Restoration of thoracic kyphosis in adolescent idiopathic scoliosis with patient-specific rods: did the preoperative plan match postoperative sagittal alignment?

PURPOSE: To determine if the planned sagittal profile for thoracic kyphosis (TK) restoration was achieved after adolescent idiopathic scoliosis (AIS) surgery using a novel hybrid construct with apical double bands and precontoured patient-specific rods (PSR) made according to the detailed surgical plan for the desired sagittal plane. METHODS: AIS patients with a Lenke type 1-4 primary right thoracic curve who underwent corrective surgery by a single surgeon and had minimum 24-month follow-up were analyzed retrospectively from a prospective database. All patients underwent simultaneous translation on two rods with apical double bands and PSR. Clinical outcomes in terms of sagittal 2D TK (T4-T12), lumbar lordosis (LL), sagittal vertical axis (SVA), pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), PI-LL mismatch, rod angle, and rod deflection were compared between preoperative, planned, and 24-month data, while 3D apical rotation, 3D TK (T5-T12), sagittal thoracolumbar angle, degree of curvature at L1-L4 and L4-S1, proximal junctional angle, and distal junctional angle were compared at baseline and at 6 and 24 months postoperatively. SRS-22 questionnaire scores were obtained at baseline and 24 months postoperatively. RESULTS: Forty-eight patients were included. Study patients had a median coronal thoracic curve of 62.7° preoperatively and 22.4° at 24-month follow-up (p < 0.001). Median TK gain was 6.5° for the entire cohort (n = 48) and 19.1° in the Lenke type 1 and 2 hypokyphotic subgroup (n = 14). Both groups had no significant changes between planned and 24-month TK (p = 0.068 and p = 0.943, respectively), rod angle (p = 0.776 and p = 0.548, respectively), or rod deflection (p = 0.661 and p = 0.850, respectively). For the overall study cohort, median LL gain was 7.0° (p < 0.001), 3D apical derotation was 10.7° (p < 0.001), and change in 3D TK was 36° (p < 0.001). No instance of proximal junctional kyphosis was observed. SRS-22 scores for pain, self-image, and satisfaction differed significantly between the preoperative and 24-month follow-up time-points. CONCLUSIONS: With sagittal plane planning, desired TK, improved reciprocal changes in LL, and minimal changes in rod shape can be achieved in patients with AIS.

Rapid Recovery Pathway for Postoperative Treatment of Adolescent Idiopathic Scoliosis.

INTRODUCTION: Postoperative pain protocols play a critical role in recovery and prognosis. Rapid recovery pathway (RRP) is a novel multimodal postoperative analgesic platform with accelerated rehabilitation. METHODS: A retrospective review of 44 patients with adolescent idiopathic scoliosis who underwent posterior spinal fusion between 2014 and 2016 was conducted. Outcomes of a conventional postoperative pain pathway were compared with patients who received RRP postoperatively. RESULTS: RRP patients had shorter length of stay (3.3 vs 4.4 days, P < 0.0001), duration with Foley (1.4 vs 2.3 days, P = 0.01), and fewer days for physical therapy clearance (2.2 vs 3.5 days, P < 0.0001). Overall pain score for RRP patients was lower (1.6 vs 2.9, P = 0.0005). The number of days with patient-controlled analgesia was shorter (1.7 vs 2.6 days, P = 0.002), and daily pain scores were consistently lower in RRP. Overall narcotic use was not significantly different (P = 1). CONCLUSION: Implementation of a standardized RRP with multimodal pain management and early mobilization strategies resulted in reduced daily and overall pain scores, earlier clearance by physical therapy, decreased length of stay, and patient-controlled analgesia usage, but overall no difference in narcotic consumption. LEVEL OF EVIDENCE: Level III, Retrospective Cohort Study.

The effects of thoracoplasty on immediate post-operative recovery in adolescent idiopathic scoliosis.

PURPOSE: The purpose of this study was to evaluate differences in pain, opiate utilization and oxygen (O2) consumption during the immediate post-operative course for patients undergoing posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) with and without thoracoplasty. METHODS: Patients aged 10-21 years old that had undergone PSF for AIS were identified from 1/1/16-8/1/18. A cohort of patients that did not have a thoracoplasty group was used as a control group. A standardized pain protocol (rapid response pathway) was implemented on all patients. A retrospective chart review was performed. Pre-operative, operative and post-operative data and SRS scores were analyzed. RESULTS: Forty-six patients (38 girls, 8 boys) were included, 23 in each group. The average age was 15.2 years (range 12.0-19.3) and BMI was 20.9 (range 13.1-37.6). Differences in visual analog scores, post-operative oxygen and narcotic consumption were not statistically significant on any POD. Total opiate utilization was 146.06 morphine milligram equivalents (MME) in the control group and 149.41 MME in the thoracoplasty group (p = 0.78). One-year SRS self-image scores were higher in the thoracoplasty group (4.24 vs 3.96) (p = 0.007). There was no difference in length of hospitalization (3.6 vs 3.5 days), levels fused (12.9 vs 12.9) or blood loss (334.1 vs 413.5 mL). There was one pleural effusion and no instances of intercostal neuralgia or pneumothorax in the thoracoplasty group. CONCLUSION: There is no increase in immediate post-operative pain, narcotic use or oxygen consumption when a thoracoplasty is performed with a PSF for AIS. Improved SRS self-image scores were seen after thoracoplasty.

