Long-term outcomes and complications of isolated anterior thoracolumbar fusion for neuromuscular scoliosis associated with myelomeningocele.

PURPOSE: Neuromuscular scoliosis associated with myelomeningocele is a difficult clinical dilemma for the treating surgeon. The traditional surgical treatment consists of a posterior spinal instrumented fusion with or without a combined anterior procedure, but this has been associated with high complication rates, mostly related to deep infection. An anterior thoracolumbar fusion is not able to address the entirety of the deformity in many cases but could potentially avoid the devastating infection risks from the posterior approach by avoiding compromised skin. This study aims to evaluate the long-term outcomes and complications associated with isolated anterior thoracolumbar fusion in this high-risk group. METHODS: This study is a retrospective analysis of patients with myelomeningocele-associated scoliosis treated with an isolated anterior spinal fusion over a 20-year time period at a single center. Surgical details, demographics, curve characteristics and complications were recorded. Comparisons were made between patients who required revision surgery and those who did not. RESULTS: Sixteen patients were enrolled with an average age of 12.7 years at the time of surgery and average follow-up of 5.5 years. Patients had on average 7.4 levels fused anteriorly with the most common levels being T10-L4. There were no deep wound infections associated with the anterior surgery. Overall, nine patients (56%) had to be revised posteriorly due to adding-on or junctional deformity at an average of 3.7 years after index procedure. Four patients were revised due to proximal adding-on, while 1 was extended distally. Four additional patients were extended both proximally and distally. Of the posterior revisions, 2 patients developed deep wound infections, and both of these were in patients extended distally. Preoperative lumbar lordosis was higher in patients who required distal extension (100 vs. 69 degrees; p = 0.035). CONCLUSIONS: Patients undergoing isolated anterior fusion for scoliosis associated with myelomeningocele have low infection rates but often require posterior revision. The majority of patients can avoid the deep infection risk associated with distal posterior surgery at long-term follow-up. LEVEL OF EVIDENCE: IV.

The Effects of Lower Extremity Rotational Malalignment on Pediatric Patient-reported Outcomes Measurement and Information System (PROMIS) Scores.

BACKGROUND: There is sparse literature demonstrating the relationship between lower limb pediatric idiopathic rotational malalignment (IRM) and patient-reported outcomes measurement information system (PROMIS) scores. Our goal is to determine and quantify the amount that IRM deformities, as measured with the 3D gait analysis, affect childrens' pain interference, mobility, and peer relationship PROMIS domains. Secondary outcomes include investigating the potential relationships between IRM and various subgroups (Pediatric Outcomes Data Collection Instrument (PODCI), gender, Body Mass Index (BMI), femur Versus tibia). We also examine whether the PROMIS domains correlate with PODCI in this population. METHODS: This study was a retrospective cohort, single institution, and consecutively recruited cases series. We identified 47 children over a 3-year period who were evaluated at the motion analysis center at our tertiary care hospital, with increased torsion of the femur or tibia. After exclusions, 25 children with IRM, documented PROMIS data and gait analysis were considered. RESULTS: Femoral malrotation had a significant relationship with female gender ( P =0.001) and increased BMI ( P <0.001). Femoral malrotation had a correlation with PROMIS pain interference ( P =0.016), whereas tibial rotation did not achieve significance ( P =0.084). In the ANOVA regression analysis, there was a strong prediction of the PROMIS mobility domain when both malrotation and pain interference were present ( P =0.007). There were Pearson Correlations of PROMIS and PODCI domains for Mobility Versus Sports ( P =0.007) and Pain Interference Versus Comfort/Pain ( P =0.004), respectively. CONCLUSION: The evident relationship between lower limb rotational malalignment and PROMIS scores signifies the likelihood for gait and pain disturbance. This in turn could show us that children are likely to be more debilitated and thus may benefit from timely correction. We aim to conduct this as a multicentre trial to confirm our findings. LEVEL OF EVIDENCE: Level IV.

Patient-Reported Outcome Measurement Information System (PROMIS) Scores in Pediatric Idiopathic Toe Walkers.

