Complications of single growing rod constructs in the treatment of severe early-onset scoliosis: a lesson relearned.

PURPOSE: Early-onset scoliosis (EOS) is one of the most challenging areas of orthopedic management. Previous studies have reported that EOS patients were associated with high risk of complications following growth-friendly surgery. This study was performed to evaluate the complications of single traditional growing rods (TGRs) in the treatment of EOS. METHODS: In a retrospective chart review study, medical records of all EOS patients treated with single TGRs between 2006 and 2018 were analyzed. Patients under the age of 10 at the time of surgery who had at least 24 months of follow-up were included. Intra- and post-operative complications included both device-related and disease-related complications. Statistical analysis was performed with SPSS. RESULTS: A total of 35 patients with a mean age of 5.7 ± 2.1 years with the mean follow-up duration of 33.3 ± 9.1 months were included in the final analysis. Of the 35 participants, 27 children (77.1%) experienced at least one complication. A total of 61 complications were observed, giving rise to 1.7 complications per patient. An unplanned surgical procedure was needed to manage 42 of the 61 complications (68.8%). Thirty-five cases of implant failure, 11 cases of deep infection, and 2 cases of junctional kyphosis were identified. CONCLUSION: It seems that even in the setting that the use of dual TGRs is not possible, the use of single TGRs as the only therapeutic modality should be minimized due to high rate of complications even as a bridge treatment. LEVEL OF EVIDENCE: Therapeutic level III.

Three-dimensional analysis of spinal deformity correction in adolescent idiopathic scoliosis: comparison of two distinct techniques.

PURPOSE: To compare 3D postoperative deformity correction using two distinct commonly utilized techniques for the treatment of adolescent idiopathic scoliosis (AIS). METHODS: AIS patients with major thoracic (Lenke 1-2) curves at two sites who underwent deformity correction via posterior spinal instrumented fusion using one of two distinct techniques were retrospectively reviewed. Patients were matched 1:1 between sites for Lenke type (95% Lenke 1) and follow-up time. The "band site" performed posteromedial translation using thoracic sublaminar bands and 5.5-mm rods. The "screw site" performed spine derotation using differential rod contouring with pedicle screws and 5.5-mm rods. 3D measures of deformity from spinal reconstructions were compared between sites. RESULTS: Preoperatively, the groups had similar thoracic curve magnitudes (band, 55 ± 12° vs. screw, 52 ± 10°; p > 0.05); the "screw site" had less T5-T12 kyphosis (2 ± 14° vs. 7 ± 12°, p = 0.05) and greater thoracic apical rotation (- 19 ± 7° vs. - 14 ± 8°, p = 0.007). Postoperatively, the "screw site" had greater percent correction (61% vs. 76%, p < 0.001) and kyphosis restoration (p = 0.002). The groups achieved a similar amount of apical derotation (p = 0.9). The "band site" used cobalt chromium rods exclusively; the "screw site" used cobalt chromium (3%) and stainless steel (97%; p < 0.001). The "band site" performed significantly longer fusions. CONCLUSIONS: Significant variations were found between two commonly utilized techniques in AIS surgery, including rod material, correction mechanisms, and fusion levels. Significantly, a greater 3D deformity correction of the coronal and sagittal planes was observed at the "screw site" compared to the "band site", but with no difference in axial plane correction.

40% reoperation rate in adolescents with spondylolisthesis.

