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

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

An Unusual Presentation of Myositis Ossificans in a Pediatric Patient.

BACKGROUND: Myositis ossificans (MO) is a rare, non-neoplastic lesion characterized by heterotopic ossification of soft tissue. The condition is predominantly seen in young adults and adolescents and is most commonly secondary to trauma. Although the exact etiology remains unclear, patients typically present with pain and restricted range of motion following trauma or overuse. MO rarely presents in the popliteal fossa of adult patients and has not been previously reported in that of a pediatric patient. METHODS: We present a 12-year-old patient with no history of direct trauma with MO in the right popliteal fossa, a highly unusual location. Initial x-rays failed to show the lesion; however, later radiographs showed an ossified mass. At peak dimensions, the ossification measured 3.8 cm anteroposterior×2.5 cm transverse×3.2 cm craniocaudal. After 14 months of observation and conservative therapy, the mass was excised. RESULTS: The patient was ultimately able to return to full activity. Radiographs taken 14 months after the excision showed no signs of recurrence of the lesion. CONCLUSIONS: To our knowledge, this is the first reported case of MO excised from the popliteal fossa of a pediatric patient and followed for >1 year. LEVEL OF EVIDENCE: Level IV-case report.

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

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

Assessment of rib hump deformity correction in adolescent idiopathic scoliosis with or without costoplasty using the double rib contour sign.

STUDY DESIGN: Level III-therapeutic study. OBJECTIVE: The purpose of this study was to determine whether the addition of costoplasty in adolescent idiopathic scoliosis surgery improved correction of the rib hump deformity. BACKGROUND: Trunk deformity is comprised of vertebral rotation, posterior vertebral element, and rib deformities. Surgical correction of the rotational deformity has been performed by segmental spinal instrumentation with vertebral derotation, but complete correction of the rib hump by derotation is rarely achieved. METHODS: A multicenter registry database for adolescent idiopathic scoliosis was reviewed with the inclusion criteria of Lenke type I curves treated with posterior spinal fusion with or without costoplasty, instrumented with pedicle screws or hybrid constructs, with a minimum follow-up of 2 years. The first group (group I) was treated with pedicle screws, direct vertebral rotation, and no costoplasty, whereas the second group (group II) was treated with pedicle screws, vertebral rotation, and costoplasty. The rib index (RI), calculated from the double rib contour sign, and Cobb angle were measured radiographically and compared between groups. RESULTS: The groups comprised 36 subjects in group I and 40 subjects in group II. The mean preoperative Cobb angles for groups I and II were 49.7 and 49.8 degrees, respectively, whereas the mean postoperative Cobb angles were 10.2 and 10.9 degrees, respectively. There was no difference in preoperative and postoperative values when comparing both groups (P=0.48 and 0.96, respectively). Before spine surgery, RI for groups I and II was 1.61 and 1.80, respectively. Postoperatively, the rib indices were 1.39 for group I and 1.29 for group II. These differences were found to be statistically significant (P=0.002 and 0.006, respectively). The amounts of correction of RI were 0.23 and 0.51 for groups I and II, respectively. This difference was found to be statistically significant (P<0.0001). The correction percentages were 13.7% and 28.3%, respectively. This difference was also found to be statistically significant (P<0.0001). CONCLUSIONS: Costoplasty combined with pedicle screws and vertebral derotation may significantly improve rib hump deformity as opposed to pedicle screws and vertebral derotation alone.

Functional outcome analysis of triplane and tillaux fractures after closed reduction and percutaneous fixation.

