Rib-on-Pelvis Deformity and Reported Pain in Neuromuscular Early-Onset Scoliosis.

BACKGROUND: Neuromuscular early-onset scoliosis (N-EOS) often presents with a long sweeping thoracolumbar scoliosis and pelvic obliquity. With severe pelvic obliquity, the ribs come into contact with the high side of the pelvis, termed rib-on-pelvis deformity (ROP). The goal of this study is to evaluate whether ROP is associated with reported pain and other health-related quality of life (HRQOL) measures. We hypothesize that ROP is associated with increased pain and negative HRQOL. METHODS: A multicenter international registry was queried for all nonambulatory patients with N-EOS from 2012 to 2022. Both surgical and nonsurgical patients were included. ROP was classified as a binary radiographic assessment of preoperative (surgical patients) and most recent follow-up (nonsurgical patients) upright radiographs. Reported pain and other HRQOL measures were assessed through the 24-Item Early Onset Scoliosis Questionnaire (EOSQ-24). Patients with nonupright radiographs or EOSQ-24 questionnaires and corresponding radiographs >4 months apart were excluded. RESULTS: Totally, 225 patients (8.4±3.1 y, 55% female) were included. The median major curve was 63.3 (IQR: 40.6 to 81.2) degrees and median pelvic obliquity was 15.5 degrees (IQR: 8.8 to 26.4). Eighty-three patients (37%) had ROP. ROP was associated with both frequency (P<0.001) and severity (P<0.001) of pain. ROP was associated with worse general health (P=0.01), increased difficulty with vocalization (P=0.02), increased frequency of shortness of breath (P=0.002), and increased difficulty sitting upright (P=0.04). Regarding overall EOSQ-24 domains, ROP was associated with worse general health, pain/discomfort, pulmonary function, and physical function (P<0.01). In a subanalysis of 76 patients who underwent surgical intervention with at least 2 years of follow-up, patients with preoperative ROP experienced significantly greater improvements in both frequency (P=0.004) and severity (P=0.001) of pain than the patients without preoperative ROP at 2 years postoperatively. CONCLUSIONS: The overall incidence of ROP in N-EOS is about 37%. ROP is associated with greater pain and worse HRQOL through the EOSQ-24 questionnaire. Furthermore, these patients experienced a greater reduction in pain after surgery. Clinicians and parents must be aware that ROP is possibly a pain generator, but responds positively to surgical intervention. LEVEL OF EVIDENCE: Level III.

The Fate of The Broken Tether: How Do Curves Treated with Vertebral Body Tethering Behave After Tether Breakage?

STUDY DESIGN: Retrospective, Multicenter. OBJECTIVE: Assess curve progression and occurrence of revision surgery following tether breakage after vertebral body tethering (VBT). SUMMARY OF BACKGROUND DATA: Tether breakage after VBT is common with rates up to 50% reported. In these cases, it remains unknown whether the curve will progress or remain stable. METHODS: Adolescent and juvenile idiopathic scoliosis patients in a multicenter registry with ≥2 year-follow-up after VBT were reviewed. Broken tethers were listed as postoperative complications and identified by increased screw divergence of >5° on serial radiographs. Revision procedures and curve magnitude at subsequent visits were recorded. RESULTS: Of 186 patients who qualified for inclusion, 84 (45.2%) patients with tether breakage were identified with a mean age at VBT of 12.4±1.4 years and mean curve magnitude at index procedure of 51.8°±8.1°. Tether breakage occurred at a mean of 30.3±11.8 months and mean curve of 33.9°±13.2°. Twelve patients (12/84, 14.5%) underwent 13 revision procedures after VBT breakage, including 6 tether revisions and 7 conversions to fusion. All tether revisions occurred within 5 months of breakage identification. No patients with curves <35° after breakage underwent revision. Revision rate was greatest in skeletally immature (Risser 0-3) patients with curves ≥35° at time of breakage (Risser 0-3: 9/17, 53% vs. Risser 4-5: 3/23, 13%, P=0.01).Curves increased by 3.1° and 3.7° in the first and second year, respectively. By two years, 15/30 (50%) progressed >5° and 8/30 (26.7%) progressed greater than 10°. Overall, 66.7% (40/60) reached a curve magnitude >35° at their latest follow-up, and 14/60 (23.3%) reached a curve magnitude greater than 45°. Skeletal maturity did not affect curve progression after tether breakage (P>0.26), but time to rupture did (P=0.048). CONCLUSION: While skeletal immaturity and curve magnitude were not independently associated with curve progression, skeletally immature patients with curves ≥35° at time of rupture are most likely to undergo additional surgery. Most patients can expect progression at least 5° in the first two years after tether breakage, though longer-term behavior remains unknown. LEVEL OF EVIDENCE: III.