STUDY DESIGN: Multicenter retrospective. OBJECTIVE: To determine the long-term complication rate associated with surgical treatment of spondylolisthesis in adolescents. There is limited information on the complication rate associated with posterior spinal fusion (PSF) of spondylolisthesis in the pediatric and adolescent population. METHODS: Patients who underwent PSF for spondylolisthesis between 2004 and 2015 at four spine centers, < 21 years of age, were included. Exclusion criteria were < 2 years of follow-up or anterior approach. Charts and radiographs were reviewed. RESULTS: 50 patients had PSF for spondylolisthesis, 26 had PSF alone, while 24 had PSF with trans-foraminal lumbar interbody fusion (TLIF). Mean age was 13.9 years (range 9.6-18.4). Mean follow-up was 5.5 years (range 2-15). Mean preoperative slip was 61.2%. 20/50 patients (40%) experienced 23 complications requiring reoperation at a mean of 2.1 years (range 0-9.3) for the following: implant failure (12), persistent radiculopathy (3), infection (3), persistent back pain (2), extension of fusion (2), and hematoma (1). In addition, there were 22 cases of radiculopathy (44%) that were transient. Rate of implant failure was related to preoperative slip angle (p = 0.02). Reoperation rate and rates of implant failure were not associated with preoperative % slip (reoperation: p = 0.42, implant failure: p = 0.15), postoperative % slip (reoperation: p = 0.42, implant failure: p = 0.99), postoperative kyphosis of the lumbosacral angle (reoperation: p = 0.81, implant failure: p = 0.48), change in % slip (reoperation: p = 0.30, implant failure: p = 0.12), change in slip angle (reoperation: p = 0.42, implant failure: p = 0.40), graft used (reoperation: p = 0.22, implant failure: p = 0.81), or addition of a TLIF (reoperation: p = 0.55, implant failure: p = 0.76). CONCLUSION: PSF of spondylolisthesis in the adolescent population was associated with a 40% reoperation rate and high rate of post-operative radiculopathy. Addition of a TLIF did not impact reoperation rate or rate of radiculopathy.

Scoliosis in Patients With Friedreich Ataxia: Results of a Consecutive Prospective Series.

STUDY DESIGN: Prospective monocentric study. OBJECTIVES: To describe the radiologic characteristics and evolution of spinal shapes in a pediatric cohort of patients with Friedreich ataxia (FA). SUMMARY OF BACKGROUND DATA: FA is a spinocerebellar degenerative disorder responsible for gait impairment in children and young adults, and several orthopedic deformities can occur during growth, including scoliosis. However, curves' characteristics and their natural evolution have been poorly described, and the subsequent therapeutic management remains controversial. METHODS: Sixty six FA patients were prospectively included between 2008 and 2017. Clinical, functional, and radiologic records were conducted twice a year. Coronal curve types, segmental measurements, and skeletal maturity were assessed. RESULTS: A scoliotic deformity was reported in 71% of the patients at a mean age of 11.7 ± 3.1 years. Average follow-up was 6 years, including 75% of patients with closed triradiate cartilage at latest examination. Mean Cobb angle was 34° ± 2°. Main right thoracic curves were the most frequent curves observed (36%), followed by double major (21%), thoracolumbar and left thoracic curves (13%), main lumbar (11%), and long C-shape curves (6%). Hyperkyphosis (>40°) was present in 66%, with an average kyphosis angle of 50° ± 3°, and anterior misalignment (>5°) occurred in 53%. The severity of the Cobb angle was neither correlated to the FA severity scores nor the age at FA diagnosis. An arthrodesis was performed in 9 patients, including 5 patients (45%) who were ambulatory at least 1 year after surgery. CONCLUSIONS: The prevalence of scoliosis in FA was high (71%), and thoracic hyperkyphosis, with anterior misalignment, was frequently observed, which might be related to the anterior imbalance frequently encountered in patients with an ataxia. Posterior fusion including sacral instrumentation was only performed in nonambulatory patients, and the loss of ambulation was not associated with spinal surgery. LEVEL OF EVIDENCE: Level IV.

External fixation: Role in decreasing postoperative complications of complex syndactyly release - A review of 18 patients.