BACKGROUND: Idiopathic toe walking (ITW) can result in early contact with the health care system and be distressing for patients and their families. The natural history of ITW is poorly characterized. Deciding how and when to intervene can be difficult.Patient-reported outcomes are utilized in the clinical setting to assess patient factors and indications that may better inform treatment plans. Patient-Reported Outcomes Measurement Information System (PROMIS) is an instrument designed to collect patient-reported outcomes. Minimum clinically important differences in PROMIS metrics have been established to facilitate clinical relevance and utility of these metrics. The purpose of this study was to characterize the patient perspective of ITW by utilizing the PROMIS scores. METHODS: Retrospective chart review was performed to identify children aged 5 to 17 with a diagnosis of ITW treated at a single tertiary care center between 2017 and 2020. Inclusion criteria were a diagnosis of ITW and completion of a PROMIS questionnaire. Exclusion criteria were neurologic disease, autism, and previous surgical treatment. Demographic, physical exam, treatment, and available motion analysis data were collected. PROMIS scores for the following domains were available: Mobility, Peer Relationships, and Pain Interference. RESULTS: Forty-five children were enrolled. Seventy-three percent of PROMIS scores were patient reported while the remainder were parent reported. PROMIS score means for the cohort by domain were Mobility: 45.2±8.2 ( P <0.000); Peer Relationships: 46.4±11.6 ( P =0.047); and Pain Interference: 47.4±9.5 ( P =0.67). Motion analysis data, available for 11 children, noted age-matched gait velocity negatively correlated ( rs =-0.652, P =0.03) with Peer Relationships. No correlations were found between other aspects of gait, body mass index, or limitations in dorsiflexion and PROMIS domains. Parents reported lower Mobility scores than children did. There were no other significant differences between patient-reported and parent-reported PROMIS scores. PROMIS scores did not differ significantly between those <10 years and those ≥10 years. CONCLUSION: In this cohort of 45 otherwise healthy children without other neurologic diagnoses, there are both clinically and statistically significant differences in PROMIS means between our cohort and the healthy age-matched population. These differences manifested in worse peer relationships and mobility scores. LEVEL OF EVIDENCE: Level IV.

Outcomes of MCGR at > 3 year average follow-up in severe scoliosis: who undergoes elective revision vs UPROR?

PURPOSE: The purpose of this study was to evaluate mid-term outcomes of magnetically controlled growing rods (MCGR), evaluate factors associated with unplanned return to the operating room (UPROR) vs achieving full length. Full length was defined as achieving > 85% of the elongating portion of the rod. METHODS: IRB approved retrospective single site study. 106 patients underwent MCGR between 2014 and 2020, 58 met inclusion criteria, all genders, ethnicities, and etiologies were included. Patients with < 1 year follow-up or previous instrumentation were excluded. RESULTS: Follow-up averaged 43 months. 23 patients achieved full length 13 were revised to a new MCGR and 10 to a fusion; 5 were fused due to skeletal maturity; 12 were still lengthening; 2 were being observed; 16 experienced UPROR. Major curves improved from 80° (50-114) preoperative to 40° (7-78) at most recent follow-up or prior to revision, and 24° (4-57) after fusion. Fusion patients averaged 1.3 (1-4) procedures prior to fusion and gained 75 mm (38-142) in T1-S1 length. 16 patients experienced UPROR, 11 were male (p = 0.0238). All failures to elongate were male as was the rod fracture. Age was not correlated with UPROR (p = 0.318), but did correlate with implant-specific causes of UPROR. Specifically, anchor failure was associated with younger age and rod failure with older age at implantation (p = 0.013). There was no correlation between UPROR and major curve, flexibility or kyphosis. CONCLUSION: This is the largest site study evaluating mid-term outcomes in MCGR patients. At > 3.5 year follow-up 47% were electively revised, 27% underwent UPROR, 26% were still lengthening, and 3% were being observed. UPROR was associated with male gender and age at implantation was associated with implant-related causes of UPROR. MCGR continues to have high complication rates, better knowledge of MCGR outcomes may improve patient education, surgical timing, and decision-making.

Baseline patient reported outcome measurement information system (PROMIS) scores in children with idiopathic scoliosis and their relation to the SRS-22.

