The Schroth Method for Pediatric Scoliosis: A Systematic and Critical Analysis Review.

BACKGROUND: The Schroth method is the most commonly used patient scoliosis-specific exercise paradigm for treating pediatric scoliosis. The aim of this study is to systematically and critically examine the evidence for the Schroth method for pediatric scoliosis. METHODS: PubMed, MEDLINE, CINAHL, and Web of Science were searched through April 5, 2024, for articles examining the Schroth method for pediatric scoliosis (<18 years old). Thirteen review questions were created spanning the study aim. Each included article was independently assessed for the level of evidence (I-IV). Research questions were given a grade of recommendation (A, B, C, and I [insufficient]). RESULTS: A total of 29 articles (41.4% Level I, 31.0% Level II, 13.8% Level II, and 13.8% Level IV) met inclusion criteria out of 845 initially retrieved, describing 1,555 patients with scoliosis aged 4 to 18 years. There was grade A evidence that the Schroth method is most commonly used for adolescent idiopathic scoliosis (AIS), can improve the angle of trunk rotation, and is safe; grade B evidence for improvement in posture; and grade I evidence for improvement in Cobb angle, cosmetic deformity, quality of life, ideal treatment parameters, economic value, utility in delaying/preventing surgery, effectiveness in relation to patient characteristics (e.g., skeletal maturity or curve size), and comparative effectiveness to other conservative interventions. CONCLUSION: While there is good evidence that the Schroth method is commonly and safely used in AIS and can minimally improve the angle of trunk rotation and fair evidence of improvement in posture, there is insufficient evidence regarding multiple important clinical and economic outcomes, such as comparative effectiveness to other conservative interventions and improvement of Cobb angle. Although clinicians may consider the Schroth method as 1 option of several conservative strategies, clinical benefit may be limited, and further high-quality research is needed to evaluate its performance in areas of insufficient evidence.

Segmental range-of-motion by vertebral level in fused and unfused patients with adolescent idiopathic scoliosis: a systematic review of the literature.

PURPOSE: This study aims to understand global and segmental spinal ROM in surgical and nonsurgical AIS patients. METHODS: This systematic review examined segmental vertebral ROM in AIS patients using PubMed, SPORTDiscus, MEDLINE, and Web of Science until October 8th, 2023. Inclusion criteria were articles on segmental motion in AIS patients, both operative and non-operative, under 18 years old. RESULTS: Seventeen articles met eligibility criteria from 2511 initially retrieved. All patients (n = 996) had AIS (549 non-operative; 447 were operative), with a frequency-weighted mean age of 15.1 ± 1.6 years and a baseline Cobb angle of 51.4 ± 13.3 degrees. Studies showed heterogenous segmental flexibility in the unfused spine, with the apical curve and upper thoracic segments being more rigid and lower segments more flexible at -5 disk segments from the apex. Most studies showed a predictable loss of motion in fused spinal regions postoperatively and a variable loss of global motion depending on the LIV and number of fused segments. A 7° global loss of total trunk flexion per level was observed with increasingly caudal LIV, starting at L1. Anterior vertebral body tethering (AVBT) preserved motion post-surgery but reduced coronal plane motion. AVBT saw less motion loss compared to posterior spinal fusion (PSF) but had higher revision and complication rates. CONCLUSION: Preservation of spinal segments correlated with improved motion postoperatively. Increasing caudal LIV in PSF showed sagittal flexion loss. AVBT preserved more sagittal ROM than PSF but increased coronal motion loss, complications, and revision rates, with the largest benefit at LIV L4. Data on segmental motion are limited and further research on postoperative segmental ROM is required.

Differentiating Between Knee Septic Arthritis and Lyme Arthritis in Children: A Clinical Prediction Algorithm for a Geographically Diverse Population.

BACKGROUND: Knee septic arthritis (SA) and Lyme arthritis (LA) often have similar presentations but bacterial SA necessitates urgent surgery. Predictive factors for differentiating SA and other infectious/inflammatory conditions have been published. Our purpose was to test these algorithms using a retrospective multicenter musculoskeletal infection database. METHODS: Patients ≤18 years old with isolated knee SA or LA were identified. Diagnostic criteria for SA were synovial WBC count >50,000 cells/mm3, imaging with fluid aspiration suggestive of SA, or joint aspirate/tissue sample cultured positive for bacteria. Diagnostic criteria for LA was positive Lyme titer. Demographics, weightbearing status, admission vitals, and laboratory tests were collected. Predictive factors from Baldwin criteria for differentiating knee SA and LA, and Kocher criteria for differentiating hip SA and transient synovitis were tested. RESULTS: One hundred fifty-five patients (119 SA and 36 LA) were analyzed. Patients with SA were younger (2.2 vs. 8.0 y), more nonweightbearing (74% vs. 33%), had a higher pulse (127 vs. 106), and higher WBC (12.4 vs. 10.2) (all P<0.001).Baldwin criteria (pain with joint motion, history of fever, CRP >40 mg/L, age <2 y) were tested. Pain with motion was not collected in our database. Of the remaining factors, the probability of SA was 63% with 0 and 92% with 3 factors (AUC 0.64). Kocher criteria (nonweightbearing, temperature >101.3°F, WBC >12.0, ESR >40) and CRP >20 mg/L were also tested. The probability of SA was 41% with 0 and 96% with all factors (AUC 0.69).Using our cohort data, regression analysis with backward stepwise elimination determined that age <4 years, nonweightbearing, admission WBC >13.0, platelets <325, and ESR >70 were predictive factors for SA. The probability of SA with 0 factors was 16%, 1 factor 52%, 2 factors 86%, 3 factors 97%, and 4 factors 100% (AUC 0.86). CONCLUSIONS: Our model identified age <4 years, nonweightbearing, admission WBC >13.0, platelets <325, and ESR >70 as independent predictive factors for knee SA. The more factors present, the higher the likelihood of having SA versus LA. LEVEL OF EVIDENCE: Diagnostic level III.