BACKGROUND: Primary and revision surgery for complete complex congenital syndactyly (CCCS) of the hand carries a risk of complications such as web maceration, which can result in flap or graft loss and alter the final appearance. No consensus emerges from the scant published data on postoperative care after CCCS surgery. The objective of this study was to assess the role for temporary external fixation in stabilising the commissure and facilitating surgical wound care. HYPOTHESIS: Using external fixation after CCCS release facilitates postoperative wound care and decreases the complication rate. MATERIAL AND METHODS: Eighteen patients requiring primary CCCS surgery or revision CCCS surgery due to adhesions or web creep were included in a single-centre retrospective study. After release, an external fixator made of Kirschner pins was installed to temporarily immobilise the inter-phalangeal joints. The dressing was changed every 3 days for 3 weeks, and the external fixator was then removed. The parents and nurses completed questionnaires that used 0-10 point scales to assess ease and duration of dressing changes and perceptions and apprehensions experienced by parents and nurses, as well as pain by patients, during dressing changes. RESULTS: No patient experienced maceration or failure of a graft or flap. Pin site discharge was noted in 1 patient and resolved fully after pin removal. Pain intensity was estimated at 4.2/10 during the first dressing change and 1.3/10 during the last dressing change. In the parents, apprehension was 9.6/10 and 5.1/10 during the first and last dressing changes, and stress was 8.1/10 and 4.1/10, respectively. Dressing change difficulty was rated 1.1/10 at the first and 0.9/10 at the last dressing change. Dressing change duration decreased from 13 to 10minutes. CONCLUSION: These encouraging results support temporary commissure stabilisation by an external fixator to decrease postoperative complication rates and facilitate dressing changes after CCCS release. LEVEL OF EVIDENCE: IV, retrospective observational study.

Correction to: Efficacy of the Game Ready® cooling device on postoperative analgesia after scoliosis surgery in children.

Unfortunately, one co-author name was incorrectly published in the original publication. The complete correct name of the co-author is given below.

Efficacy of the Game Ready® cooling device on postoperative analgesia after scoliosis surgery in children.

PURPOSE: The aim of this study was to investigate the opioid-sparing effect of a cooling brace after surgical correction of idiopathic surgery in children. METHODS: We compared two consecutive cohorts of patients before and after introducing this technique in our institution. Management of patients was standardized. The primary objective of the study was to investigate the morphine consumption during the first postoperative day. Secondary outcomes were opioid consumption at day 3, pain intensity (at days 1 and 3), the mobilization in the standing position and duration of hospitalization. RESULTS: This study included 23 and 22 patients in the control and the cooling cohorts. Cooling brace was associated with a significant decrease in morphine consumption at day 1 (1.7 [0.9, 3.3] versus 1.2 [0.5, 3.2] mg kg-1, P = 0.02) and day 3 (2.5 [0.5, 6.7] versus 1.2 [0.9, 2.5] mg kg-1, P = 0.003), and a reduction in duration of hospitalization (4 [3, 6] versus 3 [3, 4] days, P = 0.004). However, no difference was found on the pain intensity or the percentage of patient mobilized in the standing position. Number of level fused and intraoperative opioid consumption were also different between the two cohorts. However, multivariate analysis found only the use of the cooling brace as significantly associated with opioid consumption at day 1. CONCLUSION: The use of this cooling brace allows decreasing the opioid use after surgical correction of idiopathic surgery in children. The current results strongly suggest an interest of this technique in the postoperative management of patients. These slides can be retrieved under Electronic Supplementary Material.

How to Optimize Axial Correction Without Altering Thoracic Sagittal Alignment in Hybrid Constructs With Sublaminar Bands: Description of the "Frame" Technique.

STUDY DESIGN: Retrospective monocentric database study. OBJECTIVES: To describe the "frame" reduction technique and report the 3D quantitative analysis of postoperative corrections in a consecutive series of thoracic adolescent idiopathic scoliosis (AIS) patients. SUMMARY OF BACKGROUND DATA: Posteromedial translation technique using sublaminar bands have been proved to be efficient and safe for 3D correction of the deformity and overall cosmetic aspect of the trunk. However, the ability to correct the axial plane may tend to rotate the vertebra clockwise instead of counterclockwise, thus increasing apical vertebra axial rotation (AVR) and the rib hump. A technical improvement was developed to emphasize axial correction. METHODS: 60 thoracic AIS patients consecutively operated by posteromedial translation using the "frame" reduction technique were included with a minimum 2-year follow-up. Precontoured rods were connected with fixed transverse connectors according to a personalized preoperative planning. Rods were first inserted distally in the pedicle screws to achieve lumbar correction, and then in the upper anchors, and finally sublaminar bands were connected to their corresponding rods to progressively bring the concave lamina to the concave rod to correct the thoracic deformity. Sagittal and coronal 3D measures were performed preoperatively and at the latest follow-up using SterEOS (EOS Imaging, Paris, France) to assess the efficiency of the technique. RESULTS: The distance from the center of the apical vertebra to the reference axis in the frontal plane was reduced from 4.7 to 1.1 cm, traducing the efficient medial translation of the spine during correction. T1-T12 kyphosis significantly increased after surgery (28°-35°). 3D location of the upper instrumented vertebra (UIV) was not affected. The apical rotation was significantly reduced after surgery (19°-11°), and the AVR correction rate averaged 42.2%. CONCLUSION: The "frame" technique is an innovative way of using polyester bands, optimizing axial correction while respecting sagittal alignment. LEVEL OF EVIDENCE: Level IV.

