Extension services can promote pasture restoration: Evidence from Brazil's low carbon agriculture plan.

Innovation and improved practices in the livestock sector represent key opportunities tomeet global climate goals. This paper provides evidence that extension services can pro-mote pasture restoration in cattle ranching in Brazil. We use a randomized controlledtrial implemented in the context of the ABC Cerrado (a large-scale program launched in2014 aimed at fostering technology adoption through a combination of training andtechnical assistance) to examine the effects of different types of extension on agriculturalpractices, input use, and productivity. Providing technical assistance to previously trainedproducers promoted pasture restoration, induced farmers to use inputs more intensively,helped them to improve their management and soil conservation practices, and substan-tially increased revenues. A cost­benefit calculation indicates that US$1 invested in theABC Cerrado program increased profits by US$1.08 to $1.45. Incorporating carbonsavings amplifies this return considerably.

Nocardia species distribution and antimicrobial susceptibility within Australia.

BACKGROUND: Nocardia is a ubiquitous saprophyte capable of causing human disease. Disease is primarily respiratory or cutaneous, usually acquired via inhalation or inoculation. Under the influence of environmental and host factors, Nocardia incidence and species distribution demonstrate geographical variation. AIMS: To examine for differences in Nocardia incidence within Western Australia (WA) and analyse species distribution in the context of prior published studies. To analyse antibiogram data from a nationwide passive antimicrobial resistance surveillance program. METHODS: Retrospective extraction of laboratory data for Western Australian Nocardia isolates over a 21-year period. Analysis of Nocardia antimicrobial susceptibility testing data submitted to the Australian Passive Antimicrobial Resistance Surveillance (APAS) program between 2005 and 2022. RESULTS: Nine hundred sixty WA isolates were identified, giving an annual incidence of 3.03 per 100 000 population with apparent latitudinal variation. The four most common species identified within WA and amongst APAS isolates were N. nova, N. cyriacigeorgica, N. brasiliensis and N. farcinica. APAS data demonstrated that all species exhibited high rates of susceptibility to linezolid (100%) and trimethoprim-sulfamethoxazole (98%). Amikacin (>90% susceptibility for all species except N. transvalensis) was the next most active parenteral agent, superior to both carbapenems and third-generation cephalosporins. Susceptibility to oral antimicrobials (other than linezolid) demonstrated significant interspecies variation. CONCLUSIONS: We demonstrate geographical variation in the distribution of Nocardia incidence. Four species predominate in the Australian setting, and nationwide data confirm a high in vitro susceptibility to trimethoprim-sulphamethoxazole and linezolid, justifying their ongoing role as part of first-line empiric therapy.

Breaking the Rules in Three Dimensions: What to Expect After a Thoracic-only Fusion With Structural Thoracic and Thoracolumbar Curves.

OBJECTIVE: Despite guidelines to fuse both thoracic and thoracolumbar/lumbar (TH/L) curves in patients with structural curves in both regions, a thoracic-only fusion allows preservation of lumbar motion segments. The purpose of this study was to assess the 2-year postoperative three-dimensional (3D) radiographic and clinical outcomes of patients with double or triple major (thoracic curves >TH/L curves) structural curves who underwent a thoracic-only fusion. METHODS: A prospective adolescent idiopathic scoliosis registry was queried for double or triple major curves undergoing thoracic-only posterior fusion and a minimum 2-year follow-up. 3D reconstructions were generated from bi-planar radiographs. Paired sample t tests were used to assess differences in the coronal, sagittal, and axial planes pre and postoperatively, as well as Scoliosis Research Society Questionnaire-22 scores. Pearson correlations were utilized to identify variables related to spontaneous lumbar derotation. RESULTS: Twenty-two patients met the inclusion criteria. Both thoracic [61 ± 10 degrees to 20 ± 9 degrees ( P < 0.001)] and lumbar curves [41 ± 7 degrees to 22±7 degrees ( P < 0.001)] had significant coronal improvement and T5 to T12 kyphosis improved from 7 ± 14 degrees to 23 ± 8 degrees ( P < 0.001). The thoracic apical translation was significantly improved postoperatively (4.7 ± 1.5 to 0.5 ± 1 cm, P < 0.001), but the lumbar apical translation was unchanged (-1.7 ± 0.6 to -1.7±0.8 cm, P = 0.94). Scoliosis Research Society Questionnaire-22 scores significantly improved by 2 years postoperative. CONCLUSIONS: Unlike the 3D correction observed in nonstructural TH/L curves after thoracic-only fusion, patients with double or triple major curves demonstrated only spontaneous coronal correction of the lumbar curve, whereas the sagittal and axial planes were not significantly improved. These radiographic parameters did not negatively affect subjective or clinical outcomes at minimum 2-year follow-up. LEVEL OF EVIDENCE: Level IV-therapeutic.

