Serial casting in early onset scoliosis: syndromic scoliosis is no contraindication.

BACKGROUND: Serial casting is a treatment for early onset scoliosis (EOS) in young children to achieve curve correction before bracing or to postpone initial surgical treatment until the patient is older. Good results have been reported for patients with idiopathic early onset scoliosis (IS). However, there are few reports of results in non-idiopathic cases, and the benefits of non-surgical methods in the syndromic-associated early onset scoliosis subgroup are unknown. METHODS: Retrospective single-institution study of patient charts and X-rays of all cases of sustained serial casting for EOS. Staged correction was obtained by applying three consecutive casts under general anaesthesia. These were changed every 4 weeks, followed by the implementation of a custom-made full-time Chêneau brace. Correction was measured by Cobb angle (CA) and rib-vertebra angle difference (RVAD) on whole spine anterior-posterior radiographs. Statistical analysis was performed via ANOVA. RESULTS: The study group consisted of 6 patiens with IS and 10 with non-idiopathic scoliosis (NIS) - exclusively syndromic-associated. The mean age at onset of treatment was 35 months (±15). The mean follow up was 21 months (±15). In IS patients average CA/RVAD before treatment was 46°(±8)/20°(±12). In NIS patients average CA/RVAD before treatment was 55°(±15)/24°(±14). After application of the third cast, the CA/RVAD was reduced to 20°(±11)/11°(±10) in IS patients. Whereas in NIS patients average CA/RVAD after the thrid cast was 28°(±12)/18°(±13). At latest follow-up the CA/RVAD was 16°(±7)/9°(±8) in IS patients and 31°(±11)/17° (±15) in NIS patients. CONCLUSION: Syndromic etiology is not a contraindication for serial casting in EOS. Our results show a curve correction, measured in CA, of 65% in IS patients and 44% in NIS patients. Significant reduction in the morphologic deformity, measured in RVAD, was achieved in the IS cohort, but not in the NIS cohort. In all cases surgical treatment could be delayed.

Increasing Brace Treatment for Pediatric Distal Radius Buckle Fractures: Using Quality Improvement Methodology to Implement Evidence-based Medicine.

BACKGROUND: Multiple randomized trials have showed equivalent outcomes and improved patient/family satisfaction using a removable brace to treat pediatric distal radius buckle fractures (DRBF). We tested the hypothesis that we could use quality improvement (QI) methodology to increase the proportion of patients with DRBF treated with removable braces at 2 tertiary care orthopaedic clinics from a baseline of 34.8% to 80%. METHODS: Clinic billing records were reviewed monthly to determine treatment (brace vs. cast) of DRBF and tracked using control charts (p-chart). Balance measures including correct application of the diagnostic criteria and algorithm were monitored. Process measures including the number of follow-up visits, radiographs obtained, and total cost of treatment were collected. Baseline data were obtained over a 3-month period, followed by a 12-month period of interventions using Plan-Do-Study-Act cycles targeting both individuals and groups of providers. RESULTS: The proportion of DRBF treated in a brace increased from a combined baseline of 34.8% to a combined 84% at the end of the study period. Following intervention, 83% (15/18) of providers began using braces for a majority of patients (defined as >67%), with only 1 provider continuing to use casts 100% of the time. Patient preference was cited as the most common reason for use of cast treatment. There was a significant decrease in the number of radiographs obtained at 1 of 2 institutions. The charges for brace treatment averaged $630 less per patient than for cast treatment, leading to an estimated medical-cost savings of $205,000 following intervention. CONCLUSIONS: Implementation of brace treatment for pediatric DRBF using QI methodology resulted in a shift toward brace treatment in the majority of patients, leading to substantial medical and nonmedical cost savings. Although patient preference was cited as the most common reason for persistent cast treatment, the data show the use of cast treatment to be more dependent upon individual provider preference. LEVEL OF EVIDENCE: Level II-therapeutic.

Is unilateral lower leg orthosis with a circular foot unit in the treatment of idiopathic clubfeet a reasonable bracing alternative in the Ponseti method? Five-year results of a supraregional paediatric-orthopaedic centre.