Does Staphylococcus aureus nasal decontamination affect the rate of early surgical site infection in adolescent idiopathic scoliosis surgery?

PURPOSE: Surgical site infection (SSI) is a main complication after adolescent idiopathic scoliosis (AIS) surgery. Nasal colonization with S. aureus is a known risk factor for developing nosocomial infections in cardiac surgery. However, the risk in orthopedic surgery remains unclear, especially in spine surgery. This study aims to report the efficacy of a preoperative nasal decontamination program in S. aureus carriers on the incidence of early SSI after AIS posterior surgery. METHODS: Between January 2014 and July 2017, all AIS patients were screened preoperatively with nasal swabs and decontaminated if positive 5 days before surgery. Early SSI was identified, and microorganisms findings were analyzed within nasal carriage and compared to a previous series published before the decontamination program (2007-2011). RESULTS: Among the 331 AIS posterior fusion performed during the study period, incidence of positive nasal swab was 23% (n = 75). Those were preoperatively decontaminated. In comparison with the period before the nasal decontamination program, incidence of S. aureus early SSI significantly decreased from 5.1 to 1.3%, p < 0.05. None of those S. aureus decontaminated patients had an early S. aureus SSI. In all cases of S. aureus infections, S. aureus nasal screening was negative with a mean delay of 315 days (± 115) before surgery, which was significantly different from the global cohort (104 days ± 67, p < 0.05). CONCLUSIONS: Preoperative S. aureus nasal decontamination was associated with a significant decrease in S. aureus SSI. Optimal delay of nasal screening needs to be optimized in order to diagnose intermittent S. aureus carriers. These slides can be retrieved under Electronic Supplementary Material.

Proximal junctional kyphosis in thoracic adolescent idiopathic scoliosis: risk factors and compensatory mechanisms in a multicenter national cohort.

INTRODUCTION: Proximal junctional kyphosis (PJK) is a frequent complication, up to 46%, in adolescent idiopathic scoliosis surgical treatment (AIS). Several risk factors have been evoked but remain controversial. The purpose of this study was to analyze the incidence of PJK in a multicenter cohort of AIS patient and to determine risk factor for PJK. MATERIALS AND METHODS: Lenke I and II AIS patients operated between 2011 and 2015 (minimum of 2-years follow-up) were included. On fullspine X-rays, coronal and sagittal radiographic parameters were measured preoperatively, postoperatively and at final follow-up. Occurrence of radiological PJK corresponding to a 10° increase in the sagittal Cobb angle, measured between the upper instrumented vertebra (UIV) and UIV + 2, between postoperative and 2-years follow-up X-rays, was reported. RESULTS: Among the 365 patients included, 15.6% (n = 57) developed a PJK and only 10 patients required a revision surgery. Preoperatively, PJK patients had significantly larger pelvic incidence (57° ± 13° vs. 51° ± 12°), larger lumbar lordosis (LL) (63° ± 12° vs. 57° ± 11°) and bigger C7 slope. Postoperatively (3 months), in the non-PJK group, thoracic kyphosis (TK) was increased and LL was not significantly different. However, postoperatively, in the PJK group, no significant change was observed in TK, whereas C7 slope decreased and LL significantly increased. There was also a postoperative change in inflection point which was located at a more proximal level in the PJK group. Between postoperative time and final follow-up, TK and LL significantly increased in the PJK group. CONCLUSION: PJK is a frequent complication in thoracic AIS, occurring 16%, but remains often asymptomatic (less than 3% of revisions in the entire cohort). An interesting finding is that patients with high pelvic incidence and consequently large LL and TK were more at risk of PJK. As demonstrated in ASD, one of the causes of PJK might be postoperative posterior imbalance that can be due to increased LL, insufficient TK or inflection point shift during surgery. These slides can be retrieved under Electronic Supplementary Material.

