Impact of presenting patient characteristics on surgical complications and morbidity in early onset scoliosis.

This study sought to assess comorbidity profiles unique to early-onset-scoliosis (EOS) patients by employing cluster analytics and to determine the influence of isolated comorbidity clusters on perioperative complications, morbidity and mortality using a high powered administrative database. The KID database was queried for ICD-9 codes pertaining to congenital and idiopathic scoliosis from 2003, 2006, 2009, 2012. Patients <10 y/o (EOS group) were included. Demographics, incidence and comorbidity profiles were assessed. Comorbidity profiles were stratified by body systems (neurological, musculoskeletal, pulmonary, cardiovascular, renal). K-means cluster and descriptive analyses elucidated incidence and comorbidity relationships between frequently co-occurring comorbidities. Binary logistic regression models determined predictors of perioperative complication development, mortality, and extended length-of-stay (≥75th percentile). 25,747 patients were included (Age: 4.34, Female: 52.1%, CCI: 0.64). Incidence was 8.9 per 100,000 annual discharges. 55.2% presented with pulmonary comorbidities, 48.7% musculoskeletal, 43.8% neurological, 18.6% cardiovascular, and 11.9% renal; 38% had concurrent neurological and pulmonary. Top inter-bodysystem clusters: Pulmonary disease (17.2%) with epilepsy (17.8%), pulmonary failure (12.2%), restrictive lung disease (10.5%), or microcephaly and quadriplegia (2.1%). Musculoskeletal comorbidities (48.7%) with renal and cardiovascular comorbidities (8.2%, OR: 7.9 [6.6-9.4], p < 0.001). Top intra-bodysystem clusters: Epilepsy (11.7%) with quadriplegia (25.8%) or microcephaly (20.5%). Regression analysis determined neurological and pulmonary clusters to have a higher odds of perioperative complication development (OR: 1.28 [1.19-1.37], p < 0.001) and mortality (OR: 2.05 [1.65-2.54], p < 0.001). Musculoskeletal with cardiovascular and renal anomalies had higher odds of mortality (OR: 1.72 [1.28-2.29], p < 0.001) and extLOS (OR: 2.83 [2.48-3.22], p < 0.001). EOS patients with musculoskeletal conditions were 7.9x more likely to have concurrent cardiovascular and renal anomalies. Clustered neurologic and pulmonary anomalies increased mortality risk by as much as 105%. These relationships may benefit pre-operative risk assessment for concurrent anomalies and adverse outcomes. Level of Evidence: III - Retrospective Prognostic Study.

Incidence, trends, and associated risks of developmental hip dysplasia in patients with Early Onset and Adolescent Idiopathic Scoliosis.

INTRODUCTION: Early Onset and Adolescent Idiopathic Scoliosis, relatively common diagnoses (∼3% general population), have been associated with developmental dysplasia of the hip (DDH); a more rare spectrum of anomalies related to the abnormal development of acetabulum, proximal femur, and hip joint. To the best of our knowledge, no high powered investigations have been performed in an attempt to assess incidence and associated risks of DDH in scoliosis patients. METHODS: The KID database was queried for ICD-9 codes from 2003 to 2012 pertaining to EOS (Congenital and Idiopathic <10y/o) and AIS patients. Descriptive analysis assessed patient demographics and yearly trends in hip dysplasia rates. EOS and AIS patients with hip dysplasia were isolated, and incidence of hospital admissions for associated anomalies (osteonecrosis, osteoarthritis, recurrent hip dislocation, hip ankylosis) and hip arthroplasty (total + partial) were investigated. Univariate analysis of hip pathology determined significant predictors of hip arthroplasty. Binary logistic regression analysis was used to determine the relationship between these predictors. RESULTS: 111,827 scoliosis patients (EOS: 25,747; AIS: 77,183) were included. AIS patients were older (15.2 vs 4.3), more female (64.2% vs 52.1%), had a higher CCI (0.84 vs 0.64), and less racially diverse (all p < 0.001). The incidence of hip dysplasia was 1.4% for AIS patients and 3.9% for EOS patients (p < 0.001). Of the AIS (n = 1073) and EOS (n = 1005) patients with hip dysplasia, 0.3% (p > 0.05 between groups) developed hip osteonecrosis, 0% of patients were coded as having a hip labral tear, hip ankylosis, and 0.6% (EOS: 0.2%; AIS: 0.9%, p = 0.025) developed hip osteoarthritis. AIS patients were more likely to have recurrent hip dislocations (35.4% vs 17.0%, p < 0.001), and both groups had similar primary hip arthroplasty rates (6.7% vs 5.4%, p = 0.118) and revision hip arthroplasty rates (0% vs 0.4%, p = 0.053). Hip osteoarthritis (OR: 13.43[5.21-34.66], p=<0.001) and older age (OR: 1.039[1.007-1.073], p = 0.017) were the only significant predictors of hip arthroplasty (p=<.001). CONCLUSIONS: The incidence of hip dysplasia in EOS and AIS populations is higher than that of the general population. The rate of DDH was 3.9% and 1.8% for EOS and AIS, respectively. While the incidence of DDH is higher, associated anomalies of osteoarthritis, osteonecrosis, labral tears, and ankylosis appear to be a minimal risk for AIS and EOS patients with Hip Dysplasia.