Depression Screening in Pediatric Orthopedic Surgery Clinics and Identifying Patients At-Risk.

BACKGROUND: Up to 25% of youth experience a depressive episode by 18 years of age, leading the US Preventive Services Task Force to recommend depression screening within this population. This study aimed to understand the prevalence of depression identified within pediatric orthopedic clinics compared with primary care clinics after the implementation of a screening program and present data on the prevalence of moderate-severe depression across specific pediatric orthopedic clinics, characterizing and identifying specific populations at higher risk. METHODS: A retrospective review was performed to identify all patients screened using the 2-item and 9-item versions of the Patient Health Questionnaire (PHQ-2/PHQ-9) and the Columbia-Suicide Severity Rating Scale over a 2-year period (October 2018 to January 2021) within pediatric primary care and orthopaedic clinics. Demographic and clinical characteristics were collected. Statistical analysis was performed to compare scores between orthopedic and primary care clinics, as well as between the different pediatric orthopedic subspecialties and included χ 2 test, ANOVA, and logistic regression. RESULTS: There were 32,787 unique adolescent patients screened in primary care clinics, with an additional 14,078 unique adolescent patients screened in orthopaedic clinics, leading to a 30% increase in the overall number of patients receiving depression screening. 5.2% of patients in primary care pediatric clinics screened positive for moderate-severe depression versus 2.0% in pediatric orthopaedic clinics ( P <0.001). 2.7% of primary care patients were at risk of self-harm compared with 0.8% of orthopedic patients ( P <0.001). Within orthopaedic subspecialty clinics, the spine patients were at the highest risk of moderate-severe depression (3.5%), significantly higher than both the sports (1.4%, P =0.006) and patients with acute fracture (1.3%, P <0.001). CONCLUSIONS: This study demonstrates the high incidence of patients screening positive for depression in pediatric and adolescent orthopaedic clinics. By identifying high-risk clinics and patient groups, health care systems can apply a more practical approach and appropriately deploy behavioral health specialists for timely counseling and treatment discussions. LEVEL OF EVIDENCE: Level-III.

Incidence of Tether Breakage in Anterior Vertebral Body Tethering.

BACKGROUND: Thoracic anterior vertebral body tethering (TAVBT) is an emerging treatment for adolescent idiopathic scoliosis. Tether breakage is a known complication of TAVBT with incompletely known incidence. We aim to define the incidence of tether breakage in patients with adolescent idiopathic scoliosis who undergo TAVBT. The incidence of tether breakage in TAVBT is hypothesized to be high and increase with time postoperatively. METHODS: All patients with right-sided, thoracic curves who underwent TAVBT with at least 2 and up to 3 years of radiographic follow-up were included. Tether breakage between 2 vertebrae was defined a priori as any increase in adjacent screw angle >5 degrees from the minimum over the follow-up period. The presence and timing of tether breakage were noted for each patient. A Kaplan-Meier survival analysis was performed to calculate expected tether breakage up to 36 months. χ 2 analysis was performed to examine the relationship between tether breakage and reoperations. Independent t test was used to compare the average final Cobb angle between cohorts. RESULTS: In total, 208 patients from 10 centers were included in our review. Radiographically identified tether breakage occurred in 75 patients (36%). The initial break occurred at or beyond 24 months in 66 patients (88%). Kaplan-Meier survival analysis estimated the cumulative rate of expected tether breakage to be 19% at 24 months, increasing to 50% at 36 months. Twenty-one patients (28%) with a radiographically identified tether breakage went on to require reoperation, with 9 patients (12%) requiring conversion to posterior spinal fusion. Patients with a radiographically identified tether breakage went on to require conversion to posterior spinal fusion more often than those patients without identified tether breakage (12% vs. 2%; P =0.004). The average major coronal curve angle at final follow-up was significantly larger for patients with radiographically identified tether breakage than for those without tether breakage (31 deg±12 deg vs. 26 deg±12 deg; P =0.002). CONCLUSIONS: The incidence of tether breakage in TAVBT is high, and it is expected to occur in 50% of patients by 36 months postoperatively. LEVEL OF EVIDENCE: Level IV.