BACKGROUND: In the Ponseti treatment of idiopathic clubfoot, children are generally provided with a standard foot abduction orthosis (FAO). A significant proportion of these patients experience irresolvable problems with the FAO leading to therapeutic non-compliance and eventual relapse. Accordingly, these patients were equipped with a unilateral lower leg orthosis (LLO) developed in our institution. The goal of this retrospective study was to determine compliance with and the efficacy of the LLO as an alternative treatment measure. The minimum follow-up was 5 years. RESULTS: A total of 45 patients (75 ft) were retrospectively registered and included in the study. Compliance with the bracing protocol was 91% with the LLO and 46% with the FAO. The most common problems with the FAO were sleep disturbance (50%) and cutaneous problems (45%). Nine percent of patients experienced sleep disturbance, and no cutaneous problems occurred with the LLO. Thirteen percent of patients being treated with an FAO until the age of four (23 patients; 40 ft) underwent surgery because of relapse, defined by rigid recurrence of any of the components of a clubfoot. Fourteen percent of patients being treated with an LLO (22 patients; 35 ft), mostly following initial treatment with an FAO, experienced recurrence. CONCLUSION: Changing from FAO to LLO at any point during treatment did not result in an increased rate of surgery and caused few problems.

What factors impact on the implementation of clubfoot treatment services in low and middle-income countries?: a narrative synthesis of existing qualitative studies.

BACKGROUND: Around 100,000 children are born annually with clubfoot worldwide and 80% live in low and middle-income counties (LMICs). Clubfoot is a condition in which children are born with one or both feet twisted inwards and if untreated it can limit participation in everyday life. Clubfoot can be corrected through staged manipulation of the limbs using the Ponseti method. Despite its efficacy and apparent availability, previous research has identified a number of challenges to service implementation. The aim of this study was to synthesise these findings to explore factors that impact on the implementation of clubfoot services in LMICs and strategies to address them. Understanding these may help practitioners in other settings develop more effective services. METHODS: Five databases were searched and articles screened using six criteria. Articles were appraised using the Critical Appraisal Skills Programme (CASP) checklist. 11 studies were identified for inclusion. A thematic analysis was conducted. RESULTS: Thematic analysis of the included studies showed that a lack of access to resources was a challenge including a lack of casting materials and abduction braces. Difficulties within the working environment included limited space and a need to share treatment space with other clinics. A shortage of healthcare professionals was a concern and participants thought that there was a lack of time to deliver treatment. This was exacerbated by the competing demands on clinicians. Lack of training was seen to impact on standards, including the nurses and midwives attending to the child at birth that were failing to diagnose the condition. Financial constraints were seen to underlie many of these problems. Some participants identified failures in communication and cooperation within the healthcare system such as a lack of awareness of clinics. Strategies to address these issues included means of increasing resource availability and the delivery of targeted training. The use of non-governmental organisations to provide financial support and methods to disseminate best practice were discussed. CONCLUSIONS: This study identified factors that impact on the implementation of clubfoot services in LMIC settings.Findings may be used to improve service delivery.

With a biomechanical treatment in knee osteoarthritis, less knee pain did not correlate with synovitis reduction.

BACKGROUND: Braces are used to treat pain in patellofemoral joint osteoarthritis (PFJOA). In a trial, we previously reported pain improvement after 6-weeks brace use. The pain reduction did not correlate with changes in Magnetic Resonance Imaging (MRI) assessed Bone Marrow Lesion volume or static synovial volume. Studies show that changes in the synovium on dynamic contrast enhanced (DCE) MRI are more closely associated with symptom change than static synovial volume changes. We hypothesised change in synovitis assessed using dynamic imaging could explain the reduction in pain. METHOD: One hundred twenty-six men and women aged 40-70 years with painful radiographically confirmed PFJOA were randomised to either brace wearing or no brace for 6-weeks. Pain assessment and DCE-MRI were performed at baseline and 6 weeks. DCE data was analysed using Tofts's equation. Pain measures included a VAS of pain on nominated aggravating activity (VASNA), and the KOOS pain subscale. Paired t-tests were used to determine within person change in outcome measures and Spearman's correlation coefficients were used to determine the correlation between change in pain and change in the DCE parameters. RESULTS: Mean age of subjects was 55.5 years (SD = 7.5) and 57% were female. There was clear pain improvement in the brace users compared to controls (VASNA - 16.87 mm, p = <0.001). There was no significant change to the dynamic synovitis parameters among brace users nor was pain change correlated with change in dynamic synovitis parameters. CONCLUSION: The reduction in knee pain following brace wearing in patients with PFJOA is not explained by changes in synovitis. TRIAL REGISTRATION: Trial registration number UK. ISRCTN50380458 /Registered 21.5.2010.

