Bipolar Fusionless Versus Standard Fusion Surgery in Neuromuscular Scoliosis: A Two-center Comparative Study.

STUDY DESIGN: Nonrandomized controlled cohort. OBJECTIVE: To compare early results between bipolar fusionless construct (BFC) and single posterior fusion (SPF) surgery in neuromuscular scoliosis (NMS). BACKGROUND: Surgical treatments for NMS have traditionally been characterized by high complication rates. A mini-invasive BFC was developed to reduce these risks while maintaining adequate curve reduction. There is, however, a current lack of studies comparing clinical and radiologic perioperative outcomes between both techniques. METHODS: All patients surgically treated for NMS with to-pelvis construct between 2011 and 2021 at 2 centers were included and divided into 2 groups according to the surgical technique (BFC or SPF). Gender, age, main deformity region, etiology, preoperative and postoperative main curve magnitude and pelvic obliquity, surgery time, estimated blood loss and transfusion rates, length of hospital stay, the magnitude of main curve and pelvic obliquity correction, and early complications were compared. Quantitative data were compared through ANOVA or Mann-Whitney test. Analysis of qualitative outcomes was performed through Fisher exact test and logistic regressions. Kruskal-Wallis test was used to compare complications between groups. RESULTS: Eighty-nine NMS patients were included: 48 in the SPF group and 41 in the BFC group. Surgery time (203 vs. 241 min), rate (32 vs. 52%) and severity of complications, unplanned returns to the operating room (15 vs. 39%), estimated blood loss (179 vs. 364 cc), and transfusion rates (27 vs. 73%) were lower in the BFC group ( P <0.05). There were no significant differences in age, maturity stage, preoperative curve magnitude, preoperative pelvic obliquity and postoperative curve, and pelvic obliquity correction between groups. CONCLUSIONS: BFC may be a safer and less invasive option for NMS surgical treatment, resulting in similar curve corrections while significantly decreasing the number and severity of complications as well as intraoperative blood loss when compared with SPF. LEVEL OF EVIDENCE: Level -lll.

Congenital hypoplasia and aplasia of the quadriceps: Diagnosis and treatment.

BACKGROUND: Congenital absence of the quadriceps is an extremely rare condition whose management is not standardised. The objective of this study was to describe the clinical presentation, treatments, and outcomes of a multicentre cohort. HYPOTHESIS: Classification of the type of abnormality at birth helps to guide management decisions. METHODS: Fifteen patients (19 knees) were included retrospectively in this multicentre study. Data on joint range-of-motion and management were analysed. We divided the patients into three groups based on whether they had continuous hypoplasia (involving the entire quadriceps), discontinuous hypoplasia (hypoplasia of some of the muscle groups or aplasia of the distal third of the quadriceps), or aplasia (complete absence of the quadriceps with replacement by fat). RESULT: Physiotherapy was provided initially to all patients. The main treatment in the 6 patients with continuous hypoplasia was posterior release and biceps femoris lengthening. At last follow-up all 6 patients were able to walk unaided, although 4 of them had persistent knee extension lag. Quadriceps reconstruction and osteotomy to correct knee recurvatum deformity were performed in most of the 11 patients with discontinuous hypoplasia. Among them, 10 were able to walk unaided at last follow-up, and 5 had knee extension lag. The 2 patients with aplasia required knee arthrodesis after multiple surgical procedures. Both were able to walk. DISCUSSION: Depending on the classification of the abnormality at birth, different surgical procedures should be considered. Surgery should only be performed after non-operative treatment. The treatment goal is to obtain a normal mechanical axis of the limb with the knee in extension and no extension lag, in order to enable walking. LEVEL OF EVIDENCE: IV, retrospective observational study.

Surgical increase in thoracic kyphosis predicts increase of cervical lordosis after thoracic fusion for adolescent idiopathic scoliosis.

PURPOSE: The modification of cervical lordosis (CL) after adolescent idiopathic scoliosis (AIS) surgery is influenced by the correction of thoracic hypokyphosis. The quantification of the increase of CL as a function of the increase of thoracic kyphosis (TK) has never been calculated. METHODS: A total of 92 consecutive AIS patients who underwent a posterior thoracic selective fusion, corrected by simultaneous translation on 2 rods technique, with minimum 24-month follow-up, were analyzed from a prospective database. We evaluated global sagittal kyphosis and lordosis. CL was divided by the horizontal line in proximal (PCL) and distal cervical lordosis (DCL), likewise TK in proximal (PTK) and distal TK (DTK), and lumbar lordosis (LL) in proximal (PLL) and distal LL (DLL). RESULTS: The mean TK gain was 16°, 14° and 28° in the whole cohort, normokyphosis group and hypokyphosis group, respectively. The mean DCL gain was, respectively, 9°, 7° and 20° and the mean CL gain 8°, 5° and 21°. There was a strong correlation between TK gain and CL gain (coefficient = 0.86) and between TK gain and DCL gain (coefficient = 0.74). The regression equation was defined as DCLgain = - 3 + 0.75 × TKgain (p < 0.0001) corresponding on average to 60% of the TK gain. CONCLUSION: 60% of the TK gain was transferred to DCL gain. Correlations reflect the geometrical equivalence between PTK and DCL. The use of sagittal global measurements shows that DCL is equivalent to PTK and can be expressed as a function of pelvic parameters (DCL = PT + LL-PI). DCL must be considered to optimize the postoperative sagittal alignment of the spine.