Posterior cervical spinal fusion in the pediatric population using modern adult instrumentation - clinical outcome and safety.

PURPOSE: Traditionally, less rigid fixation techniques have been applied to the pediatric cervical spine. There is a lack of long-term outcome data for rigid fixation techniques. The purpose of this study was to define the clinical outcome and safety of posterior instrumented fusion in the pediatric population using adult posterior instrumentation. METHODS: A multicenter, retrospective review of pediatric patients who underwent posterior cervical fusion using a 3.5 mm posterior cervical system for any indication was performed. Outcome parameters included complications, revision and fusion rates, operative time (OR), blood loss, and postoperative neurologic status. Outcomes were compared between patient groups (posterior only versus anterior/posterior approach, short versus intermediate versus long fusion, and between different etiologies) using Mann-Whitney and chi-square test. RESULTS: Seventy-nine patients with a mean age of 9.9 years and mean follow-up of 2.8 years were included. At baseline 44 (56%) had an abnormal neurologic exam. Congenital deformities and basilar invagination were the most common indications for surgery. Posterior-only surgery was performed in 71 (90%) cases; mean number of levels fused was 4 (range 1-15). Overall, 4 (5%) operative complications and 4 (5%) revisions were reported at an average postoperative time of 2.6 years. Neurologic status remained unchanged in 74%, improved in 23%, and worsened in 3%. When comparing outcome measures between the various groups, 2 significant differences were found: OR was longer in the anterior/posterior approach group and decline of neuro status was more frequent in the long fusion group. CONCLUSION: Posterior cervical fusion with an adult 3.5 mm posterior cervical system was safe in this cohort of 79 pediatric patients irrespective of surgical technique, fusion length, and etiology, resulting in a high fusion and low complication/revision rate.

Operative differences for posterior spinal fusion after vertebral body tethering: Are we fusing more levels in the end?

PURPOSE: Little is known about the perioperative characteristics associated with a posterior spinal fusion (PSF) in adolescent idiopathic scoliosis patients previously treated with vertebral body tethering (VBT). We aimed to determine if operative time, estimated blood loss, postoperative length of stay, instrumentation type, and implant density differed in patients that received a PSF (i.e., PSF-Only) or a PSF following a failed VBT (i.e., PSF-VBT). METHODS: We retrospectively assessed matched cohort data (PSF-VBT = 22; PSF-Only = 22) from two multi-center registries. We obtained: (1) operative time, (2) estimated blood loss, (3) postoperative length of stay, (4) instrumentation type, and (5) implant density. Theoretical fusion levels prior to the index procedure were obtained for PSF-VBT and compared to the actual levels fused. RESULTS: We observed no difference in operative time, estimated blood loss, or postoperative length of stay. Instrumentation type was all-screw in PSF-Only and varied in PSF-VBT with nearly 25% of patients exhibiting a hybrid construct. There was no added benefit to removing anterior instrumentation prior to fusion; however, implant density was higher in PSF-Only (1.9 ± 0.2) than when compared to PSF-VBT (1.7 ± 0.3). An additional two levels were fused in 50% of PSF-VBT patients, most of which were added to the distal end of the construct. CONCLUSIONS: We found that operative time, estimated blood loss, and postoperative length of stay were similar in both cohorts; however, the length of the fusion construct in PSF-VBT is likely to be two levels longer when a failed VBT is converted to a PSF.

Late Infection After Spinal Fusion for Adolescent Idiopathic Scoliosis: Implant Exchange Versus Removal.