Preliminary experience with SpineEOS, a new software for 3D planning in AIS surgery.

PURPOSE: Preoperative planning of scoliosis surgery is essential in the effective treatment of spine pathology. Thus, precontoured rods have been recently developed to avoid iatrogenic sagittal misalignment and rod breakage. Some specific issues exist in adolescent idiopathic scoliosis (AIS), such as a less distal lower instrumented level, a great variability in the location of inflection point (transition from lumbar lordosis to thoracic kyphosis), and sagittal correction is limited by both bone-implant interface. Since 2007, stereoradiographic imaging system is used and allows for 3D reconstructions. Therefore, a software was developed to perform preoperative 3D surgical planning and to provide rod's shape and length. The goal of this preliminary study was to assess the feasibility, reliability, and the clinical relevance of this new software. METHODS: Retrospective study on 47 AIS patients operated with the same surgical technique: posteromedial translation through posterior approach with lumbar screws and thoracic sublaminar bands. Pre- and postoperatively, 3D reconstructions were performed on stereoradiographic images (EOS system, Paris, France) and compared. Then, the software was used to plan the surgical correction and determine rod's shape and length. Simulated spine and rods were compared to postoperative real 3D reconstructions. 3D reconstructions and planning were performed by an independent observer. RESULTS: 3D simulations were performed on the 47 patients. No difference was found between the simulated model and the postoperative 3D reconstructions in terms of sagittal parameters. Postoperatively, 21% of LL were not within reference values. Postoperative SVA was 20 mm anterior in 2/3 of the cases. Postoperative rods were significantly longer than precontoured rods planned with the software (mean 10 mm). Inflection points were different on the rods used and the planned rods (2.3 levels on average). CONCLUSION: In this preliminary study, the software based on 3D stereoradiography low-dose system used to plan AIS surgery seems reliable for preoperative planning and precontoured rods. It is an interesting tool to improve surgeons' practice, since 3D planning is expected to reduce complications such as iatrogenic malalignment and to help for a better understanding of the complications, choosing the location of the transitional vertebra. However, further work is needed to improve thoracic kyphosis planning. These slides can be retrieved under Electronic Supplementary Material.

Correction of hypokyphosis in thoracic adolescent idiopathic scoliosis using sublaminar bands: a 3D multicenter study.