Trampolines Versus Playgrounds - A Comparative Assessment of Pediatric Fractures Sustained From Recreational Play.

INTRODUCTION: Using the Pediatric Health Information System, this study compared the relative severity of fractures sustained from trampolines with those from other playground equipment. METHODS: Pediatric patients were identified in the Pediatric Health Information System with trampoline-related injuries (TRIs) or playground-related injuries (PRIs) diagnosed as fractures. Adjustments were made for hospital, year of injury, sex, age, race, median household income, and rurality through propensity score weighting. Four injury-related outcome measures were examined as a proxy for injury severity. RESULTS: A total of 133,232 patients met inclusion criteria. In unadjusted univariate analyses, TRIs were associated with greater odds of severe fracture and lower odds of receiving surgical treatment (OR = 0.954) compared with PRIs. After adjustment, TRIs sustained in late childhood and adolescence were more likely to receive surgical management (OR = 1.092 and OR = 1.192, respectively) while TRIs sustained in younger children were less likely (OR = 0.607) than PRIs. DISCUSSION: Youths in late childhood and adolescence are at increased odds of undergoing surgical management after trampoline fractures. Beyond underscoring the risks of trampoline play, our results highlight the importance of considering age in recreational injury epidemiology and the public health safety initiatives aimed at specific age groups.

Adolescent Idiopathic Scoliosis Minimum Data Set: Towards Standardization of Data Elements in History and Physical Examination.

INTRODUCTION: Nonoperative care represents a cornerstone of adolescent idiopathic scoliosis (AIS) management, although no consensus exists for a minimal data set. We aimed to determine a consensus in critical data points to obtain during clinical AIS visits. METHODS: A REDCap-based survey was distributed to Pediatric Orthopedic Society of America (POSNA), Pediatric Spine Study Group (PSSG), and International Society on Scoliosis Orthopedic and Rehabilitation Treatment (SOSORT). Respondents ranked the importance of data points in history, physical examination, and bracing during AIS visits.  Results: One hundred eighty-one responses were received (26% response rate), of which 86% were physicians and 14% were allied health professionals. About 80% of respondents worked at pediatric hospitals or pediatric spaces within adult hospitals, and 82% were academic, with the majority (57%) seeing 150+ unique AIS patients annually. Most respondents recommended six-month follow-up for patients under observation (60%) and bracing (54%). Most respondents (75%) considered family history and pain important (69%), with the majority (69%) asking about pain at every visit. Across all time points, Adam's forward bend test, shoulder level, sagittal contour, trunk shift, and curve stiffness were all considered critically important (>60%). At the first visit, scapular prominence, leg lengths, motor and neurological examination, gait, and iliac crest height were also viewed as critical. At the preoperative visit, motor strength and scapular prominence should also be documented. About 39% of respondents use heat sensors to monitor bracing compliance, and average brace wear since the prior visit was considered the most important (85%) compliance data point. CONCLUSIONS: This study establishes recommendations for a 19-item minimum data set for clinical AIS evaluation, including history, physical exam, and bracing, to allow for future multicenter registry-based studies.

How do implants overlying the spine influence "The Law of Diminishing Returns" in early-onset scoliosis patients?

PURPOSE: The "law of diminishing returns" (LODR) in early-onset scoliosis (EOS) is well-known. We hypothesized that previously observed variations between constructs may be related to the lateral distance that each construct lies from the spine. We therefore sought to determine whether the curve magnitude improvement and spinal length gains for distraction-based constructs in EOS are positively correlated with the collinearity of the spine and the convex-sided implant on posteroanterior radiographs. METHODS: A prospectively-collected, multicenter EOS registry was queried for all patients who underwent non-fusion, distraction-based instrumentation surgery. Post-index radiographs were graded from 1 to 5 based on amount of overlap between the convex-sided rod and the apical vertebra. Grade 1: convex rod is lateral to convex-sided pedicle; Grade 2: overlaps the convex-sided pedicle; Grade 3: lies between pedicles; Grade 4: overlaps concave-sided pedicle; Grade 5: medial to concave-sided pedicle. ANOVA assessed the correlations between post-index overlap grade and change in (a) curve magnitude and (b) T1-T12 height. Multivariable regression modeling further assessed these associations. RESULTS: 284 patients met all selection criteria and were included. On ANOVA, post-index grade was associated with curve magnitude (p <0.001) and T1-12 height (p = 0.028) change. Better curve correction and height change were associated with higher grade. On regression modeling, curve correction (R = 0.574) and T1-T12 height change (R = 0.339) remained significantly associated with grade when controlling for time, anchor locations, age, underlying diagnosis, and pre-index curve magnitude. CONCLUSION: More apical overlap by the convex rod was associated with better spinal deformity control and improved height gain. LEVEL OF EVIDENCE III: Therapeutic.

