Outcome of distraction-based growing rods at graduation: a comparison of traditional growing rods and magnetically controlled growing rods.

INTRODUCTION: Distraction-based growing rods have been considered as an alternative surgical option for the operative treatment of EOS. TGR has been challenged by MCGR, which is reported to have the advantage of non-invasive lengthening with fewer planned returns to theatre. This study explores the radiographic outcomes, Unplanned Returns to the Operating Room (UPROR) and complication profile of both the procedures at the end of the planned growing rod treatment with either TGR or MCGR. METHODS: We included all the EOS cases from the PSSG database that underwent either TGR or MCGR with spine-based proximal anchors, followed up to the time of graduation. Any crossover or hybrid procedures were excluded. 549 patients (409 TGR and 140 MCGR) were eligible for review. We measured the coronal curve magnitude, Kyphosis, T1-T12, T1-S1 and L1-S1 lengths at 4 time points (before and after the index surgery and before and after the definitive surgery). RESULTS: The TGR group were slightly younger at the time of the index procedure (7 years for TGR vs. 8.5 years for MCGR, p < 0.001). We noted an improvement in all radiological parameters after the growing rod implantation. The spinal lengths increased through the lengthening period, while the coronal curve magnitude and the kyphosis increased. The kyphosis normalized following the final fusion, the coronal curve magnitude reduced further with a further increase in spinal lengths. The final follow-up from the time of the index implantation to the definitive surgery was 5.1 years (IQR 3.8) in TGR and 3.5 years (IQR 1.65) in the MCGR groups. The total number of complications was fewer in the MCGR group. The overall risk of UPROR was lower in the MCGR group and implant breakage was less in the MCGR group by 4.7 times. CONCLUSIONS: This study confirms the equivalence of both the distraction-based growing rods systems from the radiological stand-point, during the lengthening phase and at the time of the definitive surgery. The TGR was more kyphogenic during the lengthening period. The complications and UPROR were fewer in the MCGR groups.

Rib-on-pelvis deformity: a modifiable driver of pain and poor health-related quality of life in cerebral palsy.

PURPOSE: Cerebral Palsy (CP) often presents with a sweeping thoracolumbar scoliosis and pelvic obliquity. With severe pelvic obliquity, the ribs come into contact with the high side of the oblique pelvis, termed rib-on-pelvis deformity (ROP). ROP can result in costo-iliac impingement, or pain associated with ROP, and can also adversely affect breathing and sitting balance. The goal of this study was to evaluate whether CP patients with ROP have worse health-related quality of life (HRQOL) before surgery and a greater improvement in HRQOL after surgery. METHODS: A retrospective analysis of a prospectively collected, multicenter, international registry was performed for all nonambulatory patients with CP treated with spinal fusion with at least two-year follow-up. HRQOL was measured via the Caregiver Priorities & Child Health Index of Life with Disabilities (CPCHILD) questionnaire domains (0 = most disability, 100 = least disability). ROP was defined as having a rib distal to the superior portion of the iliac crest on preop upright radiographs. The ROP group and control group without ROP were compared regarding six domain scores and total score of CPCHILD. Multiple linear regression was used to control for curve apex location, major coronal Cobb angle, type of tone, and pelvic obliquity. RESULTS: 340 patients met inclusion criteria (52% female, mean age 14.0 years). The mean major coronal Cobb angle was 81 degrees and mean pelvic obliquity was 22 degrees. 176 patients (51.8%) had ROP while 164 patients (48.2%) did not. ROP was independently associated with worse preoperative Positioning/Transfers/Mobility (PTM), Comfort & Emotions (C&E), and total CPCHILD score via the CPCHILD questionnaire (p < 0.05). Patients with preoperative ROP experienced a greater improvement in the C&E and PTM domains as well as total CPCHILD score than patients without ROP (p < 0.05). CONCLUSION: CP patients with rib-on-pelvis deformity experience more pain and worse HRQOL than patients without this deformity. These patients experienced a greater improvement in HRQOL after spinal fusion measured via the CPCHILD questionnaire.

Incidence of Parental Requests to Discontinue Growth-Friendly Surgical Lengthening for Early Onset Scoliosis.

BACKGROUND: The STOP questionnaire was developed to document reasons for discontinuation of growth-friendly (GF) treatment in early onset scoliosis (EOS). This study investigated the incidence of parental request (PR) on the STOP questionnaire and compared clinical information and Early Onset Scoliosis 24-Item Questionnaire (EOSQ-24) scores of PR patients with those whose parents did not request discontinuation (non-parent request [NPR]). MATERIALS AND METHODS: An international pediatric spine registry was queried for EOS patients with STOP questionnaires completed by their surgeon. Age at discontinuation, sex, and EOS etiology were recorded. GF device, number of surgical procedures, complications, STOP questionnaire reasons for discontinuation, and definitive treatment were recorded. EOSQ-24 scores and clinical information in the PR cohort were compared with the NPR cohort. RESULTS: Data for 1326 patients were analyzed. PR was listed on the STOP questionnaires of 46 (3.5%) patients, completed at a mean age of 12 years (SD, 3.2 years). There were no statistical differences in number of procedures or complications when comparing the PR cohort with the NPR cohort. PR patients more frequently had neuromuscular EOS (P=.002), more frequently were treated with magnetically controlled growing rods (33% vs 14%, P=.036), and more frequently were observed after GF discontinuation (P=.628). EOSQ-24 scores for the PR cohort were significantly lower in most domains except pain/discomfort. CONCLUSION: For 3.5% of the EOS patients, PR was listed on the STOP questionnaire. They frequently had neuromuscular EOS and frequently were treated with magnetically controlled growing rods. Additionally, these patients had statistically lower EOSQ-24 scores across most domains. [Orthopedics. 20XX;4X(X):XXX-XXX.].