INTRODUCTION: The comparison of implants and correction methods remain controversial in AIS. Excellent frontal and axial correction rates have been reported with all-screw constructs, but at the expense of sagittal alignment, which has a tendency to flatten postoperatively. Posteromedial translation using hybrid constructs seems to preserve and improve thoracic kyphosis (TK), but no series exist to date with a significant number of hypokyphotic patients. In addition, the measures of TK in 2D are often wrong in severe AIS due to axial rotation. The goals of this study were therefore to analyze the 3D radiological outcomes of a group of hypokyphotic AIS patients operated with sublaminar bands. METHODS: 35 consecutive AIS hypokyphotic patients (T4T12 <15°) operated in three centers were included, with a minimum 2-year follow-up. The surgical technique was similar in all centers, associating lumbar pedicle screws and thoracic sublaminar bands. Posteromedial translation was the main correction technique, and no patient underwent prior anterior release. 3D spinal reconstructions were performed preoperatively, postoperatively and at the latest follow-up by an independent observer using SterEOS (EOS imaging, Paris, France), and 2D and 3D measurements were compared. In addition, a new 3D parameter [sagittal shift of the apical vertebra (SSAV)], reflecting the translation of the apical vertebra of the main curve in the patient sagittal plane, was described and reported. RESULTS: The age of the cohort was 16 years and the number of sublaminar bands used for correction averaged 6 (±1.5). T1T12 and T4T12 sagittal Cobb angles appeared to be overestimated on 2D postoperatively (3°, p = 0.002 and 4°, p < 0.001, respectively). Hence, only 3D measurements were kept for the quantitative analysis of the postoperative correction. T4T12 TK significantly increased after surgery (average 8° ± 7°, p < 0.001), but 11 patients (31.4%) remained hypokyphotic. Seven out of the eight patients (87.5%) who presented a thoracic lordosis (i.e., T4T12 <0°) preoperatively were corrected after surgery (mean gain 16° ± 4°). A posterior shift (positive SSAV) of the apical vertebra was reported in 24 patients (68.6%). In this subgroup, the mean SSAV was +2 cm (±1). Good correlation was found between the SSAV and the postoperative change in 3D T4T12 kyphosis (r = 0.62). CONCLUSION: Measures in 2D tend to overestimate sagittal alignment and are not sufficient to evaluate postoperative correction. SSAV is a new 3D parameter reflecting the TK change that needs to be further investigated and used in the future. This series confirms that sublaminar bands should be considered in hypokyphotic patients, since thoracic sagittal alignment was restored in 68.6% of the cases.

Posterior-only surgery with preoperative skeletal traction for management of severe scoliosis.

PURPOSE: The surgical treatment of severe adolescent spinal deformities is challenging and carries substantial risks of mortality and morbidity. To mitigate this risk, surgeons have employed various methods as this study designed to evaluate the safety and effectiveness of preoperative halo-femoral or halo gravity traction (HGT) followed by posterior-only surgery in the management of severe scoliosis. METHOD: A total number of 23 patients with severe scoliosis treated by preoperative skeletal traction (halo gravity or halo femoral) followed by posterior fusion and instrumentation in one stage. All patients were followed for a minimum of 2 years after surgery. RESULTS: The average age of the patients was 12.7 years at the time of surgery. Mean of the Cobb angle improved from 99.9° ± 8.2° preoperatively to 75.3° ± 8° post-traction and 49.5° ± 7.7° postoperatively. Kyphosis angle corrected from 56.4° ± 9.5° to 38.6° ± 5.8°. The preop-FVC% was 41 ± 6.1% and after 1 year follow-up FVC% was 45.7 ± 7.7%. No patients required an anterior release due to amount of their deformity. DISCUSSION: Despite the benefits of modern instrumentation procedures, the treatment of severe scoliosis can be very competing. We think that by applying preoperative halo femoral traction and halo-gravity traction, managing severe scoliosis will be in safe and easy manner and can lead to better deformity correction and less neurological complications and facilitate to avoid anterior operation for severe scoliosis and its related complications.

Do Sublaminar Polyester Bands Affect the Outcomes of Postoperative Infections After Adolescent Idiopathic Scoliosis Surgery?

BACKGROUND: The incidence of surgical site infections (SSI) after adolescent idiopathic scoliosis (AIS) surgery ranges from 0.5% to 7%. There is currently a regain of interest in hybrid constructs, combining lumbar pedicle screws and thoracic sublaminar bands, but some authors have raised concerns about the risk of SSI and the difficulty of bacterial eradication. The goal of this study was therefore to assess the outcomes of SSI after AIS surgery using sublaminar bands. METHODS: A total of 524 consecutive patients operated for AIS using sublaminar bands between June 2006 and June 2014 were included. SSI cases were identified and analyzed retrospectively. Radiologic and functional outcomes were evaluated at follow-up using EOS imaging and SRS 30 scores, and compared with a control group. RESULTS: The overall SSI rate was 5.3%, with a majority of monomicrobial (86%) infections occurring in the first 6 weeks postoperative (93%). The most frequent pathogens were skin germs (Staphylococcus aureus and Propionibacterium acnes) with a community profile. Patients were treated successfully with surgical debridement without implants removal, associated with 6 weeks of antibiotherapy. However, 25% of patients required >1 surgical debridement. Instrumentation removal was decided in the 2 cases with late SSI, and performed uneventfully. Radiologic and functional outcomes at follow-up were not affected by the occurrence of SSI. CONCLUSIONS: Sublaminar bands are not associated with a higher risk of infection. However, the SSI rate in the current study stands in the upper range of the literature, and other preventive strategies should be considered. In case of early infection, bands removal is not necessary to obtain pathogen eradication, but the sublaminar implants can be pulled out safely in case of late SSI. The occurrence of SSI does not alter the outcomes at follow-up. LEVEL OF EVIDENCE: Level III.

