The Effect of Implant Density on Adolescent Idiopathic Scoliosis Fusion: Results of the Minimize Implants Maximize Outcomes Randomized Clinical Trial.

BACKGROUND: Severe adolescent idiopathic scoliosis (AIS) can be treated with instrumented fusion, but the number of anchors needed for optimal correction is controversial. METHODS: We conducted a multicenter, randomized study that included patients undergoing spinal fusion for single thoracic curves between 45° and 65°, the most common form of operatively treated AIS. Of the 211 patients randomized, 108 were assigned to a high-density screw pattern and 103, to a low-density screw pattern. Surgeons were instructed to use ≥1.8 implants per spinal level fused for patients in the high-implant-density group or ≤1.4 implants per spinal level fused for patients in the low-implant-density group. The primary outcome measure was the percent correction of the coronal curve at the 2-year follow-up. The power analysis for this trial required 174 patients to show equivalence, defined as a 95% confidence interval (CI) within a ±10% correction margin with a probability of 90%. RESULTS: In the intention-to-treat analysis, the mean percent correction of the coronal curve was equivalent between the high-density and low-density groups at the 2-year follow-up (67.6% versus 65.7%; difference, -1.9% [95% CI: -6.1%, 2.2%]). In the per-protocol cohorts, the mean percent correction of the coronal curve was also equivalent between the 2 groups at the 2-year follow-up (65.0% versus 66.1%; difference, 1.1% [95% CI: -3.0%, 5.2%]). A total of 6 patients in the low-density group and 5 patients in the high-density group required reoperation (p = 1.0). CONCLUSIONS: In the setting of spinal fusion for primary thoracic AIS curves between 45° and 65°, the percent coronal curve correction obtained with use of a low-implant-density construct and that obtained with use of a high-implant-density construct were equivalent. LEVEL OF EVIDENCE: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Predicting Satisfaction of Parents of Pediatric Patients: Perceived Quality of Providers' Communication Mitigates Negative Effects of Shorter than Desired Consultations.

This research investigated the predictors of satisfaction for parents of pediatric patients after a clinical consultation. Specifically, we assessed whether perceptions of their provider's communication quality influenced the degree to which their (dis)satisfaction with consultation length associated with their provider rating and intent to recommend the provider's office. Using patient satisfaction survey data collected after initial clinical visits to a pediatric hospital (N = 12,004), we found that communication quality was a stronger predictor for those who were dissatisfied with their consultation length, whereas communication quality made a relatively smaller difference for those who were satisfied with their consultation length. Put another way, parents' dissatisfaction with their child's consultation length mattered little when they perceived their provider to be high in communication quality, but it reduced their ratings and intentions to recommend when they perceived their provider to be low in communication quality. These results suggest that providers' communication behaviors have the capacity to buffer patients' negative evaluations otherwise incurred from shorter than desired consultations.

Narrative Review of the objective analysis of long-term outcome of the Ponseti technique: experience from Dallas.

In 2001, Texas Scottish Rite Hospital for Children (TSRH) prospectively began a clubfoot database that included all of our patients with clubfeet who were willing to enroll. Nonoperative treatment, primarily the Ponseti method, was utilized. This article summarizes the experience from Dallas treating idiopathic clubfeet using the Ponseti technique, and is based on previously published studies utilizing information from the database. Patient clinical outcomes were defined as "good" (plantigrade foot achieved either with or without a percutaneous heel-cord tenotomy), "fair" (a plantigrade foot that required a limited procedure, such as tibialis anterior tendon transfer or posterior release), or "poor" (a plantigrade foot that required posteromedial release). Nearly 95% of idiopathic clubfeet obtained initial correction using the Ponseti technique, but relapses occurred and by age two years 24% needed some surgical intervention, usually limited procedures. Use of Dimeglio's rating system before treatment strongly correlated with the probability of a "good" outcome at two years. Objective measurements of brace wear compliance (iButton) in those who reached age two years with "good" outcomes demonstrated an unexpected pattern of diminishing use of the foot abduction orthoses over the first two years of brace wear. By the 18-month period of brace wear, 1/3 patients wore the orthoses less than 6 hours per day, and nearly half of the patients wore the orthoses less than 8 hours per day. Between ages 2-5 years, nearly 21% of the corrected clubfeet at age two years needed limited procedures to maintain/regain plantigrade positioning. Lateral weight-bearing radiographs between 18-24 months were not helpful in predicting future relapse in these patients, and are no longer routinely obtained. Following these patients for normal development is important, as nearly 9% of infants initially presenting as idiopathic clubfeet were eventually found to have another disorder including neurological, syndromic, chromosomal, or spinal abnormalities. We continue to emphasize the need to devote great attention to detail when using the Ponseti method in an effort to optimize the clinical outcomes.