BACKGROUND: Late infection after posterior spinal arthrodesis for adolescent idiopathic scoliosis (AIS) is the leading cause of late revision. While implant removal and antibiotic therapy are usually curative, patients may experience deformity progression. The goal of this study was to compare outcomes after implant exchange (IE) or removal (IR) to treat late-onset (≥1 y postoperative) deep surgical site infection (SSI) after spinal arthrodesis in patients with AIS. METHODS: Using a multicenter AIS registry, patients who underwent posterior spinal fusion between 2005 and 2019 and developed late deep SSI treated with IE or IR were identified. Radiographic, surgical, clinical, and patient-reported outcomes at most recent follow-up were compared. RESULTS: Of 3,705 patients, 47 (1.3%) developed late infection 3.8±2.2 years (range 1 to 9.7 y) after index surgery. Mean follow-up after index surgery was 6.1 years, with 2.8 years (range 25 to 120 mo) of follow-up after revision surgery. Twenty-one patients were treated with IE and 26 with IR. At the latest follow-up, average major-curve loss of correction (1° vs 9°, P <0.001) and increase in kyphosis (1° vs. 8°, P =0.04) were smaller in the IE group than in the IR group. Two IR patients but no IE patients had reoperation. Patients who underwent IE had higher Scoliosis Research Society 22-Item Patient Questionnaire (SRS-22) total scores (4.38 vs. 3.81, P =0.02) as well as better subscores for self-image, function, and satisfaction at the latest follow-up than those who underwent IR only. There were no significant between-group differences in operative duration, estimated blood loss, length of hospital stay, or changes in SRS-22 total scores. No patient had a subsequent infection during the follow-up period. CONCLUSIONS: When treating late-onset deep SSI after posterior spinal fusion for AIS, single-stage IE is associated with better maintenance of major curve correction, sagittal profile, and patient-reported outcomes and fewer reoperations compared with IR, with no significant differences in blood loss, operative duration, or length of stay. No time interval from index surgery to IR was observed where the corrected deformity remained stable. Both techniques were curative of infection. LEVEL OF EVIDENCE: Level III.

Pregnancy and Childbirth After Spinal Fusion for Adolescent Idiopathic Scoliosis.

BACKGROUND: Little data exist on pregnancy and childbirth for adolescent idiopathic scoliosis (AIS) patients treated with a spinal fusion. The current literature relies on data from patients treated with spinal fusion techniques and instrumentation, such as Harrington rods, that are no longer in use. The objective of our study is to understand the effects of spinal fusion in adolescence on pregnancy and childbirth. METHODS: Prospectively collected data of AIS patients undergoing posterior spinal fusion that were enrolled in a multicenter study who have had a pregnancy and childbirth were reviewed. Results were summarized using descriptive statistics and compared with national averages using χ 2 test of independence. RESULTS: A total of 78 babies were born to 53 AIS patients. As part of their pre-natal care, 24% of patients surveyed reported meeting with an anesthesiologist before delivery. The most common types of delivery were spontaneous vaginal delivery (46%, n=36/78) and planned cesarean section (20%, n=16/78). Compared with the national average, study patients had a higher rate of cesarean delivery ( P =0.021). Of the women who had a spontaneous vaginal birth, 53% had no anesthesia (n=19/36), 19% received intravenous intermittent opioids (n=7/36), and 31% had regional spinal or epidural anesthesia (n=11/36). spontaneous vaginal delivery patients in our study cohort received epidural or spinal anesthesia less frequently than the national average ( P <0.001). Of those (n=26 pregnancies) who did not have regional anesthesia (patients who had no anesthesia or utilized IV intermittent opioids), 19% (n=5 pregnancies) were told by their perinatal providers that it was precluded by previous spine surgery. CONCLUSION: The majority of AIS patients reported not meeting with an anesthesiologist before giving birth and those who had a planned C-section did so under obstetrician recommendation. The presence of instrumentation after spinal fusion should be avoided with attempted access to the spinal canal but should not dictate a delivery plan. A multidisciplinary team consisting of obstetrician, anesthesiologist, and orthopaedic surgeon can provide the most comprehensive information to empower a patient to make her decisions regarding birth experience anesthesia based on maternal rather than provider preference. LEVEL OF EVIDENCE: IV.

Penicillin versus anti-staphylococcal beta-lactams for penicillin-susceptible Staphylococcus aureus blood stream infections: a retrospective cohort study.