Functional bracing of ACL injuries: current state and future directions.

PURPOSE: Functional braces are commonly prescribed to treat anterior cruciate ligament (ACL) injury. The results of the existing literature on functional brace use are mixed. The purpose of this study was to evaluate the history and current state of functional ACL bracing and to identify design criteria that could improve upon current bracing technologies. METHODS: A literature search was performed through the PubMed MEDLINE database in April 2013 for the keywords "anterior cruciate ligament" and "brace". Articles published between January 1, 1980, and April 4, 2013, were retrieved and reviewed. Current functional braces used to treat ACL injury were identified. The function of the native ACL was carefully studied to identify design requirements that could improve upon current bracing technologies. RESULTS: Biomechanical evaluations of functional brace effects at time zero have been mixed. Functional brace use reportedly does not improve long-term patient outcomes following ACL reconstruction, but has been shown to reduce subsequent injury rates while skiing in both ACL-deficient and reconstructed skiers. In situ force in the ACL varies with flexion angle and activity. Currently, no brace has been designed and validated to replicate the force-flexion behavior of the native ACL. CONCLUSIONS: Biomechanical and clinical evidence suggests current functional bracing technologies do not sufficiently restore normal biomechanics to the ACL-deficient knee, protect the reconstructed ACL, and improve long-term patient outcomes. Further research into a functional brace designed to apply forces to the knee joint similar in magnitude to the native ACL should be pursued. LEVEL OF EVIDENCE: III.

Diagnosis and Treatment of Idiopathic Congenital Clubfoot.

Idiopathic congenital clubfoot is the most common serious musculoskeletal birth defect in the United States and the world. The natural history of the deformity is to persist into adult life with a significant decrease in function and quality of life. The Ponseti method (serial casting, Achilles tenotomy, and bracing of the clubfoot) has become the most effective and accepted treatment of children born with clubfoot worldwide. The treatment is successful, particularly when the Ponseti-trained practitioner (often a pediatric orthopedic surgeon), the primary care clinician, and the family work together to facilitate success. An important factor in the ultimate success of the Ponseti method is parental understanding of the bracing phase. There is a very high rate of recurrent deformity when bracing is not done properly or is stopped prematurely. The importance of positive education and support for the parents to complete the entire treatment protocol cannot be overstated. The goal of treatment is a deformity-free, functional, comfortable foot. Ponseti clubfoot programs have been launched in most countries throughout the world, including many countries with limited resources. Ultimately, the goal is that every infant born with a clubfoot will have access to care with the Ponseti method. This clinical report is intended for medical practitioners who are involved in the care of pediatric patients with clubfoot. Understanding the standard of care will help these practitioners to care for patients and their families.

Treatment of children scoliosis by corrective brace with regulated force effect.

Rigid structural spine scoliosis of a child and even non progressive congenital scoliosis (e.g. isolated hemivertebra) can be treated by hypercorrective brace in full day regime. The article shows the new type of corrective brace with adjustable force effect. The brace consists of 3 stiff parts connected by joints and telescopes. The parts of brace are made from plastic according to plaster form of child trunk. The joints allow only mutual turning brace parts at frontal plane. The special telescopes were developed which operated with prescribed forces, it means the brace and trunk parts are mutually turned at prescribed moments. The article shows the algorithm for calculation of spine stress state, and spine curve correction for given brace with adjusted telescope forces. The second algorithm calculates the telescope forces for demanded spine curve correction. The computer program can be used for computer aid design of brace forces. The force effect of the new type of brace is demonstrated on a 14 months old boy with congenital scoliosis of lumbar spine (hemivertebra L1 and L3 on the right side). Curvature measured according to Coob was changed after application of this brace from 47.5° to 32.0°.