Should I stay or should I go: an assessment of criteria for safe day of surgery discharge of displaced supracondylar humerus fractures.

Immobilization type and in-hospital observation following surgical management of displaced supracondylar fractures are subject to surgeon preference and training. Our goal was to determine criteria for immediate discharge and optimal type of immobilization. Medical records of 661 patients with type III, IV or flexion-type displaced supracondylar humerus fractures treated at a level 1 pediatric trauma center from January 2013 to September 2019 were reviewed. Patients were separated into 'admission appropriate' (AA = 113) and 'discharge appropriate' (DA = 548) sub-cohorts. Neurovascular deficit at presentation (P < 0.001), post-operative physical exam deterioration (P < 0.001), age (P < 0.001) and post-operative immobilization modality (P = 0.02) were significantly different between AA and DA groups. When comparing patients who presented with neurologic deficit to those neurovascularly intact, there was a significant difference in whether circumferential immobilization was used post-operatively (P < 0.001), IV medication need (P < 0.001), discharge or admission (P < 0.001), neurologic decline (P < 0.001), return to ED (P = 0.008) and vascular compromise (P = 0.05). Twenty-four of the 56 (43%) patients who were AA and had no neurovascular finding on presentation had their immobilization adjusted (bivalved or loosened) to accommodate for swelling overnight. Only 1 was initially maintained in a splint or bivalved cast; the other 23 were initially maintained post-operatively in circumferential immobilization (P = 0.01). Our findings suggest that patients with intact neurovascular exams at presentation are candidates for early discharge, and splinting or bivalved casting may be preferable, especially in patients who are discharged.

Not Just Small Adults: Operative Versus Nonoperative Treatment in Adolescent Tibial Shaft Fractures.

BACKGROUND: The standard of care for tibial shaft fractures in young children is nonoperative management, while in adults, operative treatment is considered the mainstay. There are no clear guidelines on preferred treatment for adolescents. PURPOSE: This paper aims to 1) identify clinical and radiographic characteristics predictive of malalignment and 2) determine if treatment type affects malalignment risk. METHODS: This retrospective cohort study identified patients aged 12 to 16 years old with a tibial shaft fracture at a Level 1 pediatric trauma center. The primary outcome of interest was malalignment, classified as meeting one or more of the following: >5° coronal angulation, >5° sagittal angulation, translation (cortical width or 100% displaced), and/or rotational deformity. Comparative analyses were done to identify risk factors for malalignment. RESULTS: A total of 162 patients were included-initial treatment was "planned nonoperative" for 102 patients and "planned operative" for 60 patients. The malalignment rate was 34% in the planned nonoperative group versus 32% in the planned operative group. In a multivariate regression, older patients [odds ratio (OR)=-0.07, 95% CI: -0.13 to -0.01; P =0.024] and those with 100% initial displacement (OR=-0.35, 95% CI: -0.64 to -0.05; P =0.021) had decreased odds of malalignment, and having increased sagittal angulation (OR=0.02, 95% CI: 0.01-0.04; P =0.002) and a fibula fracture (OR=0.22, 95% CI: 0.03-0.41; P =0.023) increased the odds of malalignment. There was no difference in the rate of malalignment by initial treatment ( P =0.289). Having a planned nonoperative treatment (OR=22.7, 95% CI: 14.0-31.5; P <0.001) and having a fibula fracture (OR=8.52, 95% CI: 0.59-16.45; P =0.035) increased the time immobilized. CONCLUSIONS: This study provides insight into factors affecting tibial shaft fracture alignment among patients aged 12 to 16 years. This study suggests that the risk of malalignment is higher among patients with increased initial sagittal angulation and concomitant fibula fractures, but the risk of malalignment is comparable in patients initially treated nonoperatively and operatively. Although healing parameters on average were similar, nonoperative treatment results in longer immobilization time and time for unrestricted weight bearing. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

The impact of patient scoliosis-specific exercises for adolescent idiopathic scoliosis: a systematic review and meta-analysis of randomized controlled trials with subgroup analysis using observational studies.