Correlation between transverse plan kinematics and foot progression angle in children with spastic diplegia.

In diplegic patients, the orientation of foot progression depends on multiple factors. We investigated the relationship between foot progression alignment, hip and pelvic rotations during gait, femoral anteversion, and tibial torsion. Kinematic and clinical parameters were evaluated for 114 children who walked independently and had not undergone previous surgery. Causes of intoeing presented combined in 72% of cases. Internal foot progression correlated with internal hip rotation and showed an inverse correlation with tibial torsion. Our results indicate that data from clinical examination and gait analysis should be evaluated carefully before making treatment recommendations, especially in terms of the correction of torsional problems, in patients with cerebral palsy.

Assessment of Coronal Radiographic Parameters of the Spine in the Treatment of Adolescent Idiopathic Scoliosis.

BACKGROUND: To determine the most important preoperative factors that affect postoperative coronal parameters of scoliotic curves. METHODS: All Adolescent Idiopathic Scoliosis (AIS) patients included in the study were classified according to Lenke and King Classification. The fusion levels were selected according to the rigidity of the existing curves (correction less than 50%), tilt of T1 and shoulders, sagittal angle of the curves and with considering stable and neutral end vertebra. The radiographic coronal parameters: shoulders tilt angle, iliolumbar angle and coronal balance were measured in all patients before, after, and in the last follow-up visit. RESULTS: One hundred twenty patients after mean of 25 months follow-up (18-40 months) were included in the study. Before operation, abnormal coronal balance (more than 2 cm shift) was noticed in 46 patents (38%) and in the last visit, was noted in 22 patients (18%). Multivariate regression analysis revealed a significant predictive value of the preoperative coronal balance on the last visit coronal balance (P value=0.01). CONCLUSION: Preoperative coronal balance is very important to make a balanced spine after surgery. Other parameters like Lenke classification or main thoracic overcorrection did not affect postoperative coronal decompensation.

Sagittal spino-pelvic adjustment in severe Lenke 1 hypokyphotic adolescent idiopathic scoliosis patients.

PURPOSE: The human standing position requires permanent reciprocal spino-pelvic adjustments to obtain a dynamic and economic posture. This study focuses on a hypokyphotic Lenke 1 adolescent idiopathic scoliosis (AIS) patients cohort and points out their particular lumbo-pelvic adaptive mechanisms to maintain a neutral sagittal balance. METHODS: Preoperative retrospective analysis of prospectively collected data on a monocentric cohort of 455 AIS patients planned for corrective surgery. Radiological low-dose system coupled with a validated clinical routine software allowed to obtain data from eighty-four hypokyphotic [thoracic kyphosis (TK) <20°] Lenke 1 patients and were separately analyzed. Bilateral Student and one-way ANOVAs were conducted for statistical analysis. RESULTS: Mean Cobb angle was 46.3° (±7.2), TK was 11° (±7.1), sagittal vertical axis (SVA) was -10.1 mm (±30.9), pelvic incidence (PI) was 55.7° (±12.9). Fifty percents of patients were posteriorly imbalanced. Among them, patients with a low PI used an anteversion of their pelvis [indicated by a high pelvic tilt (PT) angle] but were not able to increase their lumbar lordosis (LL) to minimize the posterior spinal shift. CONCLUSIONS: Hypokyphotic Lenke 1 AIS patients use lumbo-pelvic compensatory mechanisms to maintain their global balance with a poor effectiveness. Subjects with a low PI have a restricted range of LL adaptation. Attention should be paid during surgical planning not to overcorrect lordosis in the instrumented levels in case of non-selective fusion, that may induce posterior shift of the fusion mass and expose to junctional syndromes and poor functional outcomes in this particular patients.

