; range, 2-14 years). RESULTS: Postoperatively, the mean major curve was smaller for healthy-weight patients (20°; range, 8°-36°) than for obese patients (23.2°; range, 12°-56°), as was the mean kyphosis (31.1° [range, 10°-56°]) versus 36° [range, 15°-33°], respectively). The postoperative lordosis was similar in both groups. Increased BMI% correlated with increased operative time, intraoperative blood loss, amount of intraoperative crystalloids, and difficulty with administration of spinal anesthesia. CONCLUSIONS: Obese patients are at higher risk for perioperative complications when undergoing spinal deformity surgery. Counseling should be done with the patient and family and weight loss recommended before surgery. LEVEL OF EVIDENCE: Level IV, prognostic study. See Instructions for Authors for a complete description of levels of evidence.

Safety and accuracy of pedicle screws and constructs placed in infantile and juvenile patients.

STUDY DESIGN: Retrospective review. OBJECTIVE: To determine the safety of pedicle screws placed in infantile and juvenile patients younger than 10 years of age, and to evaluate the accuracy and the incidence of short and long-term (>2-year follow-up) complications for the screws and construct utilized. SUMMARY OF BACKGROUND DATA: Although much has been written regarding the use of pedicle screws for the treatment of adult and adolescent spinal deformities, few studies have examined complication rates with regard to pedicle screws placed for pediatric spinal deformities in patients younger than 10 years of age. METHODS: Eighty-eight patients treated with 948 pedicle screws placed for a variety of pediatric spinal deformities were performed at a single institution. We evaluated the accuracy of pedicle screw placement via radiographic review by two spinal surgeons not involved in the surgical treatment. RESULTS: The average age at surgery was 6.8 year (range, 1 + 11 to 9 + 11 year). Five hundred ninety-four pedicle screws were placed in the thoracic spine and 354 screws in the lumbar spine. Three screws (0.32%) violated the lateral wall of the pedicle, two screws (0.21%) violated the inferior wall, and three screws (0.32%) were suspected of medial wall violation for a total of eight screws (0.84%) malpositioned. Although short-term complications occurred in nine patients (10.2%) (four-wound infection, two-foot drop, two-respiratory problems, first-sixth cranial nerve palsy), there were no insertion or short-term complications specifically related to the use of pedicle screws. Long-term complications occurred in nine patients (10.2%) (three-deformity progression, four-growing rod breakage), whereas two patients required revision surgery because of pullout and prominence of proximal thoracic pedicle screws (n = 4) placed in growing rod constructs (2.3% of patients, 0.4% of screws). CONCLUSION: There were no intraoperative or short-term pedicle screw insertion-related complications and a very low long-term complication rate (2.3% of patients, 0.4% of screws) specifically related to the use of pedicle screws in infantile and juvenile spinal deformity patients. More than 99% of screws were accurately placed.