PURPOSE: Adolescent idiopathic scoliosis (AIS) is a common pediatric spinal deformity frequently treated with patient scoliosis-specific exercises (PSSE). The purpose of this study is to perform a systematic review and meta-analysis of randomized controlled trials and sensitivity analysis of observational studies to determine the impact of PSSE on outcomes for AIS. METHODS: A systematic review and meta-analysis on impact of PSSE for patients with AIS was performed. Databases used included PubMed, CINAHL, MEDLINE, Cochrane, and ScienceDirect database inception to October 2022. Inclusion criteria included use of PSSE, patient population of AIS, and full text. RESULTS: A total of 26 articles out of 628 initial retrieved met final inclusion criteria (10 randomized controlled trials (RCTs), 16 observational studies). Total included patients (n = 2083) had a frequency weighted mean age of 13.2 ± 0.9 years and a frequency weighted mean follow-up of 14.5 ± 20.0 months. Based on only data from RCTs with direct comparison groups (n = 7 articles), there was a statistically significant but clinically insignificant improvement in Cobb angle of 2.5 degrees in the PSSE group (n = 152) as compared to the control group (n = 148; p = 0.017). There was no statistically significant improvement in Cobb angle when stratified by small curve (< 30 degrees) or large curve (> 30 degrees) with PSSE (p = 0.140 and p = 0.142, respectively). There was no statistically significant improvement in ATR (p = 0.326) or SRS-22 score (p = 0.370). CONCLUSION: PSSE may not provide any clinically significant improvements in Cobb angle, ATR, or SRS-22 scores in patients with AIS. PSSE did not significantly improve Cobb angle when stratified by curve size. LEVEL OF EVIDENCE: Level I.

Nausea and Vomiting After Posterior Spinal Fusion in Adolescent Idiopathic Scoliosis: A Systematic and Critical Analysis Review.

BACKGROUND: Postoperative nausea and vomiting (PONV) affects patient satisfaction, health care costs, and hospital stay by complicating the postoperative recovery period after adolescent idiopathic scoliosis (AIS) spinal fusion surgery. Our goal was to identify recommendations for optimal management of PONV in AIS patients undergoing posterior spinal fusion (PSF). METHODS: We performed a systematic review in June 2022, searching the PubMed and Embase electronic databases using search terms "(Adolescent idiopathic scoliosis) AND (Postoperative) AND (Nausea) AND (Vomiting)." Three authors reviewed the 402 abstracts identified from January 1991 to June 2022. Studies that included adolescents or young adults (<21 years) with AIS undergoing PSF were selected for full-text review by consensus. We identified 34 studies reporting on incidence of PONV. Only 6 studies examined PONV as the primary outcome, whereas remaining were reported PONV as a secondary outcome. Journal of Bone and Joint Surgery Grades of recommendation were assigned to potential interventions or clinical practice influencing incidence of PONV with respect to operative period (preoperative, intraoperative, and postoperative period) on the basis that potential guidelines/interventions for PONV can be targeted at those periods. RESULTS: A total of 11 factors were graded, 5 of which were related to intervention and 6 were clinical practice-related. Eight factors could be classified into the operative period-1 in the intraoperative period and 7 in the postoperative period, whereas the remaining 3 recommendations had overlapping periods. The majority of grades of recommendations given were inconclusive or conflicting. The statement that neuraxial and postoperative systemic-only opioid therapy have a similar incidence of PONV was supported by good (Grade A) evidence. There was fair (Grade B) and poor evidence (Grade C) to avoid opioid antagonists and nonopioid local analgesia using wound catheters as PONV-reducing measures. CONCLUSION: Although outcomes after spinal fusion for AIS have been studied extensively, the literature on PONV outcomes is scarce and incomplete. PONV is most commonly included as a secondary outcome in studies related to pain management. This study is the first to specifically identify evidence and recommendations for interventions or clinical practice that influence PONV in AIS patients undergoing PSF. Most interventions and clinical practices have conflicting or limited data to support them, whereas others have low-level evidence as to whether the intervention/clinical practice influences the incidence of PONV. We have identified the need for expanded research using PONV as a primary outcome in patients with AIS undergoing spinal fusion surgery.

An Analysis of Negative One-star Patient Reviews and Complaints for Pediatric Orthopaedic Surgeons throughout the United States: A Retrospective Study.

OBJECTIVE: Patients commonly use physician review websites when choosing a surgeon for an elective procedure. Although data exist regarding other orthopaedic specialties, no study has investigated one-star reviews for pediatric orthopaedic surgeons. The goal of this retrospective study was to classify the factors contributing to one-star reviews of pediatric orthopaedic surgeons to identify which areas contribute to lower patient satisfaction. METHODS: Patient ratings on a 5-star system and comments about pediatric orthopaedic surgeons were collected from the state with the most physicians registered in the "Pediatric Orthopaedic Society of North American" database for each of the 9 geographical regions of the United States as defined by the Association of American Medical Colleges. One-star reviews that included comments were classified as either surgical or nonsurgical. These comments were then further classified based on their content. RESULTS: Three hundred fifty-four one-star reviews with 700 complaints were included in this study. Of these complaints, 481 (68.7%) were from nonsurgical patients and 219 (31.3%) were from surgical patients. Nonsurgical patients were significantly more likely to reference the amount of time spent with the physician (12.9% to 6.6%, P = 0.026), wait time (11.9% to 0.0%, P < 0.001), and bedside manner (41.2% to 22.8%, P < 0.001). Patients who said they had undergone a surgical procedure in their one-star review were significantly more likely to reference a disagreement with the physician's decision or plan (35.3% to 17.5%, P < 0.001), and uncontrolled pain (21.6% to 5.2%, P < 0.001). There was no significant difference in the comments that referenced medical staff or institutional complaints between surgical and nonsurgical patients (13.8% to 11.4%, P = 0.424). CONCLUSION: Most one-star reviews of pediatric orthopaedic surgeons referenced interpersonal skills and other nonclinical aspects of a clinical encounter, with bedside manner being the most frequent complaint. Patients who had undergone surgical procedures were less likely to leave a one-star review, but if they did, their comment was usually about a disagreement with the physician's plan. CLINICAL RELEVANCE: Prognostic studies III.