Prevention of surgical site infections in pediatric spines: a single-center experience.

PURPOSE: To describe the potential issues in the methodology of surgical site infection (SSI) prevention and how it was investigated and corrected in a single institution. METHODS: A pediatric orthopedic unit experienced an increase of SSI, concerning up to 10% of scoliosis surgery cases from 2011 to 2013. An institutional procedure of multimodal and interdisciplinary risk evaluation was initiated, including a review of the literature, a morbi-mortality meeting, internal and external audits concerning the hygiene conditions in the operating room, the antibiotic prophylaxis, patients, and sterile material pathways. Several preventive actions were implemented, including the improvement of air treatment in the operating room, wound irrigation with 2L of saline before closure, application of topic vancomycine in the wound, verification of doses and timing of antibiotics injection, and use of waterproof bandages. We compared the rates of spine SSI before (retrospective group, 2011-2013) and after the implementation of various preventive measures (prospective group, 2014-2018). RESULTS: SSI occurred in 12 patients (6 idiopathic and 6 neuromuscular) out of 120 operated on (93 idiopathic, 18 neuromuscular, 9 others) in the retrospective group and 2 (both neuromuscular) out of 196 (150 idiopathic, 33 neuromuscular,13 others) in the prospective group (10% vs 1%, odds ratio=9.7, p=0.001). The groups were comparable for age, etiology, duration of surgery, body mass index, American Society of Anesthesiologists score, number of levels fused, and blood loss (p>0.2). CONCLUSION: The systematic analysis of SSI allowed for the understanding of the failures and correcting them. The current process is effectively preventing SSI. LEVEL OF EVIDENCE: 3: prospective series with case-control analysis.

Lumbopelvic parameters can be used to predict thoracic kyphosis in adolescents.

PURPOSE: Distal thoracic kyphosis (DTK) equivalent to proximal lumbar lordosis (PLL) is the sum of pelvic tilt (PT) and the difference (Δ) between lumbar lordosis (LL) and pelvic incidence (PI): PLL = DTK = PT + Δ. With the assumption that proximal thoracic kyphosis (PTK) is similar to DTK, we propose the equation TK = 2(PT + LL - PI) to express the relationship between thoracic kyphosis (TK) and pelvic parameters. The objective of this work is to verify this relationship in a normal population. METHODS: Full spine radiographs of 100 adolescents and young adults (13 to 20 years old), free from vertebral pathology, were analyzed. Measurements included pelvic parameters, LL, PLL, DLL, TK, PTK, DTK and C7 global tilt. The measured global TK was compared with the theoretical TK calculated according to the formula TK = 2(PT + LL - PI). RESULTS: The difference between measured TK and calculated TK was + 2.3° and correlated with the C7 global tilt (r = 0.86). There was a significant linear regression between TK and PT + ∆ (p < 0.0001). Given radiographs' inter-rater reliability of 5° for angled measurements, the p value (0.047) between measured TK and calculated TK is statistically significant to support the hypothesis. CONCLUSION: This work validates the formula TK = 2(PT + LL - PI) which allows the calculation of global TK as a function of PT, LL and PI. This calculated TK can be used as a target for sagittal correction of adolescents with spine deformities. These slides can be retrieved under Electronic Supplementary Material.

Can Gartland II and III supracondylar humerus fractures be treated using Blount's method in the emergency room?

BACKGROUND: Studies have established that Blount's method is reliable for treating extension supracondylar fractures (SCFs) in paediatric patients. Reduction in the emergency room (ER) under procedural sedation followed by orthopaedic treatment is increasingly used for many fracture types. The primary objective of this study was to determine whether SCF reduction in the ER was feasible, by determining the failure rate. The secondary objective was to identify causes of failure with the goal of improving patient selection to reduction in the ER. HYPOTHESIS: Gartland II and III SCFs (Lagrange-Rigault grades 2-4) can be treated in the emergency room under fluoroscopic guidance and with procedural sedation. MATERIAL AND METHODS: A retrospective study was conducted in 128 paediatric patients who underwent ER reduction of an SCF in 2014-2015. Mean age was 5.6 years. Reduction was performed either by an orthopaedic surgery resident or by a specially trained emergency physician. RESULTS: Of the 128 SCFs, 101 (79%) were Gartland II and 27 Gartland III. In the Lagrange-Rigault classification, 55 (43%) fractures were grade 2, 59 (46%) were grade 3, and 14 (11%) were grade 4. The arm was immobilised using the cuff-and-collar method described by Blount for 4 weeks. All 128 fractures healed without delay. Blount's method alone was effective in 112 (87.5%) patients. Of the 16 other patients, 15 (Lagrange-Rigault 3, n=14; and 4, n=1) had an unstable fracture after ER reduction and were managed by reduction and internal fixation in the operating room. The remaining patient (0.5%) experienced secondary displacement requiring revision surgery in the operating room. CONCLUSION: SCFs grades 2 to 4 in the Lagrange-Rigault classification (Gartland II and III) can be treated in the ER by specially trained physicians. Lagrange-Rigault grade 3/Gartland III SCFs are more likely to require subsequent internal fixation but do not contraindicate reduction in the ER. LEVEL OF EVIDENCE: IV, retrospective study.