Video-assisted functional assessment of index pollicisation in congenital anomalies.

PURPOSE: Functional results of index pollicisation are usually assessed by the clinical score of Percival. This score is based on elementary hand movements and does not reflect the function of the neo thumb in daily life activities. The aim of this study was to develop a new video-assisted scoring system based on daily life activities to assess index pollicisation functional outcomes. METHODS: Twenty-two consecutive children, operated between 1998 and 2012, were examined with a mean of 77 months after surgery. The mean age at surgery was 34 months. Post-operative results were evaluated by a new video-assisted 14-point scoring system consisting of seven basic tasks that are frequently used in daily activities. The series of tasks was performed both on the request of the examiner and in real-life conditions with the use of a hidden camera. Each video recording was examined by three different examiners. Each examiner rated the video recordings three times, with an interval of one week between examinations. Inter- and intra-observer agreements were calculated. RESULTS: Inter- and intra-observer agreements were excellent both on request (κ = 0.87 [0.84-0.97] for inter-observer agreement and 0.92 [0.82-0.98] for intra-observer agreement) and on hidden camera (κ = 0.83 [0.78-0.91] for inter-observer agreement and 0.89 [0.83-0.96] for intra-observer agreement). The results were significantly better on request than on hidden camera (p = 0.045). The correlation between the video-assisted scoring system and the Percival score was poor. CONCLUSION: The video-assisted scoring system is a reliable tool to assess index pollicisation functional outcomes. The scoring system on hidden camera is more representative of the neo thumb use in daily life complex movements. LEVEL OF EVIDENCE: Level IV.

Medial to posterior release procedure after failure of functional treatment in clubfoot: a prospective study.

PURPOSE: Two conservative techniques for clubfoot treatment are still being debated and depend upon the institution's expertise. For >40 years, the current institution has been a pioneer in the development of the physiotherapy method; however, some severe deformities remain resistant to this method which causes pain, sprains, and difficulties wearing shoes. Therefore, a surgical approach was developed simultaneously for the treatment of these residual or recurring clubfeet. The procedure reproduces the same chronological steps by performing forefoot derotation before correcting hindfoot equinus. The aim of the current study was to assess the results of this surgical technique. METHODS: All clubfeet undergoing surgery between October 1995 and February 2009 were prospectively included. Initial severity was based on Dimeglio's classification and final outcomes on the International Clubfoot Study Group (ICFSG) outcome evaluation system. Last follow-up results were assessed by physical examination and radiographs. RESULTS: A total of 137 patients with severe clubfeet (mean Dimeglio score 12.0) underwent surgery. At the mean follow-up of 10.8 years, mean ICFSG score was 4.3 (range 0-23), and 12 % required revision surgery. The rate of undercorrection and overcorrection was low (17 pes-plano-valgus ft and 11 ft with undercorrection). Eight feet had a fixed deformity. CONCLUSIONS: Severe deformities are more resistant to conservative techniques even for institutions with large experience. These deformities require further treatment, including surgery if necessary. The medial to posterior soft-tissue release is a valuable technique with stable results. LEVEL OF EVIDENCE: Level IV.

Post-traumatic cyst-like lesion in children: case report and the literature review.

Reports of post-traumatic cyst-like lesions in children are rare. These lesions occur between 1.5 and 3 months after a fracture. They are more frequent after a distal radius greenstick fracture. Conventional radiographs show a metaphyseal radiolucent lesion inside the most recent subperiosteal bone, adjacent to the initial fracture line. Post-traumatic cyst-like lesions are benign, asymptomatic, nonexpansive, and regress spontaneously. Two typical cases are described in the following report with a literature review of the etiology and main features of these lesions.