Development of Consensus-Based Best Practice Guidelines for the Peri- and Post-operative Care of Pediatric Patients with Spinal Deformity and Programmable Implanted Devices.

STUDY DESIGN: Modified Delphi consensus study. OBJECTIVE: To develop consensus-based best practices for the care of pediatric patients who have implanted programmable devices (IPDs) and require spinal deformity surgery. SUMMARY OF BACKGROUND DATA: Implanted programmable devices (IPDs) are often present in patients with neuromuscular or syndromic scoliosis who require spine surgery. Guidelines for monitoring and interrogating these devices during the peri-operative period are not available. METHODS: A panel was assembled consisting of 25 experts (i.e., spinal deformity surgeons, neurosurgeons, neuro-electrophysiologists, cardiologists, and otolaryngologists). Initial postulates were based on literature review and results from a prior survey. Postulates addressed the following IPDs: vagal nerve stimulators (VNS), programmable ventriculo-peritoneal shunts (VPS), intrathecal baclofen pumps (ITBP), cardiac pacemakers and implantable cardioverter-defibrillators (ICD), deep brain stimulators (DBS), and cochlear implants. Cardiologist and otolaryngologists participants responded only to postulates on cardiac pacemakers or cochlear implants, respectively. Consensus was defined as ≥80% agreement, items that did not reach consensus were revised and included in subsequent rounds. A total of three survey rounds and one virtual meeting were conducted. RESULTS: Consensus was reached on 39 total postulates across six IPD types. Postulates addressed general spine surgery considerations, use of intraoperative monitoring and cautery, use of magnetically-controlled growing rods (MCGRs), and use of an external remote controller to lengthen MCGRs. Across IPD types, consensus for the final postulates ranged from 94.4-100%. Overall, experts agreed that MCGRs can be surgically inserted and lengthened in patients with a variety of IPDs and provided guidance for the use of intraoperative monitoring and cautery, which varied between IPD types. CONCLUSION: Spinal deformity correction surgery often benefits from the use of intraoperative monitoring, monopolar and bipolar cautery, and MCGRs. Final postulates from this study can inform the peri- and post-operative practices of spinal deformity surgeons who treat patients with both scoliosis and IPDs. LEVEL OF EVIDENCE: V- Expert opinion.

Hip Surgery is Not More Painful Than Spine Surgery in Children With Cerebral Palsy.

BACKGROUND: Posterior spinal fusion (PSF) and hip reconstruction are commonly indicated surgeries in children with cerebral palsy (CP), particularly those functioning at GMFCS levels IV and V. These are large and often painful procedures, and previous literature suggests that hip surgery is more painful than spine surgery in this patient population. The purpose of this study is to investigate pain scores and opioid use following hip and spine surgery in a large cohort of children with CP, including many patients who have undergone both types of surgery. METHODS: A retrospective chart review was performed to identify children with CP who underwent hip reconstruction and/or PSF at a tertiary children's hospital between 2004 and 2022. Charts were reviewed for demographic data, pain scores, pain medication usage, duration of hospital stay, and complications. RESULTS: Data were collected for 200 patients (101 male, 99 female) who met inclusion criteria. Eighty-seven patients underwent hip reconstruction, 62 spinal fusion, and 51 both hip and spine surgery asynchronously. Median (interquartile range) age at the time of surgery was significantly older for spinal fusion compared with hip surgery [13.1 (4.9) vs. 8.1 (5.7) y, P<0.0001]. Length of stay was significantly longer after PSF, with a median of 6 (4) days compared with 2 (1) days after hip surgery (P<0.0001). Both maximum and average daily pain scores were similar following hip and spine surgery, with the exception that average pain scores for hip surgery were slightly higher on postoperative day 1, hip=1.73 vs. spine=1.0 (P<0.0001). The amount of opioids used, expressed as morphine milligram equivalents (MME)/kg were similar in the hip and spine surgery groups; however, it was significantly lower in the hip surgery group on postoperative day 0, hip=0.06 versus spine=0.17 (P<0.0001). For the 51 patients who underwent both hip and spine surgery, the amount of opioids used mirrored that for the entire group (similar MME/kg, though only statistically significantly less on POD 0 and 3), and pain scores were not significantly different between the 2 groups except in 2 circumstances. The 2 exceptions in these 51 patients both demonstrated lower pain scores in patients after hip surgery, including lower maximum pain scores on POD 1 (P=0.041), and lower average pain scores on POD3 (P=0.043). CONCLUSIONS: This is the largest series to date comparing postoperative pain in children with CP after hip and spine surgery, including 51 of 200 patients who underwent both types of surgery. The results of this study demonstrate that hip surgery is not more painful than spine surgery in children with CP, and conflict with the traditional belief that hip surgery is more painful. This is important information for health care providers when counseling patients and families regarding these surgeries in children with CP. LEVEL OF EVIDENCE: Level 3.