Associations of overweight status with spinal curve correction and complications in patients undergoing vertebral body tethering: a multicenter retrospective review.

PURPOSE: Our purpose was to determine associations between body mass index (BMI) category and outcomes of vertebral body tethering (VBT), a non-fusion treatment for adolescent idiopathic scoliosis (AIS) and juvenile idiopathic scoliosis (JIS). METHODS: Using a multicenter database, we identified patients with AIS or JIS who underwent VBT from 2012 to 2018 and had minimum 2-year follow-up (median, 3.0 [interquartile range 2.2, 3.8]). BMI percentiles were used to classify patients as overweight (≥ 85th percentile) or non-overweight (< 85th percentile). Univariate and multivariate regressions assessed associations between complication rates and curve correction between groups, controlling for sex, triradiate cartilage closure, and preoperative curve magnitude. RESULTS: Of 271 patients, 48 (18%) were overweight. Complication rates did not differ between groups. Factors associated with less correction from preoperative to first postoperative-erect imaging were overweight (ß = - 10, p < 0.001), male sex (ß = - 8.8 p < 0.01), closed triradiate cartilage (ß = 6.0, p = 0.01), and smaller preoperative curve (ß = 0.3, p < 0.01). Factors associated with a larger curve at latest follow-up were overweight (ß = 4.0, p = 0.02) and larger preoperative curve (ß = 0.5, p < 0.001), but tether breakage did not differ between groups (p = 0.31). CONCLUSION: In patients who were overweight, VBT was associated with less curve correction at first erect imaging and larger final curve. However, complications and curve correction during the modulation phase were not different from those of non-overweight patients. These findings suggest that surgeons should expect less correction with VBT in patients who are overweight but similar correction over time. LEVEL OF EVIDENCE: Prognostic, Level III.

Victor McKusick: Father of Medical Genetics and his Impact on Orthopaedics.

Victor McKusick, an iconic figure in medicine and considered the founding father of medical genetics, lived an exemplary life bound to inspire others. As a geneticist, McKusick was heavily involved in the Human Genome Project and the development of the widely used Online Mendelian Inheritance in Man. As a researcher and prolific writer, he published more than 700 research articles, reviews, and books. McKusick educated and inspired thousands of students, doctors, and scientists while performing landmark studies in hereditary disorders and skeletal dysplasias. This brief history describes the life of Dr. Victor McKusick and his tremendous impact on orthopaedic surgery. (Journal of Surgical Orthopaedic Advances 33(2):068-071, 2024).

Impact of Spinal Deformity and Surgery on Health-Related Quality of Life in Cerebral Palsy: A Multicenter Prospective Controlled Trial.

BACKGROUND: Spinal fusion for scoliosis associated with cerebral palsy (CP) is challenging to study because specialized outcome measures are needed. Therefore, evidence in favor of the benefits of surgery has not been firmly established. This study aimed to determine if corrective spinal fusion improves health-related quality of life (HRQoL) in children with CP scoliosis at 2 years. METHODS: Children with CP and scoliosis who met the criteria for posterior spinal fusion were offered enrollment at 16 US and Canada centers. Participants' families selected either operative intervention (OP) or nonoperative treatment (NON) in discussion with their surgeon with no influence by the decision to participate in the research study. Demographic, clinical data (function level, magnitude of deformity, comorbidities), and HRQoL (CPCHILD Questionnaire) were collected at baseline and 2 years. Change (from baseline) in total CPCHIL scores was the primary outcome. RESULTS: Three hundred one OP and 34 NON subjects had complete baseline and 2-year data. At baseline, both groups were comparable in function level, comorbid status, and CPCHILD scores (52.1 ±15.3 vs. 53.4 ±14.5; P=0.66). The OP group had a larger spinal deformity magnitude (84.5˚ ± 21.8˚ vs. 66.3˚ ± 18.1˚) (P=0.001). The total CPCHILD score improved in the OP group by 6.6 points (P<0.001). NON scores were unchanged (+1.2; P=0.65) during follow-up. There were also significant score increases in the OP group for 5 of 6 CPCHILD domains. The change in CPCHILD scores from enrollment to 2 years was more significant in the OP group (P=0.05). CONCLUSION: For children with CP who undergo spinal fusion, HRQoL improved over preoperative levels and an unchanged nonoperative control group. LEVEL OF EVIDENCE: Level II.