Clinical Outcomes and Associated Pathologies Following Pediatric Traumatic Hip Dislocations: A Systematic Review of the Literature.

INTRODUCTION: Pediatric traumatic hip dislocations are a rare condition that can have devastating short and/or long-term outcomes and associated pathologies (APs), including associated injuries (AIs) and long-term adverse events (LTAEs), with negative long-term sequelae. Currently, there are little data that exist on the rate of APs, with the most notable being avascular necrosis (AVN), for pediatric traumatic hip dislocations. The purpose of this systematic review is to evaluate the outcome relative frequency of dislocation direction, reduction type, and rate of APs for traumatic hip dislocations in the pediatric population. METHODS: A systematic review on the topic of traumatic hip dislocations in the pediatric population was performed using PubMed, ScienceDirect, Web of Science, CINAHL, and MEDLINE databases from database inception to March 30, 2023. Inclusion criteria was full-text English articles, addressed traumatic hip dislocations, and pediatric patients (<18 y old). RESULTS: A total of 24 articles (n=575 patients) met final inclusion criteria from a total of 219 articles retrieved from the initial search. For the average age of the included patients with reported age (n=433 patients), the frequency weighted mean was 9.50 years±1.75 years with a frequency weighted mean follow-up time of 74.05 months ±45.97 months (n=399 patients). The most common dislocation direction was posterior (86.4%), the most common treatment type was closed reduction (84.5%), AVN was the most common type of LTAEs (15.5% of APs), and labral/capsular injuries and acetabular fractures were the most common type of AIs (14.0% and 9.4% of APs, respectively). There were a combined total of 414 APs (72%) out of 575 total patients. CONCLUSION: Pediatric traumatic hip dislocations are associated with a high rate of AIs and LTAEs (72%, 414 APs out of 575 patients). AVN, labral/capsular injuries, and acetabular fractures are the most common APs after pediatric traumatic hip dislocations. Pediatric hip dislocations are usually posterior and commonly managed through closed reduction. LEVEL OF EVIDENCE: III, Systematic Review.

The Impact of the Addition of a Physical Therapy Assistant to the Treatment Team for Management of Neck Pain: A Retrospective Analysis of Outpatient Physical Therapy Clinics.

Introduction The impact of physical therapy assistants (PTAs) on patient outcomes, mostly in the acute and subacute setting, is well known in the literature. However, no study to date has examined the impact of using PTAs as part of a treatment team in the outpatient setting for common musculoskeletal conditions. The purpose of this study is to determine if physical therapy team composition, either physical therapists (PTs) only or a team consisting of PTs and PTAs, has a significant impact on patient outcomes in adult patients with musculoskeletal neck pain to help investigate an ideal practice pattern for outpatient physical therapy. Methods This is a retrospective cohort study analyzing the impact of physical therapy treatment team composition (PTs only, or team consisting of PTs and PTAs) on pain, active range-of-motion (AROM), and disability outcomes via the Neck Disability Index (NDI) in the conservative treatment of neck pain. All patients were treated with usual physical therapy care. Inclusion criteria involved patients with a diagnosis of neck pain (M48.2), older than 18 years old, a physical therapy evaluation procedure code (97161, 97162, 97163), and at least two visits per bout of physical therapy. Primary outcome measures were pain, bilateral rotation AROM, disability, and number of visits.  Results Included patients (n=195) had an average age of 60.8 years ± 16.1 years with an average number of total physical therapy visits of 7.4 visits ± 4.3 visits (range, 2 visits - 22 visits) with 120 patients (61.5%) treated by a PT only (PT-only group) and 75 patients (38.5%) treated by a team consisting of a PT and a PTA (PTA group). The PT-only group had significantly fewer visits than the PTA group (p<0.001). The PT-only group had a pain improvement of 2.1 points ± 2.3 points whereas the PTA group had a pain improvement of 2.2 points ± 2.4 points with no significant difference between the two groups (p=0.573). The PT-only group (n=46 patients) had an average rotation AROM improvement of 20.0 ± 17.4 degrees whereas the PTA group (n=40 patients) had an average rotation AROM improvement of 16.8 degrees ± 23.0 degrees with no significant difference between the level of rotation AROM improvement between the two groups (p=0.408). Furthermore, there was also no significant difference in the amount of NDI improvement seen in both groups (p=0.594). Conclusion There was no significant difference in patient outcomes for pain, AROM, and disability when PTAs were added to the physical therapy treatment team in the conservative management of neck pain in the outpatient setting. However, patients treated with a treatment team consisting of PTAs had significantly more visits, despite no significant change in outcomes. Randomized controlled trials are needed as the reasons for these findings can be many and require further research.