PURPOSE: PROMIS is becoming the most commonly utilized patient-reported outcome measure (PROM) in adult orthopaedics, but its adoption has lagged in pediatrics. Limited baseline data exists in pediatric-specific orthopaedic diagnoses. The objective of this study was to determine baseline PROMIS scores in patients with idiopathic scoliosis and to evaluate for correlations with the SRS-22. METHODS: This was a retrospective analysis of prospectively collected data from six tertiary care pediatric hospitals between July 2016 and July 2018. Patients with a diagnosis of idiopathic scoliosis, adequate radiographs for measurement and completion of PROMIS and SRS-22 questionnaires from the same visit were included. Only the first visit during the study period was included for each subject. Post-operative patients were excluded. Spearman correlations were performed between four PROMIS domains (Pain interference [PI], Mobility [M], Peer Relationships [PR] and Upper Extremity [UE]) and SRS-22 domains. PROMIS scores are calibrated such that 50 is the median value in a population and 10 points is equivalent to one standard deviation. RESULTS: 986 patients with a mean age of 14.6 years were included, 79.8% of which were female. The mean major curve was 33.0° (range: 10-102). The major curve was thoracic in 56.5%, thoracolumbar in 24.4% and lumbar in 19.1% of subjects. The mean PROMIS domain scores were: Pain Interference 44.5 (IQR 17.7); Mobility 52.7 (IQR 12.5); Peer Relationships 55.7 (IQR 15.0); Upper Extremity 53.4 (IQR 7.7). Correlations existed between PROMIS Pain Interference and SRS-22 pain (r = 0.704, p < 0.001) and PROMIS Mobility and SRS-22 function (r = 0.53, p < 0.001). Significant ceiling effects existed in SRS-22 Function (29.9%), Pain (19.2%) and Satisfaction (30.3%) but only for PROMIS Peer Relationships (42.1%). CONCLUSIONS: PROMIS domain scores for patients with AIS are within normal population limits. PROMIS correlates well with SRS-22 in overlapping domains, and fewer domains demonstrate a ceiling effect. There was no relationship between the magnitude of scoliosis and PROMIS domain scores. LEVEL OF EVIDENCE: II.

Continued deterioration in pulmonary function at average 23-year follow-up from early thoracic fusion in non-neuromuscular scoliosis.

PURPOSE: Historically, early-onset scoliosis was treated with early fusion to prevent further deformity at the expense of thoracic growth. This has proven to have a detrimental effect on pulmonary function. The purpose of this study is to evaluate patients' pulmonary and functional status at long-term follow-up after undergoing thoracic fusion at a young age. METHODS: All patients at a single institution who had undergone thoracic spinal fusion prior to age nine with minimum 13-year follow-up were eligible. Patients underwent pulmonary function testing, radiographic analysis, and functional testing. Results were compared to the patients' previous pulmonary function data at average of 11 years post-surgery. RESULTS: Fifteen out of twenty-eight eligible patients returned for testing. The average age at the time of surgery was 3.3 years (range 0.9-8.4 years) with follow-up of 23.6 years (range 13.2-33.2 years). There was a statistically significant interval decline in predicted forced vital capacity (42.8% versus 54.7% of normal predicted values, p = 0.0001) and predicted forced expiratory volume in one second (42.2% versus 55.2% of normal predicted values, p = 0.0001) when compared to previous follow-up. There was a strong positive correlation between thoracic height and forced vital capacity (r = 0.925, p = 0.002). CONCLUSIONS: Pulmonary function in patients who had undergone thoracic spinal fusion for scoliosis prior to the age of six continues to decline into adulthood at a rate that is faster than that of their peers. The majority of these patients have clinically important restrictive lung disease, which can be fatal. Alternative treatment strategies should be considered. LEVEL OF EVIDENCE: III.

Image Distortion in Biplanar Slot Scanning: Part 2 Technology-specific Factors.

BACKGROUND: Biplanar digital slot scanning technology has become the standard of care in the treatment of scoliosis. Yet, the amount of distortion and reproducibility of this type of imaging modality has yet to be fully investigated. In our paper "Image distortion in biplanar slot scanning: part 1 patient-specific factors" we found that there was potentially clinically impactful interimage distortion. The purpose of this study was to evaluate the degree to which this image distortion was secondary to the image acquisition process. METHODS: Four 25 mm radio-opaque markers were placed at C3, T1, T12, and L5 on a full-length skeleton model. The skeleton was imaged in 10 different positions within the scanner. Five posteroanterior and 5 lateral images were obtained in each position. Two orthopaedic attending physicians and 3 orthopaedic resident physicians measured the markers for a total of 3200 measurements. Intraclass correlation coefficients (ICCs) and 95% confidence intervals were used to examine image distortion. RESULTS: Average marker size was 24.77, with a standard error of measurement of 0.00493. Image distortion and standard error of measurement accounted for ∼0.5% to 1.5% of total the measurement. Overall, there was good reliability and consistency when looking at markers in different views (ICC 0.790), planes, and locations within the image. Horizontal measurements were found to be more consistent and have better reliability (ICC 0.881) than vertical measurements (ICC 0.386). Position within the scanner had minimal impact on the accuracy of the measurements. CONCLUSIONS: This study demonstrates that there is minimal error due to image acquisition and measurement when using a biplanar slot scanner. Biplanar slot scanning technology tended to underestimate the size of the marker; however, the least accurate measurements only erred by 1.5% from the true length. This indicates that unlike traditional radiographs the sources of error in biplanar slot scanning images are not due to parallax and are likely due to patient-specific factors and rather than the technology itself.