A Six Week Therapeutic Ballet Intervention Improved Gait and Inhibitory Control in Children With Cerebral Palsy-A Pilot Study.

Children with cerebral palsy (CP) have motor impairments that make it challenging for them to participate in standard physical activity (PA) interventions. There is a need to evaluate adapted PA interventions for this population. Dance can promote coordination, posture, muscle strength, motor learning, and executive functioning. This pilot study evaluated the feasibility and the effects of a new therapeutic ballet intervention specifically designed for children with CP. Methods: Eight children with CP (9-14 y/o; 75% female) participated in a 6-week therapeutic ballet intervention. Outcomes were measured in multiple domains, including body composition (DXA), muscle strength (hand-grip dynamometer), habitual physical activity, gait and selective motor control functions, and executive functioning. Follow-up assessments of habitual physical activity, gait, and executive functioning were completed 4 to 5 weeks post-intervention. Results: Five of the eight participants were overfat or obese based on DXA percentage of body fat. All participants were below the 50th percentile for their age and gender for bone density. Four participants showed a trend to improve hand-grip strength in one hand only, while one improved in both hands. There were significant improvements in gait across time points (pre, post, and follow-up), specifically in time of ambulation (X pre = 4.36, X post = 4.22, X follow-up = 3.72, d = 0.056, p = 0.02), and in step length (cm) on the right: X pre = 48.29, X post = 50.77, X follow-up = 52.11, d = 0.22, p = 0.027, and left stride: X pre = 96.29, X post = 102.20, X follow-up = 104.20, d = 0.30, p = 0.027, indicating gait changes in bilateral lower extremities. There was improvement in inhibitory control (d = 0.78; 95% Confidence Limit = ±0.71, p < 0.05) with large individual responses primarily among those above the mean at baseline. Conclusions: Therapeutic ballet may prove to be a useful intervention to promote physiological and cognitive functions in children with CP. Results demonstrated feasibility of the physical, physiological, and cognitive assessments and suggested improvements in participants' gait and inhibitory control with large individual responses. Modifications to personalize the intervention may be needed to optimize positive outcomes. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT03681171.

WEARABLE SENSOR-BASED GAIT CLASSIFICATION IN IDIOPATHIC TOE WALKING ADOLESCENTS.

Idiopathic toe walking on the balls of the feet is commonly found in children. Many toddlers who are just beginning to walk show signs of toe walking, but when toe walking persists after two years of age, the child's risk of falling increases as well as the risk of other developmental delays. Idiopathic toe-walking is estimated to occur in 7 to 24% of children. In order to address the problem of toe walking and assess improvements due to intervention, one needs to identify heel-toe gait versus toe-toe gait in natural environments of idiopathic toe walkers. The aim of this study was to investigate if learning algorithms utilizing triaxial accelerometers and gyroscopes from wearable sensors could detect and differentiate heel-toe gait versus toe-toe gait. In this study, 5 adolescents (13± 5 years) patients with idiopathic toe walking characteristics wore inertial sensor at L5 - S1 joint. New interventions can be designed for idiopathic toe walking population, but currently, it is a challenge to quantify the efficiency of toe-walking intervention. In recent times, with the advancement of machine learning classification methods and powerful computing, longitudinal data from wearable sensors can be used to accurately classify gait abnormalities. The aim of this study was to investigate machine learning methods to classify toe-toe walking versus heel-toe walking using data from a single inertial sensor. We found that k-means clustering was successful in differentiating toe walking with that of typical walking signals. We found that some of the linear variability based features such as standard deviation, Root Mean Square (RMS), and kurtosis contained most of the variability among the data and could therefore distinguish toe-toe gait versus heeltoe gait through clustering. The k-means cluster provided an 82% accuracy score with a specificity of 83% and sensitivity of 86%. We further utilized Recurrent Convolution Neural Network (RNN) such as Long Short-Term Memory (LSTM). The LSTM model was another classification method that was used to distinguish between toe-toe gait and heel-toe gait. Wearable sensors integrated with machine and deep learning algorithms have the capability to transform current on-going therapy methods and monitor patients longitudinally for their improvement in gait. These novel learning-based techniques could successfully classify toe walking gait and help in estimating the efficacy of the treatment in idiopathic toe walking adolescents.

CUSTOMIZED WEARABLE SENSOR-BASED INSOLES FOR GAIT RE-TRAINING IN IDIOPATHIC TOE WALKERS.