What is the role of plastic surgery for incisional closures in pediatric spine surgery? Results from a pediatric spine study group survey.

Current best practice guidelines recommend a plastics-style multilayer wound closure for high-risk pediatric spine surgery. However, plastic surgery closure of spinal incisions remains controversial. This study investigates surgeon perceptions and practice patterns regarding plastic surgery multilayered closure (PMC) in pediatric spine surgery. All surgeons in an international pediatric spine study group received a 30-question survey assessing incisional closure practices, frequency of plastic surgery collaboration, and drain management. Relationship to practice size, setting, geographic region, and individual diagnoses were analyzed. 87/178 (49%) surgeons responded from 79% of participating sites. Plastics utilization rates differed by diagnosis: neuromuscular scoliosis 16.9%, early onset scoliosis 7.8%, adolescent idiopathic scoliosis 2.8% (P < 0.0001). Plastics were used more for early onset scoliosis [odds ratio (OR) 18.5, 95% confidence interval (CI): 8.5, 40.2; P < 0.001] and neuromuscular scoliosis [OR 29.2 (12.2, 69.9); P < 0.001] than adolescent idiopathic scoliosis. Plastics use was unrelated to practice size, setting, or geographic region (P ≥ 0.09). Respondents used plastics more often for spina bifida and underweight patients compared to all other indications (P < 0.001). Compared to orthopaedic management, drains were utilized more often by plastic surgery (85 vs. 21%, P = 0.06) and for longer durations (P = 0.001). Eighty-nine percent of surgeons felt plastics increased operative time (58 ±â€…37 min), and 34% felt it increased length of hospitalization. Surgeons who routinely utilize plastics were more likely to believe PMC decreases wound complications (P = 0.007). The perceived benefit of plastic surgery varies, highlighting equipoise among pediatric spine surgeons. An evidence-based guideline is needed to optimize utilization of plastics in pediatric spine surgery.

Incidental dural tears during pediatric posterior spinal fusions.

PURPOSE: To characterize the frequency of incidental dural tears in pediatric spine surgery, their treatment, complications, and results of long-term follow-up. METHODS: A retrospective review of all pediatric patients who underwent a posterior spinal fusion (PSF) between 2004-2019 at a tertiary children's hospital was conducted. Electronic medical records were reviewed for patient demographics, intra-operative data, presence of an incidental dural tear, repair method, and patient outcomes. RESULTS: 3043 PSFs were reviewed, with 99 dural tears identified in 94 patients (3.3% overall incidence). Mean follow-up was 35.7 months (range 0.1-142.5). When the cause of the dural tear was specified, 69% occurred during exposure, 5% during pedicle screw placement, 4% during osteotomy, 2% during removal of implants, and 2% during intra-thecal injection of morphine. The rate of dural tears during primary PSF was significantly lower than during revision PSF procedures (2.6% vs. 6.2%, p < 0.05). 86.9% of dural tears were repaired and/or sealed intraoperatively, while 13.1% had spontaneous resolution. Postoperative headaches developed in 13.1% of patients and resolved at a mean of 7.6 days. There was no difference in the incidence of headaches in patients that were ordered bedrest vs. no bedrest (p > 0.99). Postoperative infections occurred in 9.5% of patients and 24.1% patients were identified to have undergone a revision surgery. CONCLUSIONS: Incidence of intra-operative dural tears in pediatric spine surgery is 3.3%. Although complications associated with the dural tear occur, most resolve over time and there were no long-term sequelae in patients with 2 years of follow up. LEVEL OF EVIDENCE: Level IV.

Spinal Manifestations of Skeletal Dysplasia: A Practical Guide for Clinical Diagnosis.