Bracing for adolescent idiopathic scoliosis in practice today.

BACKGROUND: The use of orthoses in adolescent idiopathic scoliosis has a long history. The purpose of this article is to summarize the current practice of bracing in the treatment of adolescent idiopathic scoliosis. METHODS: The literature from the past 25 years was reviewed for primary papers that contained accepted inclusion criteria for bracing, meta-analyses, and summaries of existing opinion. Recent literature was also reviewed for current bracing practices. RESULTS: The highest level of existing evidence comes from a prospective center-randomized study by Nachemson et al, which showed that bracing was effective for single curves of 25 to 35 degrees in female patients with a starting Risser score of 0 to 2. Two other studies with meta-analyses came to opposite conclusions because of variations in the examined investigations. Although there are few studies that compare different types of treatment, most show an improved outcome versus historical controls. The yearly number of peer-reviewed papers on the topic has increased markedly over this time. Two prospective randomized multicenter trials are underway. Reviews suggest that most orthopaedic specialists recommend bracing but that they differ on expected results. There is also a proliferation of interest in bracing by nonorthopaedists, with more varied indications. There are many types of full-time and part-time braces, and their designs and indications are described. CONCLUSIONS: Brace treatment for adolescent idiopathic scoliosis continues to be frequently used, and the number of brace types has increased. Predicting progressive curves and refining indications requires additional investigation.

A novel passive neck orthosis for patients with degenerative muscle diseases: Development & evaluation.

The current study evaluated the effect of a passive neck orthosis, developed for patients suffering from progressive muscular diseases, on neck muscle activity in 10 adult healthy participants. The participants performed discrete head movements involving pure neck flexion (-10 to 30°), pure neck rotation (up to 30° left and right) and combined neck flexion-rotation (-10 to 30°) in steps of 10° by moving a cursor on a screen to reach predefined targets and staying on target for 10 s. Surface electromyography (EMG) was recorded from upper trapezius and sternocleidomastoid muscles and amplitudes were averaged over the static phases in trials with and without the orthosis. Moreover, the variability in head position and time required to perform the tasks were compared between conditions. Wearing the orthosis caused significant reductions (p = 0.027) in upper trapezius activity (a change of 0.2-1.5% EMGmax) while working against gravity. The activity level of the sternocleidomastoid muscle increased (p ≤ 0.025) by 0.3-1.0% EMGmax during pure and combined rotations without any pain reported. The orthosis showed potential to reduce the activity level of the upper trapezius muscle, the main load bearing muscle of the neck. Further study will be carried out to evaluate the effect in different patient groups.

Analysis of remaining motion using one innovative upper airway opening cervical collar and two traditional cervical collars.

The aim of this study was to compare the remaining motion of an immobilized cervical spine using an innovative cervical collar as well as two traditional cervical collars. The study was performed on eight fresh human cadavers. The cervical spine was immobilized with one innovative (Lubo Airway Collar) and two traditional cervical collars (Stifneck and Perfit ACE). The flexion and lateral bending of the cervical spine were measured using a wireless motion tracker (Xsens). With the Weinman Lubo Airway Collar attached, the mean remaining flexion was 20.0 ± 9.0°. The mean remaining flexion was lowest with the Laerdal Stifneck (13.1 ± 6.6°) or Ambu Perfit ACE (10.8 ± 5.8°) applied. Compared to that of the innovative Weinmann Lubo Airway Collar, the remaining cervical spine flexion was significantly decreased with the Ambu Perfit ACE. There was no significant difference in lateral bending between the three examined collars. The most effective immobilization of the cervical spine was achieved when traditional cervical collars were implemented. However, all tested cervical collars showed remaining motion of the cervical spine. Thus, alternative immobilization techniques should be considered.