BACKGROUND: There are limited data regarding the outcomes of triplane and tillaux fractures. The purpose of our study was to provide a long-term follow-up analysis of the functional outcomes as they relate to articular displacement using validated outcome tools. METHODS: A retrospective chart and radiographic review was performed to identify the age, the sex, the treatment method, complications, the fracture type, and articular displacement. Most patients underwent closed reduction with percutaneous fixation. We used 2 validated outcome measures, namely the Foot and Ankle Outcomes Score and the Marx Activity Scale, to assess functional results at a minimum of 2 years from the time of injury. RESULTS: We identified 78 patients between 2000 and 2009 who underwent computed tomographic scan evaluation of either a triplane (n=58) or a tillaux fracture (n=20). Triplane fractures occurred at a significantly younger age than tillaux fractures for both men and women (P=0.01). Women were found to suffer transitional fractures at a younger age than men (P<0.001). Patients with residual articular displacement of up to 2.4 mm after definitive treatment did not have worse functional outcomes compared with those who had an anatomic reduction on any of the Foot and Ankle Outcomes Score subscales and the Marx Activity Scale. Similarly, there was no correlation between the magnitude of residual gap or step-off with functional outcome when the gap and step-off are <2.5 mm. Patients with longer-term follow-up (>4 y) did not have deterioration of function compared with those with a follow-up of 2 to 4 years. CONCLUSIONS: Tillaux and triplane fractures have good medium-term outcomes after reduction and fixation. Using primarily closed reduction and percutaneous fixation techniques, patients with a residual displacement of <2.5 mm after treatment have a uniformly good result. Functional results do not deteriorate at longer-term follow-up (4 to 10 y) as long as adequate reduction has been achieved. Percutaneous fixation yielded uniformly good results on all scales. LEVEL OF EVIDENCE: Therapeutic level III.

Dural ectasia in a child with Larsen syndrome.

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

Correction of spine deformity in patients with Melnick-needles syndrome: report of 2 cases and literature review.

BACKGROUND: Melnick-Needles syndrome (MNS) is a rare X-linked dominant disorder affecting the skeletal system and connective tissue. To date, < 70 cases with MNS have been documented. Although few reports in the literature have shown that these patients might develop kyphoscoliosis, there is no report regarding long-term follow-up of patients with MNS undergo spine surgery. The aim of this study is to describe 2 unique cases of MNS with long-term follow-up after instrumented posterior spinal fusion, multiple-level Ponte osteotomies, and pedicle subtraction osteotomies. METHODS: A 17-year-old female patient (patient 1) was evaluated for the first time at our institution. She was diagnosed with MNS, severe kyphoscoliosis, and restrictive lung disease. After pulmonary function improvement, she underwent posterior spinal fusion. Halo-femoral traction with gradual weight increase was used a week before spinal surgery. Surgical correction of her spinal deformity was achieved through a hooks-and-wires construct. The second patient was an 18-year-old female (patient 2) who carried the diagnosis of MNS when she was first seen at our institution. She had a significant thoracolumbar junction kyphosis and gibbous. She also suffered from significant pulmonary disease with a stent in her right main stem bronchus. A posterior procedure consisting of multiple-level Ponte osteotomies and pedicle subtraction osteotomy at L2 was carried out. RESULTS: Eight- and 5-year follow-up of patients 1 and 2, respectively, demonstrated solid fusion, a well-maintained correction, and no evidence of implant breakage. CONCLUSIONS: The reported cases add to the literature of excellent long-term results of spinal deformity correction with instrumented posterior spinal fusion in patients with MNS. Patients with this condition should be closely monitored from early childhood for the development of spine deformity so that early referral to a spine surgeon can be made followed by appropriate treatment, if necessary.

Approaches to treating NF1 tibial pseudarthrosis: consensus from the Children's Tumor Foundation NF1 Bone Abnormalities Consortium.

BACKGROUND: Neurofibromatosis 1 (NF1) is an autosomal dominant disorder with various skeletal abnormalities occurring as part of a complex phenotype. Tibial dysplasia, which typically presents as anterolateral bowing of the leg with subsequent fracture and nonunion (pseudarthrosis), is a serious but infrequent osseous manifestation of NF1. Over the past several years, results from clinical and experimental studies have advanced our knowledge of the role of NF1 in bone. On the basis of current knowledge, we propose a number of concepts to consider as a theoretical approach to the optimal management of tibial pseudarthrosis. METHODS: A literature review for both clinical treatment and preclinical models for tibial dysplasia in NF1 was performed. Concepts were discussed and developed by experts who participated in the Children's Tumor Foundation sponsored International Bone Abnormalities Consortium meeting in 2011. RESULTS: Concepts for a theoretical approach to treating tibial pseudarthrosis include: bone fixation appropriate to achieve stability in any given case; debridement of the "fibrous pseudarthrosis tissue" between the bone segments associated with the pseudarthrosis; creating a healthy vascular bed for bone repair; promoting osteogenesis; controlling overactive bone resorption (catabolism); prevention of recurrence of the "fibrous pseudarthrosis tissue"; and achievement of long-term bone health to prevent recurrence. CONCLUSIONS: Clinical trials are needed to assess effectiveness of the wide variation of surgical and pharmacologic approaches currently in practice for the treatment of tibial pseudarthrosis in NF1. LEVEL OF EVIDENCE: Level V, expert opinion.