Skeletal dysplasias are a group of genetic conditions defined by atypical bone or cartilage growth and development. Skeletal abnormalities include short stature, limb deformity, joint contracture, and spinal deformity. Over 90% of disorders have a known genetic mutation that can definitively determine the diagnosis. As patients may present with a primary spinal concern, a careful clinical and radiographic evaluation can allow the physician to develop a working diagnosis to guide additional evaluation. Spinal manifestations include scoliosis and kyphoscoliosis, cervical instability, cervical kyphosis, thoracolumbar kyphosis, spinal stenosis, and atypical vertebral body morphology. An understanding of the affected conditions, prevalence, and natural history of these radiographic findings aids the orthopaedic surgeon in establishing a diagnosis and guides appropriate orthopaedic care.

Coronal decompensation following thoracic vertebral body tethering in idiopathic scoliosis.

PURPOSE: Post-operative coronal decompensation (CD) continues to be a challenge in the treatment of adolescent idiopathic scoliosis (AIS). CD following selective spinal fusion has been studied. However, there is currently little information regarding CD following Vertebral Body Tethering (VBT). Thus, the goal of this study is to better understand the incidence and risk factors for CD after VBT. METHODS: Retrospective review of a prospective multicenter database was used for analysis. Inclusion criteria were patients undergoing thoracic VBT, a minimum 2-year follow-up, LIV was L1 or above, skeletally immature (Risser ≤ 1), and available preoperative and final follow-up AP and lateral upright radiographs. Radiographic parameters including major and minor Cobb angles, curve type, LIV tilt/translation, L4 tilt, and coronal balance were measured. CD was defined as the distance between C7PL and CSVL > 2 cm. Multiple logistic regression model was used to identify significant predictors of CD. RESULTS: Out of 136 patients undergoing VBT, 94 patients (86 female and 6 male) met the inclusion criteria. The mean age at surgery was 12.1 (9-16) and mean follow-up period was 3.4 years (2-5 years). Major and minor curves, AVR, coronal balance, LIV translation, LIV tilt, L4 tilt were significantly improved after surgery. CD occurred in 11% at final follow-up. Lenke 1A-R (24%) and 1C (26%) had greater incidence of CD compared to 1A-L (4%), 2 (0%), and 3 (0%). LIV selection was not associated with CD. Multivariate logistic regression analysis yielded 1A-R and 1C curves as a predictor of CD with the odds ratio being 17.0. CONCLUSION: CD occurred in 11% of our thoracic VBT patients. Lenke 1A-R and 1C curve types were predictors for CD in patients treated with VBT. There were no other preoperative predictors associated with CD.

Prescription Opioid Use for Adolescents With Neurocognitive Disability Undergoing Surgery: A Pilot Study.

INTRODUCTION: Parents frequently report retaining unused opioid pills following their child's surgery due to fear of untreated postoperative pain. Assessment of pain in adolescents with neurocognitive disability is challenging. We hypothesized that parents of adolescents with neurocognitive disability may report less opioid use and higher opioid pill retention. METHODS: Adolescents (13-20 y) undergoing elective surgery (posterior spinal fusion, hip reconstruction, arthroscopy, tonsillectomy) were prospectively enrolled from a tertiary children's hospital from 2019 to 2020. Only adolescents prescribed opioids at discharge were included. Parents completed a preoperative survey collecting sociodemographic characteristics and two postoperative surveys at 30- and 90-d. Neurocognitive disability was determined at time of enrollment by caregiver report, and included adolescents with cerebral palsy, severe autism spectrum disorder, and discrete syndromes with severe neurocognitive disability. RESULTS: Of 125 parent-adolescent dyads enrolled, 14 had neurocognitive disability. The median number of opioid pills prescribed at discharge did not differ by neurocognitive disability (29, interquartile range {IQR}: 20.0-33.3 versus 30, IQR: 25.0-40.0, P = 0.180). Parents of both groups reported similar cumulative days of opioid use (7.0, IQR: 3.0-21.0 versus 6.0, IQR:3.0-10.0, P = 0.515) and similar number of opioid pills used (4, IQR: 2.0-4.5 versus 12, IQR: 3.5-22.5, P = 0.083). Parents of both groups reported similar numbers of unused opioid pills (17, IQR: 12.5-22.5 versus 19, IQR: 8.0-29.0, P = 0.905) and rates of retention of unused opioids (15.4% versus 23.8%, P = 0.730). CONCLUSIONS: The number of opioid pills prescribed did not differ by neurocognitive disability and parents reported similar opioid use and retention of unused opioid pills. Larger studies are needed to identify opportunities to improve postoperative pain control for children with neurocognitive disability.

Consensus-Based Best Practice Guidelines for the Management of Spinal Deformity and Associated Tumors in Pediatric Neurofibromatosis Type 1: Screening and Surveillance, Surgical Intervention, and Medical Therapy.