The objective of the study is to assess the efficacy and tolerability of penicillins compared to anti-staphylococcal beta-lactams for treatment of penicillin-susceptible Staphylococcus aureus bloodstream infections (PSSA BSI). A retrospective cohort study was conducted of 140 sequential PSSA BSI presenting to a local health district (90 cases included). Penicillin susceptibility was confirmed by disc diffusion, Vitek® and Nitrocefin beta-lactamase methods. Clinical information regarding comorbidities and infection complexity was recorded. Antibiotic choice, dosage and duration were reviewed. Outcomes were compared according to the definitive treatment with either penicillin or ASBLs. The primary outcome was 30-day mortality. Secondary outcomes included renal injury, microbiological relapse and treatment tolerability. Ninety patients met inclusion criteria and were included in subsequent analysis. Of PSSA BSI, 69% were community acquired. Eighty-two percent had complex PSSA infections. The average duration of bacteraemia was 2.8 days (SD = 1.8 days). Sixty-six patients received definitive penicillin treatment, with a mean of 3.5 days of empiric antibiotics prior to penicillin. Twenty-four patients received definitive ASBL treatment (11 cefazolin, 13 flucloxacillin). There was no difference in 30-day mortality between groups (p = 1). There was no difference in renal injury (p > 0.5), hospital length of stay (p = 0.59) or microbiological relapse within 1 year (p = 0.17). Penicillin treatment was well tolerated. Our data supports penicillin as a suitable and well-tolerated alternative to ASBL in managing complex PSSA BSI.

How often does the preoperative plan for freehand pedicle screw placement match the actual surgical execution in adolescent idiopathic scoliosis?

PURPOSE: To provide a baseline for comparison with future advancements, this study determined the accuracy of preoperative planning of pedicle screw placement using standard radiographs for posterior fusion (PSF) for adolescent idiopathic scoliosis (AIS). METHODS: Ninety-five patients with AIS planned for PSF were prospectively enrolled. Preoperative planning was based upon standard upright posteroanterior and lateral radiographs. The planned number of screws to be placed at each level was recorded. Intraoperatively, all screws were placed by freehand technique. The number of successfully placed screws and the reasons for abandoning screw placement were documented. RESULTS: There were a total of 1783 pedicle screws planned preoperatively. The average planned implant density was 2.0 implants/vertebra. A total of 1723 (96.6%) of the planned screws were placed successfully. Fourteen (0.8%) screws were abandoned after attempted placement (range 0-2 screws/case). Of 241 screws planned in pedicles noted to be "hypoplastic," 13 resulted in the use of a hook or no instrumentation. The placement was not attempted for 49 (range 0-7/case) planned screws due to intraoperative decision-making and a sense that the curve was flexible enough not to require every screw. Three cases (3.2%) required instrumentation of an additional level. CONCLUSIONS: Standard spine radiographs allow for accurate preoperative planning for freehand pedicle screw placement in AIS. Ninety-seven percent of planned screws were placed successfully. The primary reason for deviation from the preoperative plan was intraoperative surgeon decision-making rather than difficulty with screw placement. This study will serve as a baseline when considering the utilization of navigation in PSF for AIS.

The classification of scoliosis braces developed by SOSORT with SRS, ISPO, and POSNA and approved by ESPRM.

PURPOSE: Studies have shown that bracing is an effective treatment for patients with idiopathic scoliosis. According to the current classification, almost all braces fall in the thoracolumbosacral orthosis (TLSO) category. Consequently, the generalization of scientific results is either impossible or misleading. This study aims to produce a classification of the brace types. METHODS: Four scientific societies (SOSORT, SRS, ISPO, and POSNA) invited all their members to be part of the study. Six level 1 experts developed the initial classifications. At a consensus meeting with 26 other experts and societies' officials, thematic analysis and general discussion allowed to define the classification (minimum 80% agreement). The classification was applied to the braces published in the literature and officially approved by the 4 scientific societies and by ESPRM. RESULTS: The classification is based on the following classificatory items: anatomy (CTLSO, TLSO, LSO), rigidity (very rigid, rigid, elastic), primary corrective plane (frontal, sagittal, transverse, frontal & sagittal, frontal & transverse, sagittal & transverse, three-dimensional), construction-valves (monocot, bivalve, multisegmented), construction-closure (dorsal, lateral, ventral), and primary action (bending, detorsion, elongation, movement, push-up, three points). The experts developed a definition for each item and were able to classify the 15 published braces into nine groups. CONCLUSION: The classification is based on the best current expertise (the lowest level of evidence). Experts recognize that this is the first edition and will change with future understanding and research. The broad application of this classification could have value for brace research, education, clinical practice, and growth in this field.