Spontaneous improvement of olisthetic scoliosis in children following lumbosacral fusion for high-grade spondylolisthesis: A report of four new cases and systematic review of the literature.

Background: The study aim was to present four new well-documented cases of spontaneous improvement of olisthetic scoliosis and to analyze well-documented cases from the literature. Methods: Surgical log search and systematic review were conducted. Inclusion criteria were (1) age less than 18 years, (2) symptomatic high-grade (≥50%) spondylolisthesis, (3) scoliosis ≥20o, (4) primary surgical treatment via lumbosacral fusion, (5) complete x-rays, and (6) minimum 1-year radiographic follow-up or until curve resolution. Results: A total of 13 patients with average age of 13.9 years were included in the study, 4 from the authors' surgical logs and 9 from the literature. Slip percentage of L5-S1 ranged from 51% to 95%. Olisthetic curve magnitude averaged 34.6° (range: 20°-45°) with majority (8/13) demonstrating long thoracic curves with lateral trunk shift. All but one of these were apex right with rightward trunk shift. The remainder of the curves were isolated lumbar curves, with an apex left morphology without trunk shift. Eleven of the 13 patients showed curve improvement following isolated lumbosacral fusion. Three patients experienced a decrease in curve magnitude of 12°-28° and eight patients enjoyed complete resolution (≤10°) of their scoliosis. Conclusion: The current study summarizes 13 well-documented cases of olisthetic scoliosis (4 new cases and 9 from the literature) that associated with symptomatic high-grade spondylolisthesis. All were treated via a primary posterior lumbosacral fusion strategy. Eleven of the 13 curves showed spontaneous improvement (8 complete resolution of scoliosis) following their lumbosacral surgery. Level of evidence: Therapeutic level IV.

Triplane and Tillaux fractures: is a 2 mm residual gap acceptable?

Children's ankle fractures are the second most common growth plate fractures in humans and one of the top 10 reasons for pediatric orthopaedic hospital admissions. Because triplane and Tillaux fractures occur during the period of distal tibial physeal closure, they are considered transitional injuries. The distal tibial physis closes in a unique, asymmetric pattern (middle, then medial, and finally lateral), and it is the portion of the physis that is open at the time of injury that is vulnerable to fracture in this age group. Triplane and Tillaux fractures occur after supination external rotation and compression stress with unpredictable multiplanar fracture patterns. The fracture may appear different on different x-ray projections, making computed tomography mandatory to determine the number of fragments. Because most of these fractures are intra-articular, anatomic or near-anatomic reduction of the joint surface is recommended to minimize future posttraumatic ankle arthritis. Because these fractures occur at the end of growth, they rarely result in growth arrest.

Safety and efficacy of growing rod technique for pediatric congenital spinal deformities.