BACKGROUND: Spinal conditions, such as scoliosis and spinal tumors, are prevalent in neurofibromatosis type 1 (NF1). Despite the recognized importance of their early detection and treatment, there remain knowledge gaps in how to approach these manifestations. The purpose of this study was to utilize the experience of a multidisciplinary committee of experts to establish consensus-based best practice guidelines (BPGs) for spinal screening and surveillance, surgical intervention, and medical therapy in pediatric patients with NF1. METHODS: Using the results of a prior systematic review, 10 key questions that required further assessment were first identified. A committee of 20 experts across medical specialties was then chosen based on their clinical experience with spinal deformity and tumors in NF1. These were 9 orthopaedic surgeons, 4 neuro-oncologists/oncologists, 3 neurosurgeons, 2 neurologists, 1 pulmonologist, and 1 clinical geneticist. An initial online survey on current practices and opinions was conducted, followed by 2 additional surveys via a formal consensus-based modified Delphi method. The final survey involved voting on agreement or disagreement with 35 recommendations. Items reaching consensus (≥70% agreement or disagreement) were included in the final BPGs. RESULTS: Consensus was reached for 30 total recommendations on the management of spinal deformity and tumors in NF1. These were 11 recommendations on screening and surveillance, 16 on surgical intervention, and 3 on medical therapy. Five recommendations did not achieve consensus and were excluded from the BPGs. CONCLUSION: We present a set of consensus-based BPGs comprised of 30 recommendations for spinal screening and surveillance, surgical intervention, and medical therapy in pediatric NF1.

Concave and convex growth do not differ over tethered vertebral segments, even with open tri-radiate cartilage.

PURPOSE: To assess the following hypotheses related to vertebral body tethering (VBT): 1. VBT is associated with asymmetric (concave > convex) increases in height over the instrumented vertebra. 2. The instrumented Cobb angle improves following VBT surgery with growth. METHODS: This is a retrospective case series of pediatric patients from a multicenter scoliosis registry treated with VBT between 2013 to 2021. INCLUSION CRITERIA: patients with standing radiographs at < 4 months and ≥ 2 years after surgery. Distances between the superior endplate of the UIV and the inferior endplate of the LIV were measured at the concave corner, mid-point, and convex corner of the endplates. The UIV-LIV angle was recorded. Subgroup analyses included comparing different Risser scores and tri-radiate cartilage (TRC) closed versus open using student t-tests. RESULTS: 83 patients met inclusion criteria (92% female; age at time of surgery 12.5 ± 1.4 years) with mean follow-up time of 3.8 ± 1.4 years. Risser scores at surgery were: 0 (n = 33), 1 (n = 12), 2 (n = 10), 3 (n = 11), 4 (n = 12), and 5 (n = 5). Of the 33 Risser 0 patients, 17 had an open TRC, 16 had a closed TRC. The UIV-LIV distance at concave, middle, and convex points significantly increased from immediate post-op to final-follow-up for Risser 0 patients, but not for Risser 1-5 patients. Increases in UIV-LIV distance were not significantly different between concave, middle, and convex points for all groups. There was no significant improvement or worsening in UIV-LIV angle for any group. CONCLUSION: At a mean of 3.8 years following VBT, 33 Risser 0 patients demonstrated significant growth in the instrumented segment, though there was no difference between concave or convex growth, even for patients with open TRC.

Deformity angular ratio is associated with neuromonitoring changes without a vertebral column resection: spinal deformity is more influential than type of surgery.

PURPOSE: The purpose of this study is to investigate the effect of the deformity angular ratio (DAR) on intra-operative neuromonitoring (IONM) signal changes during posterior spinal fusion (PSF) without vertebral column resection (VCR). METHODS: Retrospective review of severe pediatric spinal deformity patients treated with PSF without VCR or three-column osteotomy from 2008 to 2018. Exclusion criteria were prior instrumentation, lack of IONM, and incomplete radiographic data. Coronal DAR (C-DAR), sagittal DAR (S-DAR), and total DAR (T-DAR) were calculated and compared between patients with IONM signal loss and those without. RESULTS: Two hundred and fifty-three patients met inclusion criteria. Forty-seven of two hundred and fifty-three (19%) patients had IONM signal loss. Intra-operative wake-up test was performed in seven cases; three of seven (43%) had a neurological deficit on wake-up test. All neurological deficits resolved at a mean of 41 days postop. IONM loss was associated with increased kyphosis (p = 0.003) and was not associated with Cobb angle (p = 0.16). S-DAR (p = 0.03) and T-DAR (p = 0.005) were associated with IONM signal loss but C-DAR was not (p = 0.06). Increased incidence of IONM signal loss was seen with S-DAR > 7 (p = 0.02) or T-DAR > 27 (p = 0.02). Twenty-four of ninety-two (26%) patients with S-DAR > 7 had IONM signal loss compared to twenty-three of one hundred and sixty-one (14%) with S-DAR ≤ 7 (OR, 2.1; 95% CI, 1.1-4.0). Seven of sixteen (44%) patients with T-DAR > 27 had signal loss compared to forty of two hundred and thirty-seven (17%) patients with T-DAR ≤ 27 (OR, 3.8; 95% CI, 1.3-10.9). CONCLUSION: Patients with S-DAR > 7 or T-DAR > 27 have a higher risk of IONM loss during pediatric PSF even in the absence of a VCR or three-column osteotomies.