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

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

Adolescent Idiopathic Scoliosis: Increased Body Mass Associated with Decreased Bracing Outcomes.

Bracing reduces the need for surgical intervention in patients with adolescent idiopathic scoliosis (AIS). However, bracing outcomes with variable body mass index (BMI) are understudied. The authors sought to determine the association of BMI with bracing outcomes. The authors performed a retrospective cohort study of 104 patients presenting with AIS. Initial Risser score, hours of bracing per day, BMI percentile, and curve magnitude pre- and postbracing were collected. There was no detectable difference between years of brace wear or primary curve magnitude at time of presentation between both groups. Overall, 29% (25/87) of underweight/normal weight patients and 59% (10/17) of overweight/obese patients had curves ≥ 45 degrees at the end of bracing (p = 0.016). Odds of having a curve ≥ 45 degrees after bracing were 3.5 (95% confidence interval: 1.2 to 10.3, p = 0.021) times higher for overweight/obese patients compared with underweight/normal weight patients. Increased overlying adipose tissue may reduce the corrective forces required to straighten the spine. (Journal of Surgical Orthopaedic Advances 33(1):029-032, 2024).

Outcomes after completing growth-friendly surgical treatment for early-onset scoliosis in patients with skeletal dysplasia.

Aims: The aim of this study was to compare outcomes after growth-friendly treatment for early-onset scoliosis (EOS) between patients with skeletal dysplasias versus those with other syndromes. Methods: We retrospectively identified 20 patients with skeletal dysplasias and 292 with other syndromes (control group) who had completed surgical growth-friendly EOS treatment between 1 January 2000 and 31 December 2018. We compared radiological parameters, complications, and health-related quality of life (HRQoL) at mean follow-up of 8.6 years (SD 3.3) in the dysplasia group and 6.6 years (SD 2.6) in the control group. Results: Mean major curve correction per patient did not differ significantly between the dysplasia group (43%) and the control group (28%; p = 0.087). Mean annual spinal height increase was less in the dysplasia group (9.3 mm (SD 5.1) than in the control group (16 mm (SD 9.2); p < 0.001). Mean annual spinal growth adjusted to patient preoperative standing height during the distraction period was 11% in the dysplasia group and 14% in the control group (p = 0.070). The complication rate was 1.6 times higher (95% confidence interval (CI) 1.3 to 2.0) in the dysplasia group. The following complications were more frequent in the dysplasia group: neurological injury (rate ratio (RR) 5.1 (95% CI 2.3 to 11)), deep surgical site infection (RR 2.2 (95% CI 1.2 to 4.1)), implant-related complications (RR 2.0 (95% CI 1.5 to 2.7)), and unplanned revision (RR 1.8 (95% CI 1.3 to 2.5)). Final fusion did not provide additional spinal height compared with watchful waiting (p = 0.054). There were no significant differences in HRQoL scores between the groups. Conclusion: After growth-friendly EOS treatment, patients with skeletal dysplasias experienced a higher incidence of complications compared to those with other syndromes. Surgical growth-friendly treatment for skeletal dysplasia-associated EOS should be reserved for patients with severe, progressive deformities that are refractory to nonoperative treatment.

Evaluation of cervical spine clearance scores in children younger than 3 years with blunt trauma.

OBJECTIVE: The PEDSPINE I and PEDSPINE II scores were developed to determine when patients require advanced imaging to rule out cervical spine injury (CSI) in children younger than 3 years of age with blunt trauma. This study aimed to evaluate these scores in an institutional cohort. METHODS: The authors identified patients younger than 3 years with blunt trauma who received cervical spine MRI from their institution's prospective database from 2012 to 2015. Patient demographics, injury characteristics, and imaging were compared between patients with and without CSI using chi-square and Wilcoxon rank-sum tests. RESULTS: Eighty-eight patients were identified, 8 (9%) of whom had CSI on MRI. The PEDSPINE I system had a higher sensitivity (50% vs 25%) and negative predictive value (93% vs 92%), whereas PEDSPINE II had a higher specificity (91% vs 65%) and positive predictive value (22% vs 13%). Patients with CSI missed by the scores had mild, radiologically significant ligamentous injuries detected on MRI. Both models would have recommended advanced imaging for the patient who required halo-vest fixation (risk profile: no CSI, 81.9%; ligamentous, 10.1%; osseous, 8.0%). PEDSPINE I would have prevented 52 (65%) of 80 uninjured patients from receiving advanced imaging, whereas PEDSPINE II would have prevented 73 (91%). Using PEDSPINE I, 10 uninjured patients (13%) could have avoided intubation for imaging. PEDSPINE II would not have spared any patients intubation. CONCLUSIONS: Current cervical spine clearance algorithms are not sensitive or specific enough to determine the need for advanced imaging in children. However, these scores can be used as a reference in conjunction with physicians' clinical impressions to reduce unnecessary imaging.