The Hudson Brace technique for emergency burr holes, an aide-memoire for the front-line military surgeon.

Traumatic brain injury is the leading cause of death in conflict and early surgical intervention achieves better outcomes. The British Army surgical kit includes a Hudson Brace and bit and Gigli saw for decompression of the cranial cavity. Here we demonstrate the Hudson Brace technique for non-neurosurgeons.

Adolescent Idiopathic Scoliosis Bracing Success Is Influenced by Time in Brace: Comparative Effectiveness Analysis of BrAIST and ISICO Cohorts.

STUDY DESIGN: Comparative effectiveness study OBJECTIVE.: To evaluate factors leading to higher percentage of brace failures in a cohort of North American patients with adolescent idiopathic scoliosis relative to their peers in Italy. SUMMARY OF BACKGROUND DATA: Studies of bracing in United States have shown worse outcomes than studies from European centers, possibly due to sample characteristics or treatment approaches. METHODS: Sample: Braced patients, aged 10 to 15, Risser <3, Cobb 20°- to 40°, observed to Cobb ≥40° and/or ≥Risser 4 selected from prospective databases. Comparators: Bracing per Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST) (TLSO) and Italian Scientific Spine Institute (ISICO) protocol (SPoRT braces with or without SEAS exercises). Baseline characteristics (sex, age, BMI, Risser, Cobb, curve type) and average hours of brace wear/day. Differences in programs (e.g., SEAS, type of brace, weaning protocol) were captured by a variable named "SITE." OUTCOME: Treatment failure (Cobb ≥40 before Risser 4). STATISTICS: Comparison of baseline characteristics, analyses of risk factors, treatment components, and outcomes within and between cohorts using logistic regression. RESULTS: A total of 157 BrAIST and 81 ISICO subjects were included. Cohorts were similar at baseline but differed significantly in terms of average hours of brace wear: 18.31 in the ISICO versus 11.76 in the BrAIST cohort. Twelve percent of the ISICO and 39% of the BrAIST cohort had failed treatment. Age, Risser, Cobb, and a thoracic apex predicted failure in both groups. SITE was related to failure (odds ratio [OR] = 0.19), indicating lower odds of failure with ISICO versus BrAIST approach. With both SITE and wear time in the model, SITE loose significance. In the final model, the adjusted odds of failure were higher in boys (OR = 3.34), and those with lowest BMI (OR = 9.83); the odds increased with the Cobb angle (OR = 1.23), and decreased with age (OR = 0.41) and hours of wear (OR = 0.86). CONCLUSION: Treatment at the ISICO resulted in a lower failure rate, primarily explained by longer average hours of brace wear. LEVEL OF EVIDENCE: 3.

Comparison of surgical and nonsurgical containment methods for patients with Legg-Calvé-Perthes disease of the onset ages between 6.0 and 8.0 years: Salter osteotomy versus a non-weight-bearing hip flexion-abduction brace.

Since bone healing potential decreases with age, patients with Legg-Calvé-Perthes disease should receive treatment appropriate to their age group. Nonsurgical treatment is commonly applied to patients under 6.0 years of age at the onset and surgical treatment is recommended for those over 8.0 years of age, but it remains unclear which is better for those between 6.0 and 8.0 years. The aim of this retrospective study was to compare outcomes of Salter osteotomy and a non-weight-bearing brace in this age group. Inclusion criteria were unilateral Legg-Calvé-Perthes disease patients who were 6.0-8.0 years of age at the onset, who had more than 50% femoral head involvement without hinge abduction, and who underwent either Salter osteotomy (n = 35) or a non-weight-bearing hip flexion-abduction brace (n = 18). Radiological and clinical outcomes at skeletal maturity were compared between the two groups. The mean follow-up durations were 9.4 years in the Salter osteotomy group and 10.0 years in the brace group. There was no significant difference in the modified Waldenström classification at the beginning of treatment and the Catterall and modified lateral pillar classifications evaluated at the fragmentation stage between the groups. At skeletal maturity, the Stulberg classification, the sphericity deviation score, femoral head overgrowth, and the articulo-trochanteric distance were similar between the groups, but the Salter osteotomy group showed significantly smaller lateralization of the femoral head and better acetabular shape and coverage than the brace group: femoral head lateralization (P < 0.001), acetabular depth-to-width ratio (P = 0.002), Sharp angle (P < 0.001), lateral acetabular shape (P = 0.027), acetabular head index (P < 0.001). There was no significant difference in hip pain and motion between the groups. In this age group, Salter osteotomy provides better femoral head position and acetabular shape and coverage than a non-weight-bearing brace.