Rate and risk factors for pediatric cervical spine fusion pseudarthrosis: opportunity for improvement.

PURPOSE: Although the pediatric population typically has a high union rate, the cervical spine has a reputation for frequent pseduarthrosis, as high as 38% in some prior series. Our purpose was to examine the rate and risk factors for pseudarthrosis in pediatric cervical spine fusions. METHODS: Retrospective review of all patients with ≥ 2 years follow-up undergoing cervical spinal fusion between January 2004 and December 2019 at a tertiary pediatric hospital. Pseudarthrosis was defined as an absence of radiographic union as assessed by the attending surgeon for which revision surgery was performed. RESULTS: 64 patients (mean age: 8.4 ± 4.7 years) met inclusion criteria. Mean follow-up was 63.3 ± 41.4 months (range: 24-187 months). 28 fusions (44%) included the occiput. 41 patients (64%) had instrumentation, while 23 patients (36%) had uninstrumented fusions. 48 (75%) patients had a halo for a mean of 97.6 ± 49.5 days. The incidence of pseudarthrosis was as follows: overall = 8/64 (12.5%); posterior fusion = 14.8% (8/54); anterior fusions = 0% (0/4); and anteroposterior fusions = 0% (0/6). The rate of pseudarthrosis was over 8 times higher in fusions involving the occiput (occipitocervical fusion: 25.0%; 7/28 vs. cervical alone: 2.8%; 1/36; p = 0.02). Although not statistically significant, the rate of pseudarthrosis was 3 times higher in uninstrumented fusions (21.7%; 5/23) than instrumented fusions (7.3%; 3/41) (p = 0.12). In patients with uninstrumented fusion to the occiput, pseudarthrosis rate was 35.7% (5/14), which was higher compared to those who did not (6.0%; 3/50) (p = 0.01). Incidence of pseudarthrosis was similar in patients who received autograft (13.0%; 7/54) compared to allograft alone (10.0%; 1/10) (p > 0.999). CONCLUSIONS: The pseudarthrosis rate in pediatric cervical spine fusions remained high despite frequent use of halo immobilization and autograft. Patients with uninstrumented occipitocervical fusions are at particularly high risk with more than 1 in 3 developing a pseudarthrosis. STUDY DESIGN: Retrospective, Comparative. LEVEL OF EVIDENCE: III.

Adolescent idiopathic scoliosis patients treated with bracing, surgery, or observation showed no difference in behavioral and emotional function over a 2-year period.

The purpose of this study was to assess if behavior and emotional function, as measured by the Pearson Behavioral Assessment Survey for Children, Second Edition (BASC-2) in patients and parents, changes with differing treatment protocols in patients with adolescent idiopathic scoliosis (AIS). One previous study showed abnormal BASC-2 scores in a substantial number of patients diagnosed with AIS; however, no study has assessed how these scores change over the course of treatment. AIS patients aged 12 to 21 years completed the BASC-2. The 176-item questionnaire was administered to subjects at enrollment, assessing behavioral and emotional problems across 16 subscales of 5 domains: school problems, internalizing problems, inattention/hyperactivity, emotional symptoms index, and personal adjustment. Parents were given an equivalent assessment survey. Surveys were administered again after 2 years. Subject treatment groups (bracing, surgery, and observation) were established at enrollment. Patients were excluded if they did not complete the BASC-2 at both time points. Forty-six patients met the inclusion criteria, with 13 patients in the surgical, 20 in the bracing, and 13 in the observation treatment groups. At enrollment, 26% (12/46) of subjects with AIS had a clinically significant score in 1 or more subscales, and after 2 years 24% (11/46) of subjects reported a clinically significant score in at least 1 subscale (P = .8). There were no significant differences in scores between enrollment and follow-up in any treatment group. Similar to what was reported in a previous study, only 36% (4/11) of patients had clinically significant scores reported by both patient and parent, conversely 64% (7/11) of parents were unaware of their child's clinically significant behavioral and emotional problems. Common patient-reported subscales for clinically significant and at-risk scores at enrollment included anxiety (24%; 11/46), hyperactivity (24%; 11/46), attention problems (17%; 8/46), and self-esteem (17%; 8/46). At 2-year follow-up, the most commonly reported subscales were anxiety (28%; 13/46), somatization (20%; 9/46), and self-esteem (30%; 14/46). Patients with AIS, whether observed, braced or treated surgically, showed no significant change in behavior and emotional distress over the course of their treatment, or compared with each other at 2-year follow-up.