Clinical Outcomes Associated With the Addition of a Physical Therapist Assistant to a Rehabilitation Team When Treating Musculoskeletal Shoulder Pain in the Outpatient Setting: A Retrospective Cohort Study.

Introduction Musculoskeletal shoulder pain (MSP) is a common condition frequently treated in an outpatient setting by a physical therapy rehabilitation team. Treatment teams can consist of physical therapists (PTs) with or without physical therapist assistants (PTAs). It is currently unknown how different physical therapy team compositions can impact patient outcomes in the outpatient setting. The purpose of this study is to examine how the addition of PTAs to a physical therapy treatment team would impact clinical outcomes when treating patients with MSP in the outpatient setting. Methods This study is a retrospective cohort analysis comparing clinical outcomes for pain, active range of motion (AROM), and disability for patients with MSP when treated by physical therapy treatment teams with or without the presence of PTAs. Inclusion criteria were patients treated for MSP in an outpatient physical therapy clinic without a history of shoulder surgery. Depending on the rehabilitation team composition, patients were divided into a PT-only group or a PTA group. Results Total patients (n = 238) had a mean age of 62.6 ± 12.6 years (median: 64 years) with a mean total number of physical therapy visits of 7.8 ± 4.9 visits (median: 7.0 visits). Of the entire cohort, the PT-only group had 100 patients and the PTA group had 138 patients. There was no significant difference in the magnitude of pain improvement (mean: 1.5 versus 1.9 points, p = 0.177), the magnitude of abduction AROM improvement (mean: 17.6 versus 13.9 degrees, p = 0.173), and the magnitude of disability improvement (mean: 18.9 versus 13.4 percentage points, p = 0.221) between the PT-only group and the PTA group. However, the PT-only group had significantly fewer total visits as compared to the PTA group (6.7 versus 8.6 visits, p < 0.001). Conclusion The addition of PTAs to a rehabilitation team when treating patients with MSP in the outpatient setting does not appear to adversely impact pain, AROM, or disability outcomes. However, patients treated only by PTs had significantly less visits with similar outcomes. More research is needed to determine the interplay between cost, healthcare utilization, and patient outcomes to maximize quality care.

Rib-to-spine and rib-to-pelvis magnetically controlled growing rods: does the law of diminishing returns still apply?

PURPOSE: The Law Of Diminishing Returns (LODR) has been demonstrated for traditional growing rods, but there is conflicting data regarding the lengthening behavior of Magnetically Controlled Growing Rods (MCGR). This study examines a cohort of patients with early-onset scoliosis (EOS) with rib-to-spine or rib-to-pelvis-based MCGR implants to determine if they demonstrate the LODR, and if there are differences in lengthening behaviors between the groups. METHODS: A prospectively collected multicenter EOS registry was queried for patients with MCGR with a minimum 2-year follow-up. Patients with rib-based proximal anchors and either spine- or pelvis-based distal anchors were included. Patients with non-MCGR, unilateral constructs, < 3 lengthenings, or missing > 25% datapoints were excluded. Patients were further divided into Primary-MCGR (pMCGR) and Secondary-MCGR (sMCGR). RESULTS: 43 rib-to-spine and 31 rib-to-pelvis MCGR patients were included. There was no difference in pre-implantation, post-implantation and pre-definitive procedure T1-T12 height, T1-S1 height, and major Cobb angles between the groups (p > 0.05). Sub-analysis was performed on 41 pMCGR and 19 sMCGR rib-to-spine patients, and 31 pMCGR and 17 sMCGR rib-to-pelvis patients. There is a decrease in rod lengthenings achieved at subsequent lengthenings for each group: rib-to-spine pMCGR (rho = 0.979, p < 0.001), rib-to-spine sMCGR (rho = 0.855, p = 0.002), rib-to-pelvis pMCGR (rho = 0.568, p = 0.027), and rib-to-pelvis sMCGR (rho = 0.817, p = 0.007). Rib-to-spine pMCGR had diminished lengthening over time for idiopathic, neuromuscular, and syndromic patients (p < 0.05), with no differences between the groups (p > 0.05). Rib-to-pelvis pMCGR neuromuscular patients had decreased lengthening over time (p = 0.01), but syndromic patients had preserved lengthening over time (p = 0.65). CONCLUSION: Rib-to-spine and rib-to-pelvis pMCGR and sMCGR demonstrate diminished ability to lengthen over subsequent lengthenings.

Age and CRP Associated With Improved Tissue Pathogen Identification in Children With Blood Culture Negative Osteomyelitis: Results From the CORTICES Multicenter Database.