Idiopathic toe walking is associated with lack of heel strike during the initial contact phase of a gait cycle. Idiopathic toe walking affects 5-12% of healthy children in the US. In the case of idiopathic toe walkers: typically, a child can heel-toe walk, but habitually walk on their toes. A corrective intervention is needed during the early age of a child. In this pilot study, we developed a wearable insole with tactile corrective feedback. A total of five subjects (13±4 years) participated in this study. A customized insole was designed with two pressure sensors, inertial measurement units, a vibration tactor and on-board data storage SD card. A vibration biofeedback was provided to the participants if three consecutive toe-toe strikes were found while walking. We found that the average proportion of heel to toe strikes was 0%,66%,64%,53% and 67 % among participants. We also found median time of return to habitual walk of toe-toe gait was 13 seconds. All analysis was conducted on a walking data ranging from 2 to 20 hours of walking. All five subjects reported that the customized insoles were helpful and motivated them for a corrective gait. This novel research with wearable sensors will help physical therapists to utilize innovative intervention methods for gait training in idiopathic toe walkers.

Intra-articular enzyme replacement therapy with rhIDUA is safe, well-tolerated, and reduces articular GAG storage in the canine model of mucopolysaccharidosis type I.

BACKGROUND: Treatment with intravenous enzyme replacement therapy and hematopoietic stem cell transplantation for mucopolysaccharidosis (MPS) type I does not address joint disease, resulting in persistent orthopedic complications and impaired quality of life. A proof-of-concept study was conducted to determine the safety, tolerability, and efficacy of intra-articular recombinant human iduronidase (IA-rhIDUA) enzyme replacement therapy in the canine MPS I model. METHODS: Four MPS I dogs underwent monthly rhIDUA injections (0.58 mg/joint) into the right elbow and knee for 6 months. Contralateral elbows and knees concurrently received normal saline. No intravenous rhIDUA therapy was administered. Monthly blood counts, chemistries, anti-rhIDUA antibody titers, and synovial fluid cell counts were measured. Lysosomal storage of synoviocytes and chondrocytes, synovial macrophages and plasma cells were scored at baseline and 1 month following the final injection. RESULTS: All injections were well-tolerated without adverse reactions. One animal required prednisone for spinal cord compression. There were no clinically significant abnormalities in blood counts or chemistries. Circulating anti-rhIDUA antibody titers gradually increased in all dogs except the prednisone-treated dog; plasma cells, which were absent in all baseline synovial specimens, were predominantly found in synovium of rhIDUA-treated joints at study-end. Lysosomal storage in synoviocytes and chondrocytes following 6 months of IA-rhIDUA demonstrated significant reduction compared to tissues at baseline, and saline-treated tissues at study-end. Mean joint synovial GAG levels in IA-rhIDUA joints were 8.62 ± 5.86 µg/mg dry weight and 21.6 ± 10.4 µg/mg dry weight in control joints (60% reduction). Cartilage heparan sulfate was also reduced in the IA-rhIDUA joints (113 ± 39.5 ng/g wet weight) compared to saline-treated joints (142 ± 56.4 ng/g wet weight). Synovial macrophage infiltration, which was present in all joints at baseline, was abolished in rhIDUA-treated joints only. CONCLUSIONS: Intra-articular rhIDUA is well-tolerated and safe in the canine MPS I animal model. Qualitative and quantitative assessments indicate that IA-rhIDUA successfully reduces tissue and cellular GAG storage in synovium and articular cartilage, including cartilage deep to the articular surface, and eliminates inflammatory macrophages from synovial tissue. CLINICAL RELEVANCE: The MPS I canine IA-rhIDUA results suggest that clinical studies should be performed to determine if IA-rhIDUA is a viable approach to ameliorating refractory orthopedic disease in human MPS I.

Freedom of acetabular fragment rotation following three surgical techniques for correction of congenital deformities of the hip.

Femoral head coverage achieved with an acetabular osteotomy for hip dysplasia is achieved by acetabular rotation that can be restricted by osteotomy orientation and soft tissue attachments to the acetabular fragment. Procedures that allow excess rotation or motion in an undesirable direction (especially external rotation) may have undesirable consequences. Rotational aspects of these procedures have not been well described and are not well appreciated radiographically. This study examined the angular motion related to three operative techniques for redirectional acetabular osteotomies. The freedom of motion allowed for the Ganz periacetabular, Carlioz triple, and Tonnis triple osteotomies was quantified using three-dimensional motion measurement. The Ganz osteotomy allowed the greatest amount of motion. The Carlioz osteotomy allowed statistically less motion and depicted the "coupled motion" phenomenon in which a maximal angular rotation in one plane (abduction) is associated with a predicted angular change in another plane (external rotation). The Tonnis osteotomy allowed freedom of motion similar to the Ganz osteotomy without coupled motion.

A comparison of the fixation stability of multiple screw constructs for two types of pelvic osteotomies.

Periacetabular osteotomies are performed to improve femoral head coverage in a variety of clinical conditions. The stability of the osteotomy fragment between Ganz's periacetabular osteotomy was compared with that of Tonnis's triple innominate osteotomy under simulated weight-bearing conditions with a variety of screw constructs using three-dimensional analysis of fragment displacement and angular rotation. Generally, small amounts of displacement (<2 mm) and angular rotation (<3 degrees) were encountered for each fixation technique. Because the Ganz procedure violates the triradiate cartilage, it is not feasible in the immature patient. Thus, an understanding of fixation requirements in other available osteotomies to maintain fragment position is necessary.