Treatments and Sequelae of Pediatric Pathologic Proximal Femur Fractures Due to Benign Bone Cyst.

BACKGROUND: The proximal femur is a common location for pathologic fractures in children, yet there is little published information regarding this injury. The purpose of this study was to investigate the outcomes of pediatric pathologic proximal femur fractures due to benign bone tumors. METHODS: A retrospective review of patients treated for pathologic proximal femur fractures from 2004 to 2018 was conducted. Inclusion criteria were age below 18 years and pathologic proximal femur fracture secondary to a benign bone tumor. Patients were excluded if they had <1 year of follow-up. Medical charts and serial radiographs were reviewed for fracture classification, underlying pathology, treatment, complications, and time to fracture healing. RESULTS: A total of 14 patients were included. Mean age was 6±3 (3 to 11) years, and mean follow-up was 44±21 (22 to 86) months. Index treatment was spica casting in 9/14 (68%) patients, while 5/14 (32%) were treated with internal fixation. Of the 9 patients initially treated with casting, 22% (2/9) required repeat spica casting at a mean of 0.6 months after index treatment, 67% (6/9) required internal fixation at a mean of 20.3 months after index treatment, and 11% (1/9) did not require revision treatment. Eighty-eight percent (8/9) of patients treated with casting required revision treatment compared with 40% (2/5) of those treated with internal fixation (P=0.05). Nonunion occurred after 1 refracture, malunion with coxa vara occurred in 2 fractures, and the remaining 11/14 (84%) fractures had a union at a mean of 4.9±3.0 months All cases of malunion occurred in patients initially treated nonoperatively. There were 19 distinct complications in 10/14 (71%) patients. The incidence of any revision surgery was 64% (9/14). CONCLUSIONS: In this series, pediatric pathologic proximal femur fractures demonstrated prolonged time to union, high incidence of revision surgery (64%), and substantial complication rate (71%). In children with pathologic proximal femur fractures, treatment with internal fixation is recommended as this series showed a 78% failure rate of initial conservative management. LEVEL OF EVIDENCE: Level IV.

Outcomes of Operatively Managed Lumbar and Sacral Facet Fractures in Pediatric Athletes: A Case Series.

BACKGROUND: Facet fractures have been reported in a total of 6 young athletes in 4 previous publications. These injuries were not diagnosed on magnetic resonance imaging (MRI) or radiographs, and were identified on computed tomography (CT). Our purpose was to report a series of athletes with operatively managed facet fractures. This may be an under-recognized diagnosis. METHODS: Retrospective review of pediatric patients with operatively managed isolated lumbar or sacral facet fractures from 3 tertiary pediatric hospitals from 2014 to 2019. Clinical records and imaging studies were reviewed. RESULTS: Ten patients with symptomatic lumbar or sacral facet fractures met inclusion criteria (mean age at presentation; 13.3±2.1 years, 70% Female). All patients reported competitive participation in sports. On physical examination, 10/10 (100%) of patients had lower back pain that was exacerbated with lumbar spine extension. Limited CT scans demonstrated facet fractures in 10/10 (100%) patients not detected on plain film or MRI. All patients experienced significant relief of pain following excision of the facet fracture fragment. At time of first postoperative visit, 9/10 (90%) patients were pain free while one had generalized back pain thought to be related to fibromyalgia and not facet pathology. At time of last follow-up, 2/10 (20%) of patients reported nonspecific back pain that was not localized in the area of the facet fracture, while 80% (8/10) remained pain free. All patients 100% (10/10) returned to full participation to sports. There were no complications noted in this series. Average follow-up was 27 months (range: 1 to 68 mo). CONCLUSIONS: Athletes with localized back pain exacerbated by spine extension may have a facet fracture. As facet fractures are usually not identified with radiographs or MRI, a limited CT scan should be considered in the evaluation of pediatric athletes with localized back pain exacerbated by extension. In this series, surgical excision of facet fracture fragments was safe and provided predictable pain relief.