Advanced containment methods for Legg-Calvé-Perthes disease: triple pelvic osteotomy versus Chiari osteotomy.

INTRODUCTION: The goal of intervention in Legg-Calvé-Perthes disease (LCPD) is to prevent femoral head deformation by containing the head within the acetabulum. Currently, surgical containment methods are the mainstay of treatment, and pelvic osteotomies have been shown to be successful. They include triple pelvic osteotomy (TPO), Salter osteotomy, Chiari osteotomy and shelf procedure. The purpose of this study was to compare clinical and radiologic results for Chiari osteotomy and TPO in LCPD. METHODS: 29 children treated between 1980 and 2010 for LCPD in 2 centres were reviewed. 19 underwent TPO, and 10, Chiari osteotomy. Two independent observers assessed sequential radiographs and medical data. Each hip was preoperatively classed by clinical data, Catteral, Herring and Salter-Thompson classification, centre-edge angle (CE), and acetabular index (AI). The 2 groups were first tested for their comparability. After surgery the hips were classified by Stulberg classification, CE, AI, Harris Hip Score (HHS) and performance of further surgery. Chiari osteotomy and TPO have been secondary compared on these data by Wilcoxon test. RESULTS: Average follow-up was 4.2 years. The 2 groups were comparable before surgery. At first and last follow-up examination, statistically significantly superior results in patients with TPO regarding Stulberg classification (p = 0.01), AI (p = 0.002), pain (p = 0.02) and function (p = 0.01) in the HHS score were found. No differences were noticed concerning CE angle. CONCLUSIONS: In our series, TPO provided better radiologic and clinical outcomes compared to Chiari osteotomy, specially concerning the final Stulberg classification. We concluded that TPO should be preferred when indicated.

Relationship between thoracic hypokyphosis, lumbar lordosis and sagittal pelvic parameters in adolescent idiopathic scoliosis.

PURPOSE: Sagittal spine and pelvic alignment of adolescent idiopathic scoliosis (AIS) is poorly described in the literature. It generally reports the sagittal alignment with regard to the type of curve and never correlated to the thoracic kyphosis. The objective of this study is to investigate the relationship between thoracic kyphosis, lumbar lordosis and sagittal pelvic parameters in thoracic AIS. METHODS: Spinal and pelvic sagittal parameters were evaluated on lateral radiographs of 86 patients with thoracic AIS; patients were separated into hypokyphosis group (n = 42) and normokyphosis group (n = 44). Results were statistically analyzed. The lumbar lordosis was lower in the hypokyphosis group, due to the low proximal lordosis. The thoracic kyphosis was not correlated with any pelvic parameters but with the proximal lordosis. The pelvic incidence was correlated with sacral slope, pelvic tilt, lumbar lordosis and highly correlated with distal lumbar lordosis in the two groups. There was a significant linear regression between thoracic kyphosis and proximal lordosis and between pelvic incidence and distal lordosis. CONCLUSIONS: We can consider that the proximal part of the lordosis depends on the thoracic kyphosis and the distal part depends on the pelvic incidence. The hypokyphosis in AIS is independent of the pelvic parameters and could be described as a structural parameter, characteristic of the scoliotic deformity.

Percutaneous aspiration irrigation drainage technique in the management of septic arthritis in children.

BACKGROUND: Septic arthritis in childhood is a therapeutic emergency. The authors present their experience using an intermediate technique with the advantages of the percutaneous aspiration irrigation drainage: joint aspiration, irrigation, and declivious drainage. METHODS: All children were treated by joint aspiration under fluoroscopic control, large volume irrigation, and declivious nonsuction drainage associated with immobilization and intravenous antibiotics during 8 days to 10 days. The draining system was removed when clinical improvement (namely apyrexia) and the decrease of biological inflammatory response were obtained. A late follow-up phone interview was made for each patient. Fifty-two patients were included in this study, with a mean age of 4.3 years. The most common sites of arthritis were the hip (19 of 52, 36%) and the knee (17 of 52, 32%), but ankle (8 of 52, 15%), shoulder (12%), and elbow (3%) were also involved. RESULT: Apyrexia was obtained after a mean period of 2 days. The mean draining duration was 4.5 days. On the last follow-up visit (at 21 months on average; range, 12-56 months), all patients except one were totally painless and had no limitation of physical activity. CONCLUSION: Percutaneous aspiration irrigation drainage assured very good results in this study population, with rapid clinical and biological improvement and the absence of long-term sequelae. The advantages of this technique include permanent joint access and control of synovial effusions, with only one general anesthesia and minimal iatrogenic morbidity.