BACKGROUND: Growing rod surgery is a modern alternative treatment for young children with early onset scoliosis. This is the first study focused on its use in progressive congenital spinal deformities. METHODS: A retrospective study of 19 patients from the international multicenter Growing Spine Study Group with progressive congenital spinal deformities undergoing growing rod surgery who had a minimum of 2 years follow-up. We analyzed demographic and radiographic data including age at initial surgery, number of abnormal vertebrae per patient, number of lengthenings postoperatively, Cobb angle of the major curve preoperative, postoperative initial and at last follow-up, T1-S1 length, space available for the lung (SAL), length of follow up, and complications. RESULTS: The mean age at surgery was 6.9 years (range: 3.2 to 10.7 y). The mean number of affected vertebrae per patient was 5.2 (range: 2 to 9 vertebrae). The mean number of lengthening was 4.2 (range: 1 to 10 lengthening) per patient. The major Cobb angle improved from 66 degrees (range: 40 to 95 degrees) preoperatively to 45 degrees (range: 13 to 79 degrees) initial postoperative and 47 degrees (range: 18 to 78 degrees) at the last follow-up. The mean T1-S1 length increased from 268.3 mm (range: 192 to 322 mm) postoperatively to a mean of 315.4 mm (range: 261 to 357 mm) at last follow-up. The mean T1-S1 length increase was 11.7 mm/y. The SAL ratio increased from 0.81 preoperatively to 0.94 at latest follow-up. The mean postoperative follow-up was 4 years (range: 2 to 6.6 y). Five patients (38%) had undergone final fusion and 14 are still under treatment. Complications have occurred in 8 patients (42%). There were 14 (14%) complications in 100 procedures: 11 implant related, 2 pulmonary, and 1 postoperative infection. There were no neurological complications. CONCLUSIONS: Growing rods are a safe and effective treatment technique in selected patients with congenital spinal deformities. The deformity, spinal growth, and the SAL improved. The incidence of complication was relatively low. LEVEL OF EVIDENCE: Level IV, case series.

C-1 lateral mass screw fixation in children with atlantoaxial instability: case series and technical report.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To evaluate the feasibility, safety, and efficacy of incorporating C-1 lateral mass screws into fusion constructs in children with atlantoaxial instability. SUMMARY OF BACKGROUND DATA: The operative treatment of atlantoaxial instability varies widely based on anatomy, patient age, and surgeon preference. The modified Harms construct, consisting of polyaxial C-1 lateral mass screws together with C-2 pedicle or pars screws and rods, has shown satisfactory fusion rates and minimal incidence of complications in adult patients. However, its utility in the pediatric population remains unproven, largely because of the technical challenges and risks inherent in placing C-1 lateral mass screws in children with immature bone quality, extensive anatomical variability, and smaller osseous structures. METHODS: We retrospectively reviewed the records of all pediatric patients with atlantoaxial instability treated surgically, with a fusion construct incorporating C-1 lateral mass screws, at our institution between July 1, 2005 and June 30, 2008. Eight patients were identified and their relevant clinical data were abstracted from the medical record. RESULTS: All patients had C-1 lateral mass screws placed as part of a fixation construct. Six cases used C-2 pedicle screws and 2 cases used C-3 lateral mass screw fixation for the inferior portion of the construct. There were 6 female and 2 male patients. Age at the time of the surgery ranged from 5 to 13 years (mean 9 y), and follow-up ranged from 11 to 38 months (mean 23 mo). No C-2 nerve root was sacrificed in any patient. There were no intraoperative or postoperative complications, including neurological injury, vascular injury, or hardware-related complications. Successful fusion was documented with dynamic cervical spine radiography in all cases. CONCLUSIONS: C-1 lateral mass screw placement is generally feasible and safe in pediatric patients. With a nearly 2-year average follow-up, C1-2 rigid screw/rod fixation has proven to be an effective treatment modality for pediatric atlantoaxial instability in our series.

Perfused, pulseless, and puzzling: a systematic review of vascular injuries in pediatric supracondylar humerus fractures and results of a POSNA questionnaire.