Self-Experienced Trunk Appearance in Individuals With and Without Idiopathic Scoliosis.

STUDY DESIGN: Cross-sectional. OBJECTIVE: The aim of this study was to describe the self-experienced trunk appearance in individuals with and without idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: Idiopathic scoliosis is the most common spinal deformity. A large scoliotic deformity increases the risk of back pain and pulmonary dysfunction. The deformity has also a psychological impact. METHODS: The pictorial part of the spinal appearance questionnaire (pSAQ) was administered to 1416 individuals with idiopathic scoliosis (386 untreated, 529 brace treated, 501 surgically treated) and 272 individuals without scoliosis from the general population. Comparisons were made between individuals with and without scoliosis, between treatment groups and sex in the scoliosis group. RESULTS: Mean (95% confidence interval) age of the individuals with scoliosis was 36.2 (35.5-36.9) years and for the individuals without scoliosis 40.2 (37.9-42.4). pSAQ total was 12.3 (12.1-12.5) for individuals with scoliosis and 7.4 (7.3-7.6) for individuals without scoliosis (P < 0.001, adjusted for age and sex). pSAQ total was 11.5 (11.1-11.9) for untreated, 13.0 (12.6-13.3) for brace treated, and 12.3 (11.9-12.6) for surgically treated individuals (P < 0.001, adjusted for sex and curve size). The pSAQ total between males and females with idiopathic scoliosis did not differ (P = 0.22 adjusted for age and curve size). CONCLUSION: This study shows that individuals with idiopathic scoliosis have more concern about their body appearance than individuals without scoliosis. Untreated individuals are not as bothered of their spinal appearance as treated individuals. Males and females with scoliosis do not differ significantly in the perception of their spinal appearance. LEVEL OF EVIDENCE: 3.

Orthosis in Thoracolumbar Fractures: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

STUDY DESIGN: Systematic review and meta-analysis of randomized controlled trial (RCT). OBJECTIVE: The aim of this study was to evaluate radiological and clinical outcomes of acute traumatic thoracolumbar fractures in skeletally mature patients treated with orthosis, versus no immobilization. SUMMARY OF BACKGROUND DATA: Orthosis is traditionally used in conservative treatment of thoracolumbar fractures. However, recent studies suggest no benefit, and a possible negative impact in recovery. METHODS: Databases were searched from inception to June 2019. Studies were selected in two phases by two blinded reviewers; disagreements were solved by consensus. Inclusion criteria were: RCT; only patients with acute traumatic thoracolumbar fractures; primary conservative treatment; comparison between orthosis and no orthosis. Exclusion criteria were inclusion of nonacute fractures, patients with other significant known diseases and comparison of groups different than use of an orthosis. Two independent reviewers performed data extraction and quality assessment. Fixed-effects models were used upon no heterogeneity, and random-effects model in the remaining cases. A previous plan for extraction of radiological (kyphosis progression; loss of anterior height) and clinical (pain; disability; length of stay) outcomes was applied. PRISMA guidelines were followed. RESULTS: Eight articles/five studies were included (267 participants). None reported significant differences in pain, kyphosis progression, and loss of anterior height. One reported a better ODI with orthosis at 12 but not at 24 weeks. No other study reported differences in disability. All authors concluded an equivalence between treatments.Meta-analysis showed a significant increase of 3.47days (95% confidence interval 1.35-5.60) in mean admission time in orthosis group. No differences were found in kyphosis at 6 and 12 months; kyphosis progression between 0 to 6 and 0 to 12 months; loss of anterior height 0 to 6 months; VAS for pain at 6 months; VAS change 0 to 6 months. CONCLUSION: Orthosis seems to add no benefit in conservative treatment of acute thoracolumbar fractures. This should be considered in guidelines and reviews of health care policies. LEVEL OF EVIDENCE: 3.