Image Distortion in Biplanar Slot Scanning: Patient-specific Factors.

BACKGROUND: Error within imaging measurements can be due to processing, magnification, measurement performance, or patient-specific factors. Previous length measurement studies based on radiographs have shown good intraclass correlation coefficients (ICCs) on single images; but have not assessed interimage distortion. In our study, "image distortion in biplanar slot scanning: technology-specific factors" we determined that there is minimal image distortion due to the image acquisition when using biplanar slot scanning. In this study, we aim to determine the role of patient-specific factors in image distortion, specifically evaluating interimage distortion. METHODS: Digital radiographs and biplanar slot scanner images were reviewed in 43 magnetically controlled growing rod (MCGR) patients. Fifty-five postoperative anteroposterior digital radiographs, 184 follow-up biplanar slot-scanner scanner posteroanterior and 76 biplanar slot-scanner scanner laterals were measured by 2 residents and 1 attending. The manufacturer reported average actuator diameter of 9.02 mm was used as our reference width. RESULTS: Overall, within image interobserver ICC were moderate to excellent (0.635 to 0.983), but the interimage ICCs were poor (0.332). Digital radiographs consistently overestimated the MCGR actuator width (mean=9.655) and biplanar slot-scanner scanner images underestimated it (mean=8.935). The measurement range was large with biplanar slot-scanner scanner posteroanterior (up to 15%) and lateral (22%) measurements and with digital radiographs (39%). Patients with abnormal muscle tone had higher degrees of measurement variability. CONCLUSIONS: We found that neither biplanar slot scanning nor digital radiography was precise or accurate. Digital radiographs consistently overestimated MCGR actuator width and biplanar slot scanning underestimated it. The poor ICC's within and between image subtypes and large standard error of measurement reflected a magnitude of distortion that needs to be accounted for when using length measurements clinically. Unlike the clinically insignificant error that we noted in our previous study "image distortion in biplanar slot scanning: technology-specific factors" (0.5% to 1.5% of the measurement), the error noted in this study (0.2% to 38.5% of the measurement) has the potential to be clinically significant. Patients who have abnormal muscle tone had larger measurement errors, likely stemming from motion during the slot scanning process. LEVEL OF EVIDENCE: Level III.

Paper #1: Continued deterioration in pulmonary function at minimum 18-year follow-up from early thoracic fusion in non-neuromuscular scoliosis.

Patients who underwent thoracic spinal fusion at a young age returned at minimum 18-year follow-up for pulmonary function and functional activity testing. There was a statistically significant decline in their pulmonary function test results when compared to previous values from 11-year follow-up, and their functional activity was limited.

The Difficult Supracondylar Humerus Fracture: Flexion-Type Injuries.

Although flexion-type supracondylar humerus fractures account for a minority of all supracondylar humerus fractures, they warrant special attention because of their relatively high rate of requirement for open reduction and their potential for ulnar nerve injury or entrapment. The severity of flexion-type supracondylar humerus fractures may be difficult to appreciate on initial radiographs; therefore, surgeons must have a high index of suspicion in the evaluation of a patient who has a suspected flexion-type supracondylar humerus fracture. Nondisplaced or minimally displaced flexion-type supracondylar humerus fractures can be treated with long arm casting. Displaced flexion-type supracondylar humerus fractures require surgical reduction and stabilization. The unique instability of and reduction position for flexion-type supracondylar humerus fractures make reduction and pinning more of a challenge compared with the more common extension-type supracondylar humerus fractures; therefore, special considerations are required in the surgical setup and planning for flexion-type supracondylar humerus fractures.