BACKGROUND: Supracondylar humerus fractures that present with a perfused, viable hand yet no pulse continue to be a source of controversy. The purpose of this study was to conduct a systematic review of the literature and perform a Pediatric Orthopaedic Society of North America (POSNA) opinion poll regarding management of pulseless supracondylar humeral fractures in children. METHODS: A systematic review of the literature was conducted for relevant observational studies concerning neurovascular injuries in supracondylar humerus fractures. Single case reports and non-English language studies were excluded. Data were pooled for defined subgroups and 95% confidence intervals were reported. The results from the literature were then compared to popular opinion via a POSNA-approved survey concerning management of pulseless supracondylar humerus fractures. RESULTS: A total of 331 cases of pulseless supracondylar fractures were identified from the literature, irrespective of perfusion status. In all, 157 fractures remained pulseless after closed reduction and stabilization. Of the fractures that continued to be pulseless despite adequate reduction, 82% [95% confidence interval (CI)=0.82 (0.76-0.88)] were found to have a documented brachial artery injury. POSNA members presumed this number would be 28% [95% CI=0.28 (0.22-0.34)]. A total of 98 perfused (aka pink) supracondylar fractures were identified. Of these pulseless, perfused fractures, 70% [95% CI=0.70 (0.58-0.82)] had a documented brachial artery injury. POSNA members speculated that this number would be 17% [95% CI=0.17 (0.12-0.22). A total of 54 patients had minimum 1 year follow-up data after vascular revascularization, and 91% [95% CI=0.91 (0.83-0.99)] of these patients had a patent artery based on vascular studies. POSNA members believed this number would be 55% [95% CI=0.55 (0.48-0.62)]. CONCLUSIONS: Our study revealed that common dogma regarding watchful waiting of pulseless and perfused supracondylar fractures needs to be questioned. In the vast majority of published cases, an absence of pulse is an indicator of arterial injury, even if the hand appears pink and warm, suggesting the need for more aggressive vascular evalvation and vascular exploration and repair in selected cases. Moreover, patency rates for revascularization procedures appear sufficiently high, making this intervention worthwhile.

Skeletal abnormalities in neurofibromatosis type 1: approaches to therapeutic options.

The skeleton is frequently affected in individuals with neurofibromatosis type 1, and some of these bone manifestations can result in significant morbidity. The natural history and pathogenesis of the skeletal abnormalities of this disorder are poorly understood and consequently therapeutic options for these manifestations are currently limited. The Children's Tumor Foundation convened an International Neurofibromatosis Type 1 Bone Abnormalities Consortium to address future directions for clinical trials in skeletal abnormalities associated with this disorder. This report reviews the clinical skeletal manifestations and available preclinical mouse models and summarizes key issues that present barriers to optimal clinical management of skeletal abnormalities in neurofibromatosis type 1. These concepts should help advance optimal clinical management of the skeletal abnormalities in this disease and address major difficulties encountered for the design of clinical trials.

Idiopathic chondrolysis of the hip in children: early MRI findings.

OBJECTIVE: The objective of our study was to identify the early MRI findings characteristic of idiopathic chondrolysis of the hip in children. CONCLUSION: A geometric region of abnormal signal intensity centered in the proximal femoral epiphysis, accompanied by ipsilateral ill-defined acetabular bone marrow edema, mild synovial hypertrophy, and minimal if any joint fluid, in a child with a painful stiff hip are early MRI findings characteristic of idiopathic chondrolysis.

Pulmonary function changes after various anterior approaches in the treatment of adolescent idiopathic scoliosis.

STUDY DESIGN: Prospective radiographic and chart review of pulmonary function in patients who underwent 3 different anterior spinal surgery approaches for adolescent idiopathic scoliosis (AIS). OBJECTIVE: To assess the impact on pulmonary function in patients with AIS after anterior surgical approaches, including open thoracotomy, thoracoscopic with and without thoracoplasty, and thoracoabdominal 2 years after surgery. SUMMARY OF BACKGROUND DATA: Potential advantages of anterior surgery in the treatment of AIS include saving of distal motion segments and improving kyphosis restoration in the thoracic spine, possibly at the cost of pulmonary function impairment. Although thoracoscopic spinal instrumentation and fusion has recently been shown to induce less pulmonary impairment compared with open thoracotomy, no study has evaluated the effect of thoracoplasty as an adjunct to thoracoscopic surgery, nor the effects of the thoracoabdominal approach for thoracolumbar curvature. METHODS: A multicenter spinal deformity database was queried for patients who underwent an anterior approach for either Lenke I or Lenke V idiopathic scoliosis. There were 68 patients in the thoracotomy group, 44 in the thoracoscopic group, and 19 in the thoracoabdominal group. Absolute and percent-predicted values of forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), and total lung capacity (TLC) were evaluated preoperatively and at 2-year follow-up, and comparisons were made within and between each group. RESULTS: Comparing between groups at 2 years postoperatively, the thoracotomy group demonstrated significantly greater decreases (-10.97% and -12.97%) in both percent-predicted FEV1 and FVC, respectively, when compared with the thoracoscopic group (-4.40% and -4.73%), respectively. Percent-predicted TLC in the thoracoscopic group increased (3.19%), but decreased in the thoracotomy group (-8.00%). Subanalysis of the thoracoscopic group at 2 years revealed that the addition of a thoracoplasty (3 to 5 ribs) significantly reduced percent-predicted FEV1 (-11.6%, P = 0.0013) and percent-predicted FVC (-16.0%, P = 0.017) from baseline. Patients who underwent thoracoscopy alone without a thoracoplasty experienced no significant detrimental changes in these parameters at 2 years, and instead experienced significant increases in absolute TLC (P < 0.001) and percent-predicted TLC (P = 0.035). There were no significant changes demonstrated in the thoracoabdominal group for all 3 parameters. CONCLUSIONS: Slight declines in pulmonary function at 2-year follow-up were noted in both the thoracotomy and thoracoscopic groups, but to a significantly greater extent in those with an open thoracotomy. Significantly greater impairment in pulmonary function was seen in thoracoscopic patients who underwent thoracoplasty, whereas those without thoracoplasty either had no significant declines at 2 years or experienced slight but significant improvement. No significant diminishment was noted for the thoracoabdominal approach, despite disruption of the diaphragm.