BACKGROUND: Acute hematogenous osteomyelitis (AHO) is a relatively common condition in children, and identifying the offending pathogen with blood or tissue cultures aids in diagnosis and medical management while reducing treatment failure. Recent 2021 AHO clinical practice guidelines from the Pediatric Infectious Disease Society recommend obtaining routine tissue cultures, particularly in cases with negative blood cultures. The purpose of this study was to identify variables associated with positive tissue cultures when blood cultures are negative. METHODS: Children with AHO from 18 pediatric medical centers throughout the United States through the Children's ORthopaedic Trauma and Infection Consortium for Evidence-based Study were evaluated for predictors of positive tissue cultures when blood cultures were negative. Cutoffs of predictors were determined with associated sensitivity and specificity. RESULTS: One thousand three children with AHO were included, and in 688/1003 (68.6%) patients, both blood cultures and tissue cultures were obtained. In patients with negative blood cultures (n=385), tissue was positive in 267/385 (69.4%). In multivariate analysis, age ( P <0.001) and C-reactive protein (CRP) ( P =0.004) were independent predictors. With age >3.1 years and CRP >4.1 mg/dL as factors, the sensitivity of obtaining a positive tissue culture when blood cultures were negative was 87.3% (80.9-92.2%) compared with 7.1% (4.4-10.9%) if neither of these factors was present. There was a lower ratio of methicillin-resistant Staphylococcus aureus in blood culture-negative patients who had a positive tissue culture 48/188 (25.5%), compared with patients who had both positive blood and tissue cultures 108/220 (49.1%). CONCLUSION: AHO patients with CRP ≤ 4.1 mg/dL and age under 3.1 years are unlikely to have clinical value from tissue biopsy that exceeds the morbidity associated with this intervention. In patients with CRP > 4.1 mg/dL and age over 3.1 years, obtaining a tissue specimen may add value; however, it is important to note that effective empiric antibiotic coverage may limit the utility of positive tissue cultures in AHO. LEVEL OF EVIDENCE: Level III-Retrospective comparative study.

The McKenzie Method Is an Effective Rehabilitation Paradigm for Treating Adults With Moderate-to-Severe Neck Pain: A Systematic Review With Meta-Analysis.

Neck pain is a common musculoskeletal condition frequently managed with numerous conservative interventions. The McKenzie method of mechanical diagnosis and therapy (MMDT) is a form of physical therapy evaluation and treatment that aims to improve pain and disability in patients with musculoskeletal pain, including neck pain. To date, no systematic review with meta-analysis has examined the use of the McKenzie MMDT for neck pain. This study aimed to examine the effectiveness of the McKenzie MMDT in adult patients with neck pain. A systematic review and meta-analysis were performed using PubMed, ScienceDirect, MEDLINE, CINAHL, Web of Science, and Google Scholar. Full search terms were "McKenzie method" OR "McKenzie approach" OR "McKenzie treatment" AND "neck pain." Inclusion criteria were the use of the McKenzie MMDT, level I randomized control trials (RCTs), adults, and outcomes of pain (0-10 scale) and disability (neck disability index). A total of 11 RCTs met the final selection criteria from 1,955 articles on initial search with 289 patients receiving the McKenzie MMDT out of 677 total patients. For meta-analysis, there was a clinically insignificant but statistically significant improvement in pain (1.14/10 points) in patients receiving the McKenzie MMDT versus control interventions (p<0.02). There was no significant improvement in the neck disability index score between the McKenzie MMDT versus control interventions (p=0.19). For severity of pain, there was a clinically and statistically significant improvement in moderate or severe pain (2.06/10 points; p<0.01), but not in mild-to-moderate pain (p=0.84) when comparing the McKenzie MMDT to control interventions. Overall, the McKenzie MMDT provides very small but statistically significant improvements in neck pain of all severity compared to control interventions. However, the McKenzie MMDT does provide clinically and statistically significant pain improvement in moderate-to-severe neck pain. Use of the McKenzie MMDT did not provide any significant improvement in disability compared to control interventions. This study is the first systematic review with meta-analysis on the effectiveness of the McKenzie MMDT for adult patients with neck pain.

When to Perform Fusion Short of the Pelvis in Patients with Cerebral Palsy?: Indications and Outcomes.