Elastic Intramedullary Nails in the Treatment of Pediatric Length Unstable Femur Fractures.

BACKGROUND: Elastic intramedullary nails (EINs) are the treatment of choice for school-age children (5 to 12) with diaphyseal femur fractures. Previous literature suggests that EINs are an effective treatment for stable fracture patterns, but may be inadequate for unstable fracture patterns. The purpose of this study was to evaluate whether patients with length unstable fractures had a higher complication rate than those with length stable fractures when treated with EINs. METHODS: All patients with diaphyseal femur fractures treated with EINs over a 22-year period at a single institution were reviewed. Patients were excluded if they had a pathologic fracture, neuromuscular disorder, spinal cord injury with subsequent involvement of affected limb, metabolic bone disease, or if they did not have at least 6-month follow-up. RESULTS: A total of 85 patients with 87 diaphyseal femur fractures treated with EINs were included in the study. In all, 57.5% of the fractures were categorized as length stable and 42.5% were length unstable. Fourteen percent of length stable patients had a residual angular deformity compared with 5.4% of the length unstable group (P=0.24). The length unstable group experienced more shortening at the fracture site than the patients in the length stable group (P=0.003), but no patient required further intervention for their shortening. Two patients in the length stable group experienced overgrowth >2 cm and required subsequent surgery. No relationship was observed between fracture pattern and frequency of complications (length stable 8% vs. length unstable 10.8%, P=0.69). Finally, the knee immobilizer group (10.7%) and the long leg cast group (18.2%) had significantly higher complication rates than the single leg spica cast group (0%, P<0.05). CONCLUSIONS: There was no significant difference in complication rate between length stable and unstable fractures treated with EINs. Adjunctive spica casting may be protective against postoperative complications. While fracture shortening was more likely in the length unstable group, it did not result in increased rate of limb length discrepancy at final follow-up. LEVEL OF EVIDENCE: Level IV, Case Series.

Best Practice Guidelines for Surgical Site Infection in High-risk Pediatric Spine Surgery: Definition, Prevention, Diagnosis, and Treatment.

BACKGROUND: Prior "best practice guidelines" (BPG) have identified strategies to reduce the risk of acute deep surgical site infection (SSI), but there still exists large variability in practice. Further, there is still no consensus on which patients are "high risk" for SSI and how SSI should be diagnosed or treated in pediatric spine surgery. We sought to develop an updated, consensus-based BPG informed by available literature and expert opinion on defining high-SSI risk in pediatric spine surgery and on prevention, diagnosis, and treatment of SSI in this high-risk population. MATERIALS AND METHODS: After a systematic review of the literature, an expert panel of 21 pediatric spine surgeons was selected from the Harms Study Group based on extensive experience in the field of pediatric spine surgery. Using the Delphi process and iterative survey rounds, the expert panel was surveyed for current practices, presented with the systematic review, given the opportunity to voice opinions through a live discussion session and asked to vote regarding preferences privately. Two survey rounds were conducted electronically, after which a live conference was held to present and discuss results. A final electronic survey was then conducted for final voting. Agreement ≥70% was considered consensus. Items near consensus were revised if feasible to achieve consensus in subsequent surveys. RESULTS: Consensus was reached for 17 items for defining high-SSI risk, 17 items for preventing, 6 for diagnosing, and 9 for treating SSI in this high-risk population. After final voting, all 21 experts agreed to the publication and implementation of these items in their practice. CONCLUSIONS: We present a set of updated consensus-based BPGs for defining high-risk and preventing, diagnosing, and treating SSI in high-risk pediatric spine surgery. We believe that this BPG can limit variability in practice and decrease the incidence of SSI in pediatric spine surgery. LEVEL OF EVIDENCE: Not applicable.

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.

Radiographic Coronal Imbalance and Shoulder Asymmetry Continue to Improve Between 2 and 5 Years Following Surgery of Adolescent Idiopathic Scoliosis.