Revision of a lumbar disc arthroplasty following late infection.

Anterior removal of a lumbar total disc replacement implant is often a very technically demanding procedure. The anterior retroperitoneal anatomy is prone to scarring, limiting remobilization and making a direct anterior exposure above the L5-S1 level difficult if not impossible to achieve safely. Anterolateral approach strategies can be more safely achieved at L4-L5 and above, but may require vertebral osteotomy in order to remove a keeled prosthesis. Successful conversion to a fusion with implant removal can be achieved, even when osteotomy is needed for implant removal. This Grand Rounds case presentation involves an unusual late retroperitoneal abscess following two-level TDR with direct extension to one of the implants, and the subsequent nonoperative and operative management. Removal of a well-fixed keeled implant at the L4-L5 level following nonoperative treatment of a surrounding retroperitoneal abscess and conversion to fusion represents close to, if not a 'worst-case' scenario for revision TDR. However, with proper preoperative planning and surgical experience, a safe and successful procedure can be the end result.

Allograft versus no graft with a posterior multisegmented hook system for the treatment of idiopathic scoliosis.

STUDY DESIGN: A prospective, randomized study. OBJECTIVE: To compare the clinical results of posterior spinal fusion (PSF) with allograft augmentation versus no graft for patients with adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: The use of allograft has become a standard means of augmenting a PSF. Many studies have shown equal rates of fusion when comparing allograft with autogenous iliac crest. There have been no studies to directly compare the results obtained with allograft with those achieved without the use of any bone graft at all. METHODS: Ninety-one patients with AIS were randomized into two treatment groups. Seventy-six patients had greater than 2-year follow-up and are included in this review. The Allograft Group consisted of 37 patients who underwent a standard PSF using a multisegmented hook-screw and rod system with the use of corticocancellous allograft for augmentation. The No Graft Group included 39 patients with AIS who underwent the same procedure without any bone graft. All autogenous bone resulting from a thoracoplasty and any local bone (for example, that removed from spinous processes) was discarded in both groups. Patients with at least 2 years of radiographic and clinical follow-up were evaluated using established criteria for possible or definite pseudarthrosis. Treatment groups were similar with respect to age, preoperative deformity, and correction obtained. RESULTS: The overall definitive pseudarthrosis rate for this study was 1.3% (1 of 76 patients). The 1 patient with pseudarthrosis was in the Allograft Group (1 of 37, or 2.7%, P = 0.98 as defined by our criteria), versus none of 39 in the No Graft Group. Two patients in each group (5.4% in the Allograft Group and 5.1% in the No Graft Group) met the radiographic criteria for possible pseudarthrosis. This establishes a P value of 0.65 comparing risk of possible pseudarthrosis in the two groups. CONCLUSION: Our results suggest that a PSF using newer-generation multisegmented hook-screw and rod systems can be successful with allograft and/or local bonegraft without the use of supplemental autogenous bone graft (from the iliac crest or ribs) in patients with AIS.