Matched Comparison of Magnetically Controlled Growing Rods with Traditional Growing Rods in Severe Early-Onset Scoliosis of ≥90°: An Interim Report on Outcomes 2 Years After Treatment.

BACKGROUND: Severe early-onset scoliosis (EOS) is managed surgically but represents a challenge due to limited implant fixation points, large curve size, and fragile patients with comorbidities. Magnetically controlled growing rods (MCGRs) have the advantage of avoiding surgical intervention for routine lengthening, but their ability to address severe EOS has not been studied, to our knowledge. METHODS: A retrospective review of a prospectively collected international database identified 44 children with severe (≥90°) EOS treated with MCGRs who met our study criteria. Etiology, age, and sex-matched patients treated with traditional growing rods (TGRs) were identified from the same database. Patients were evaluated at a 2-year follow-up. No patients with vertically expandable prosthetic titanium ribs (VEPTRs) were included. The health-related quality of life was evaluated with the 24-Item Early Onset Scoliosis Questionnaire (EOSQ-24). RESULTS: The mean preoperative major coronal curve was 104° in the MCGR group and 104° in the TGR group. At the 2-year follow-up, the mean major coronal curves were 52° and 66° (p = 0.001), respectively. The mean T1-T12 heights were 155 mm and 152 mm preoperatively and 202 mm and 192 mm at the 2-year follow-up (p = 0.088). According to Kaplan-Meier analysis, the 2-year unplanned-revision-free survival was 91% in the MCGR group and 71% in the TGR group (p < 0.005). The 2-year score in the EOSQ-24 pulmonary function domain was better in the MCGR group. There were no other significant differences in the EOSQ-24 scores between the groups. CONCLUSIONS: MCGRs for severe EOS provided significantly better major curve correction with significantly fewer unplanned revisions than TGRs at a 2-year follow-up. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Pre-operative nutrition assessments do not improve outcomes in cerebral palsy patients undergoing varus derotational osteotomy.

ABSTRACT: Pre-operative nutritional assessments have been used as a "cornerstone" to help optimize nutritional status and weight in children with cerebral palsy (CP) to lower the risk of postoperative complications. However, the potential value of nutritional assessments on surgical outcomes in patients with CP undergoing major orthopedic surgery remains unproven.Do pre-operative nutritional assessments reduce complication rates of varus derotational osteotomy surgery in children with CP? Are complication rates higher in patients with a gastrostomy tube (G-tube) and can they be decreased by pre-operative nutritional assessment?One-hundred fifty-five patients with CP who underwent varus derotational osteotomy from January 1, 2012 through December 31, 2017 at a tertiary pediatric hospital with minimum 6 months follow-up were retrospectively identified. One-hundred-ten (71%) were categorized as "non-ambulatory" (Gross Motor Function Classification System [GMFCS] IV-V), and 45 (29%) as "ambulatory" (GMFCS I-III). Variables assessed included age, GMFCS level, G-tube, body mass index (BMI) percentile, complications, and if patients underwent pre-operative nutritional assessment.One-hundred-eleven patients (71.6%) underwent pre-operative nutritional assessment. Sixty-two of 155 patients (40.0%) had G-tubes. In non-ambulatory patients with G-tubes, BMI percentile changes were not significantly different between patients with a pre-operative nutritional assessment compared to those without at 1 (P = .58), 3 (P = .61), 6 (P = .28), and 12 months (P = .21) postoperatively. In non-ambulatory patients who underwent pre-operative nutritional assessment, BMI percentile changes were not significantly different between those with and without G-tubes at 1 (P = .61), 3 (P = .71), 6 (P = .19), and 12 months (P = .10). Pulmonary complication rates were significantly higher in non-ambulatory patients with G-tubes than in non-ambulatory patients without G-tubes (20% vs 4%, P = .03). Pre-operative nutritional assessments did not influence postoperative complication rates for non-ambulatory patients with or without a G-tube (P = .12 and P = .16, respectively). No differences were found in postoperative complications between ambulatory patients with and without G-tubes (P = .45) or between ambulatory patients with or without nutritional assessments (P = .99).Nutritional assessments, which may improve long term patient nutrition, should not delay hip surgery in patients with CP and progressive lower extremity deformity. Patients and their families are unlikely to derive any short-term nutritional improvement using routine pre-operative evaluation and surgical outcomes are unlikely to be improved.Level of Evidence: III, retrospective comparative.