BACKGROUND: Managing patients with coronal imbalance (CI) and shoulder height asymmetry following scoliosis surgery can be challenging. Little is known about the course of findings over time and whether they improve or persist. The aim was to report the rate of suboptimal radiographic CI or shoulder asymmetry (SA) at 5 years in patients who were already reported to have CI or SA 2 years after surgery for adolescent idiopathic scoliosis (AIS). METHODS: An AIS database was reviewed for patients with both 2- and 5-year follow-up after surgery. From this cohort, patients with CI>2 cm or SA>2 cm at their 2-year follow-up were identified and reevaluated, using the same parameters, at 5-year follow-up. RESULTS: Of 916 patients, 157 (17%) patients had CI and 69 (8%) patients had SA at 2-year follow-up. At 5 years this improved to 53 (6%) and 11 patients (1%), respectively. CONCLUSIONS: Having coronal or shoulder imbalance 2 years after surgery for AIS does not guarantee continued imbalance 5 years after surgery. Most patients demonstrate some improvement in these measures of clinical deformity. Anticipating the potential course following a postoperative coronal balance and shoulder height differences can help surgeons manage and counsel their patients appropriately. LEVELS OF EVIDENCE: Level II-therapeutic.

A multicentre outbreak of ST45 MRSA containing deletions in the spa gene in New South Wales, Australia.

BACKGROUND: Early identification of MRSA by diagnostic medical microbiology laboratories enables improved antimicrobial choice and outcomes. The Cepheid Xpert® MRSA/SA BC test rapidly identifies Staphylococcus aureus bloodstream infections through spa gene detection and methicillin resistance via mecA gene detection. Recent emergence of S. aureus with deletions in the spa gene has resulted in false-negative results for this test, leading to misidentification of infections with this organism, particularly MRSA ST45. OBJECTIVES: To investigate the emergence and prevalence of ST45 MRSA in New South Wales (NSW), Australia. METHODS: WGS read data from six NSW hospitals were collected for 131 ST45 MRSA isolates and analysed. RESULTS: Of the 131 ST45 MRSA investigated, 88.5% (116/131) contained a deletion in the spa gene that appeared to have arisen once in approximately 2010 followed by clonal expansion. Given the successful establishment of this 'spa-deletion' MRSA clone, the Cepheid Xpert® MRSA/SA BC test became unreliable for confirming S. aureus bacteraemia in NSW. Subsequently, the algorithm used by this test has been updated and evaluated to take into account the presence of S. aureus with either a spa deletion or SCCmec target variations. CONCLUSIONS: This study highlighted the applied use of WGS for assessing diagnostic assays and informing necessary changes to ensure the viability of the Cepheid Xpert® MRSA/SA BC test in the context of the new 'spa-deletion' MRSA clone. It demonstrated how continued surveillance through WGS can reveal evolutionary events that may impact diagnostic assays, allowing corrective modifications to be made in real time.

Preoperative SRS pain score is the primary predictor of postoperative pain after surgery for adolescent idiopathic scoliosis: an observational retrospective study of pain outcomes from a registry of 1744 patients with a mean follow-up of 3.4 years.

BACKGROUND: Traditionally, adolescent idiopathic scoliosis (AIS) has not been associated with back pain, but the increasing literature has linked varying factors between pain and AIS and suggested that it is likely underreported. PURPOSE: Our objective was to investigate factors associated with post-op pain in AIS. METHODS: A prospectively collected multicenter registry was retrospectively queried. Pediatric patients with AIS having undergone a fusion with at least 2 years of follow-up were divided into two groups: (1) patients with a postoperative SRS pain score ≤ 3 or patients having a reported complication specifically of pain, and (2) patients with no pain. Patients with other complications associated with pain were excluded. RESULTS: Of 1744 patients, 215 (12%) experienced back pain after postoperative recovery. A total of 1529 patients (88%) had no complaints of pain, and 171 patients (10%) had pain as a complication, with 44 (2%) having an SRS pain score ≤ 3. The mean time from date of surgery to the first complaint of back pain was 25.6 ± 21.6 months. In multivariate analysis, curve type (16% of Lenke 1 and 2 curves vs. 10% of Lenke 5 and 6, p = 0.002) and a low preoperative SRS pain score (no pain 4.15 ± 0.67 vs. pain 3.75 ± 0.79, p < 0.001) were significant. When comparing T2-4 as the upper instrumented vertebrae in a subgroup of Lenke 1 and 2 curves, 9% of patients had pain when fused to T2, 13% when fused to T3, and 18% when fused to T4 (p = 0.002). CONCLUSION: 12% of all AIS patients who underwent fusion had back pain after postoperative recovery. The most consistent predictive factor of increased postoperative pain across all curve types was a low preoperative SRS pain score. These slides can be retrieved under Electronic Supplementary Material.