Spondylolisthesis: intraobserver and interobserver reliability with regard to the measurement of slip percentage.

BACKGROUND: Spondylolisthesis is often diagnosed and treated on the basis of measurements obtained from radiographs. Many physicians will perform surgery regardless of the patient's symptoms above a specific slip percentage. However, current methods used to assess slip percentage are vague and lack appropriate standardization, leaving physicians to devise personal evaluation techniques. This study presents a defined method to calculate slip percentage that takes advantage of modern technology, is fast and simple to perform, and shows excellent intraobserver/interobserver reliability. METHODS: Four pediatric orthopaedic attendings each reviewed 30 radiographic cases of spondylolisthesis (grades 1 to 4) at the L5 to S1 level. The radiographs were measured twice through computer using PACS information management software with an interval of 2 days to 2 weeks between sessions. Using the PACS line tool, observers superimposed 6 lines onto each radiograph from which measurements were derived. The numerator in slip percentage (anterior displacement) was determined by 2 methods: the distance between a line outlining the posterior border of the sacrum and A: a line outlining the posterior border of L5 or B: a line parallel starting at the inferior, posterior corner of L5. The denominator in slip percent was determined by 2 methods. C: length of the inferior border L5 or D: length of the superior border of L5. This resulted in 4 different equations of slip percentage: A/C, A/D, B/C, and B/D. Analysis was performed using intraclass correlation coefficient. RESULTS: Slip percentage=A/D resulted in the highest intraclass correlation coefficient for both intraobserver and interobserver reliability (0.87 and 0.85, respectively). Slip percentage=B/C showed the poorest intraobserver reliability (0.69). Slip percentage=B/C and B/D had equally poor interobserver reliability (0.59). CONCLUSIONS: Defining the numerator in slip percentage as the distance between a line outlining the posterior border of the sacrum and a line outlining the posterior border of L5 (A) results in the highest intraobserver/interobserver reliability. Defining the denominator in slip percentage as the length of the superior border of L5 (D) results in the highest intra/inter observer reliability. LEVEL OF EVIDENCE: Diagnostic level III.

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

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

Postlaminectomy kyphosis in an achondroplastic adolescent treated for spinal stenosis.

We report a case of a skeletally immature achondroplastic adolescent with significant thoracolumbar lordosis who presented with neurogenic claudication and urinary incontinence progressing over a 1-year period. She underwent decompressive lumbar laminectomy from T12 to L5 with preservation of the facet joints. Over the ensuing 4 years of follow-up, she developed a progressive thoracolumbar kyphosis that progressed to 105 degrees. She remained neurologically intact and was fully ambulatory, but had severe back pain in the area of the deformity. Because of the severity and progression of her deformity, a combined anterior and posterior fusion and stabilization was required. We present this case and a review of the literature on spinal stenosis in achondroplasia and the complication of post-laminectomy kyphosis.