Patients with scoliosis secondary to cerebral palsy (CP) are often treated with posterior spinal fusion (PSF) with or without pelvic fixation. We sought to establish criteria to guide the decision of whether or not to perform fusion "short of the pelvis" in this population, and to assess differences in outcomes. Methods: Using 2 prospective databases, we analyzed 87 pediatric patients who underwent PSF short of the pelvis from 2008 to 2015 to treat CP-related scoliosis and who had ≥2 years of follow-up. Preoperative radiographic and clinical variables were analyzed for associations with unsatisfactory correction (defined as pelvic obliquity of ≥10°, distal implant dislodgement, and/or reoperation for increasing deformity at 2- or 5-year follow-up). Continuous variables were dichotomized using the Youden index, and a multivariable model of predictors of unsatisfactory correction was created using backward stepwise selection. Finally, radiographic, health-related quality-of-life, and clinical outcomes of patients with fusion short of the pelvis who had neither of the 2 factors associated with unsatisfactory outcomes were compared with those of 2 matched-control groups. Results: Deformity correction was unsatisfactory in 29 of 87 patients with fusion short of the pelvis. The final model included preoperative pelvic obliquity of ≥17° (odds ratio [OR], 6.8; 95% confidence interval [CI], 2.3 to 19.7; p < 0.01) and dependent sitting status (OR, 3.2; 95% CI, 1.1 to 9.9; p = 0.04) as predictors of unsatisfactory correction. The predicted probability of unsatisfactory correction increased from 10% when neither of these factors was present to a predicated probability of 27% to 44% when 1 was present and to 72% when both were present. Among matched patients with these factors who had fusion to the pelvis, there was no association with unsatisfactory correction. Patients with independent sitting status and pelvic obliquity of <17° who had fusion short of the pelvis had significantly lower blood loss and hospital length of stay, and better 2-year health-related quality-of-life scores compared with matched controls with fusion to the pelvis. Conclusions: In patients with scoliosis secondary to CP, pelvic obliquity of <17° and independent sitting status are associated with a low risk of unsatisfactory correction and better 2-year outcomes when fusion short of the pelvis is performed. These may be used as preoperative criteria to guide the decision of whether to perform fusion short of the pelvis in patients with CP. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Utilization of Clinical Practice Guideline Interventions in the Conservative Management of Mechanical Neck Pain: A Retrospective Analysis.

INTRODUCTION: Neck pain is a common musculoskeletal condition frequently treated by physical therapists. The American Physical Therapy Association (APTA) published a clinical practice guideline (CPG) in 2008 with a revision in 2017 to improve the diagnosis and treatment of neck pain. One subset of neck pain in the CPG is "Neck Pain with Mobility Deficits," also called mechanical neck pain. Little data exists on the adherence of physical therapists to the CPG-recommended treatments for neck pain as well as the outcomes associated with the utilization of the CPG. The purpose of this study is to examine both CPG treatment adherence and associated outcomes in patients treated for mechanical neck pain by physical therapists in the outpatient setting. METHODS: Retrospective chart review of patients (n=224) who received physical therapy for neck pain between 2018 and 2022. Data ranges were chosen due to the publication of the CPG revision in 2017. Six interventions for mechanical neck pain from the CPG were examined: thoracic manipulation, cervical mobilization, transcutaneous electrical stimulation (TENS), dry needling, advice to stay active, and scapular resistance exercises. The exclusion criteria were a history of cervical spine surgery. Other data collected included age, sex, characteristics of the evaluating physical therapist, and the number of visits. RESULTS: For CPG treatment adherence, 4.5% of patients received thoracic manipulation, 47.8% of patients received cervical mobilization, 12.5% of patients received TENS, 22.8% of patients received dry needling, 99.1% of patients received advice to stay active, and 89.3% of patients received scapular resistance exercises. There was no significant improvement in pain, range of motion (ROM), and function based on a number of CPG interventions used during the bout of physical therapy (p=0.17 to p=0.74). Patients who were evaluated by a physical therapist who was an Orthopedic Certified Specialist (OCS) were more likely to receive more interventions recommended by the CPG (p<0.01). CONCLUSION: CPG-recommended treatments are used with varying frequency by physical therapists when treating mechanical neck pain. Thoracic manipulation is rarely used while scapular resistance exercises are frequently used. There was no significant improvement in pain, ROM, or function based on the number of CPG-recommended treatments used during the bout of physical therapy.

Current trends in surgical magnitude of neuromuscular scoliosis curves: a study of 489 operative patients with non-ambulatory cerebral palsy.

PURPOSE: A curve magnitude at which posterior spinal fusion (PSF) is indicated for children with cerebral palsy (CP) scoliosis is not defined. We sought to evaluate whether agreement exists for a curve magnitude at which PSF is undertaken for CP scoliosis and to evaluate outcomes by quartile of curve magnitude and flexibility at time of fusion. METHODS: A prospective multicenter pediatric spine database was queried for patients with a Gross Motor Function Classification Scale (GMFCS) IV or V who underwent PSF for CP scoliosis. Demographics, surgical indications, and correlations between curve magnitude, postoperative radiographic outcomes, and Caregiver's Priorities and Child Health Index of Life and Disabilities (CPCHILD) scores were evaluated for patients with at least 2 years of follow-up. RESULTS: 489 patients from 15 sites were analyzed. Median major Cobb angle at time of PSF was 87° and significantly varied by site (p < 0.001). Median Cobb angle on flexibility studies was 55° and median percent correction on flexibility studies was 36.3%. Severity of the curve at surgery correlated significantly with lower overall quality of life and CPCHILD score (p < 0.05). Larger residual curves correlated with larger operative curves (p < 0.001) and decreased flexibility on preoperative flexibility studies (p < 0.001), although postoperative CPCHILD scores did not differ by curve size or flexibility at time of fusion or by size of residual curve (p > 0.05). CONCLUSION: The median curve magnitude is large and there is substantial variability in curve size of CP scoliosis at time of fusion, although clinical outcomes are not negatively influenced by larger operative magnitudes. Further study should aim to narrow surgical indications by defining unacceptable radiographic outcomes. LEVEL OF EVIDENCE: Level III.