Early experiences with a novel (robot hand) technique in the course of microneurosurgery.

BACKGROUND: The physiologic tremor may cause difficulties in microsurgery, in spite of using armrest. The new (robot hand) technique consists of the I-III finger support, which holds the instruments on Bethlehem (ANDAN BT, Budapest, Hungary) bridge above the operation area, which reduces the tremor at the end of the instruments. METHODS: Exact measurement of tremor reduction was performed. Last year, 23 microsurgical cases were operated on by the robot hand technique. RESULTS: The tremors of the operating hand and the number of complications have decreased effectively. CONCLUSION: By this technique, the microsurgical work has become more precise.

Brace treatment can serve as a time-buying tactic for patients with congenital scoliosis.

BACKGROUND: Infantile patients with congenital scoliosis (CS) can be confronted with increasing risk of mortality and morbidity. To date, the effectiveness of conservative treatment in CS has not been sufficiently investigated. We aimed to evaluate the bracing outcome in patients with CS and to investigate whether wearing brace can effectively delay the surgical procedures. METHODS: A total of 39 braced CS patients including 25 boys and 14 girls were reviewed for the eligibility to be included in this study. Radiographic parameters including curve magnitude and T1 to T12 height were evaluated for each patient at the initiation of the treatment and at the final follow-up (FU), respectively. Duration of the follow-up and requirement of surgical interventions were also recorded. The student t test was used to compare the radiographic parameters between the initial visit and the last FU. RESULTS: The mean initial age at bracing was 4.1 ± 2.3 years, and 7.5 ± 1.8 brace modifications were performed during a mean FU period of 42.1 ± 26.5 months. The mean curve magnitude before bracing was 44.1 ± 12.2°, which was corrected to 41.3 ± 13.5° at the final visit (p = 0.33). T1-T12 height increased from 13.4 ± 2.5 to 17.1 ± 2.8 cm during the treatment (P < 0.001). Nine patients underwent surgical intervention due to the curve progression more than 5°, with the time of surgery delayed for 32.1 ± 18.2 months. CONCLUSIONS: Brace treatment is an effective time-buying modality for CS patients, which may help maintain the body growth and delay the surgical intervention.

Approach to scoliosis changed due to causes other than evidence: patients call for conservative (rehabilitation) experts to join in team orthopedic surgeons.

PURPOSE: To look critically at the present reality of AIS (Adolescent Idiopathic Scoliosis) treatment and verify the hypothesis that the current prevalence of a single medical specialty could be creating distortions in patient care and/or cure. METHOD: This is a multifaceted study comprising a review of the evidence on AIS, a bibliometric study of the general and orthopedic literature since Medline start, and two case reports. RESULTS: Evidence exists to support the efficacy of exercises, bracing and fusion (grade B, B and C recommendations, respectively), but in clinics exercises are generally ignored; braces are used with some criticism, while fusion is generally considered the only reliable treatment. The literature on AIS treatment prevails in journals of orthopedic surgery, and therapy papers focused on surgery have increased from 34 to 55% over the past two decades. The two clinical cases show how an incorrect psychological approach to the patient and family, as well as inappropriate conservative treatments can have disastrous consequences for patients. CONCLUSIONS: Our results seem to confirm the initial hypothesis: The interest of the AIS treatment community (composed almost exclusively by orthopedic surgeons) has shifted toward fusion whereas research has increased, while conservative treatment is suffering a decrease in professional interest (and diminished research). AIS requires expert, committed evidence-based care, but other specialists totally devoted to conservative treatment, particularly (but not exclusively) Physical and Rehabilitation Medicine specialists, should enter the field to create better treating teams.