Is Anterior Release Obsolete or Does It Play a Role in Contemporary Adolescent Idiopathic Scoliosis Surgery? A Matched Pair Analysis.

STUDY DESIGN: A retrospective analysis of a prospectively collected database was performed. OBJECTIVE: The purpose of this study is to compare 3-dimensional correction associated with the anterior release (AR) and contemporary posterior instrumentation versus posterior-only surgery. SUMMARY OF BACKGROUND DATA: The role of AR as a tool in the treatment of adolescent idiopathic scoliosis (AIS) has seen a decline with the popularization of thoracic pedicle screw instrumentation. METHODS: Five surgeons were queried for all surgical thoracic AIS cases from 2003 to 2010 treated with thoracoscopic AR/fusion and contemporary posterior instrumentation and fusion and thoracic pedicle screw instrumentation (>80% screws) with 2-year follow-up. These cases were then matched with posterior spinal fusion only cases from a multicenter prospective database. The 2 groups were matched on the basis of major curve magnitude within 5 degrees, T5-T12 kyphosis within 9 degrees, and angle of trunk rotation within 9 degrees. Radiographic and clinical parameters were compared for the 2 groups. Continuous variables were analyzed with analysis of variance and categorical dependent variables with the χ test. RESULTS: A total of 47 cases of AR were matched to 47 (1:1 match) posterior spinal fusion cases. Preoperative parameters were similar between groups (P>0.05). Postoperatively, AR cases had a lower major curve (20 vs. 25 degrees, P=0.034; 72% vs. 66% correction, P=0.037). T5-T12 kyphosis was greater in the AR cases (26 vs. 20 degrees; P=0.005). The angle of trunk rotation was similar for the groups. Anchor density was lower in the AR group (1.6 vs. 1.9; P<0.0001). There were 3 complications associated with the AR: 1 pneumothorax and 2 conversions to minithoracotomies for failure to maintain single lung ventilation. CONCLUSIONS: AR improves coronal and sagittal plane correction in contemporary AIS surgery with a satisfactory complication profile with less pedicle screw density required for clinically similar corrections. A further prospective study on the benefits of AR may help define specific indications.

Rigid segmental cervical spine instrumentation is safe and efficacious in younger children.

PURPOSE: The utilization of cervical spine instrumentation in the young pediatric patient is not well reported. This study presents outcomes and complications of cervical spine instrumentation in patients who underwent cervical spine fusion surgery before age 10. METHODS: Radiographic and clinical data were collected on all patients who underwent cervical spine surgery with instrumentation at a single institution between January 1, 2006, and March 31, 2015. Patients were ≤ 10 years of age at the time of surgery with any cervical spine deformity/injury diagnosis. Patient demographics, details on cervical spine diagnosis, procedural data, imaging data, and postoperative follow-up data were collected. RESULTS: Twenty children met the criteria and were included in the study with a mean follow-up of 10.6 months (3 months-2 years). Initial indication for cervical spine correction surgery included deformity (7 cases), trauma (6 cases), instability (3 cases), stenosis (2 cases), rotary subluxation (1 case), and infection (1 case). Fifteen cases were treated with adult 3.5-mm cervical spine instrumentation, 3 with wiring (1 sublaminar and 2 spinous process), and 2 with cannulated screws. Postoperative immobilization included 16 halo fixation, 3 collars, and 1 CTO. Overall, there were five complications related to the surgery. Two patients who had wiring (1 sublaminar and 1 spinous process) developed a non-union and required revision surgery (1 with cannulated screws and 1 with 3.5-mm segmental cervical spine instrumentation). One patient developed a postoperative infection that required incision and drainage. Five patients developed superficial pin infections for their halo. Two deformity patients experienced neurological complications that were likely unrelated to the cervical instrumentation. CONCLUSIONS: Rigid segmental fixation can be safe and efficacious when used in pediatric cervical spine patients. Whether used with halo or orthosis, patients experience minimal to no complications from the instrumentation and achieve successful fusion. Cervical spine wiring had a high risk of non-union requiring revision surgery. The incidence of wound infection was low with one in 20 cases.