Are Some Randomized Clinical Trials Impossible?

Congenital tibial pseudarthrosis is a rare condition seen in neurofibromatosis type 1 (NF1), and treatment is complex. A randomized, placebo-controlled trial of bone morphogenetic protein (rhBMP-2; INFUSE bone graft) at time of tibial surgery was developed by the Neurofibromatosis Clinical Trials Consortium. Patients were randomized to receive rhBMP-2 that would, or would not, be added to the standard surgical procedure consisting of resection of pseudarthrosis tissue, insertion of a rigid intramedullary rod, and placement of autogenous iliac crest bone graft. Despite involvement of 16 centers with wide experience with NF1 orthopaedic management, only 5 patients (of 54 required) were able to be enrolled in the study during a 3-year time period. Because of the inability to recruit sufficient patients, this study was closed in June 2019, with plans to terminate. The obstacles that were encountered during the study are summarized. The authors question whether a randomized, placebo-controlled trial of a rare pediatric orthopaedic condition is possible to accomplish. Recommendations are provided to guide future studies of orthopaedic manifestations of NF1.Level of Evidence: Level V.

Genetic association and characterization of FSTL5 in isolated clubfoot.

Talipes equinovarus (clubfoot, TEV) is a congenital rotational foot deformity occurring in 1 per 1000 births with increased prevalence in males compared with females. The genetic etiology of isolated clubfoot (iTEV) remains unclear. Using a genome-wide association study, we identified a locus within FSTL5, encoding follistatin-like 5, significantly associated with iTEV. FSTL5 is an uncharacterized gene whose potential role in embryonic and postnatal development was previously unstudied. Utilizing multiple model systems, we found that Fstl5 was expressed during later stages of embryonic hindlimb development, and, in mice, expression was restricted to the condensing cartilage anlage destined to form the limb skeleton. In the postnatal growth plate, Fstl5 was specifically expressed in prehypertrophic chondrocytes. As Fstl5 knockout rats displayed no gross malformations, we engineered a conditional transgenic mouse line (Fstl5LSL) to overexpress Fstl5 in skeletal osteochondroprogenitors. We observed that hindlimbs were slightly shorter and that bone mineral density was reduced in adult male, but not female, Prrx1-cre;Fstl5LSL mice compared with control. No overt clubfoot-like deformity was observed in Prrx1-cre;Fstl5LSL mice, suggesting FSTL5 may function in other cell types to contribute to iTEV pathogenesis. Interrogating published mouse embryonic single-cell expression data showed that Fstl5 was expressed in cell lineage subclusters whose transcriptomes were associated with neural system development. Moreover, our results suggest that lineage-specific expression of the Fstl genes correlates with their divergent roles as modulators of transforming growth factor beta and bone morphogenetic protein signaling. Results from this study associate FSTL5 with iTEV and suggest a potential sexually dimorphic role for Fstl5 in vivo.

Spinal balance and lumbar curve stability after selective thoracic fusion in idiopathic scoliosis.

PURPOSE: Selective thoracic fusion (STF) for double curve patterns in idiopathic scoliosis is an attractive treatment option. However, short-term coronal decompensation and truncal imbalance are known findings. Previous studies with hook constructs showed that eventually balance is achieved via an increase in lumbar curve magnitude, as the lumbosacral obliquity did not change following surgery. Our aim is to investigate patients with idiopathic curves who underwent STF using all-pedicle screw constructs to determine if the uninstrumented lumbar curve and lumbosacral obliquity responded in the same manner as was previously reported with all-hook constructs. METHODS: 102 consecutive patients with Lenke 1B, 1C or 3C curves who underwent STF using all-screw constructs at a single institution were included in this study. Radiographic assessment was performed, and patient reported outcomes were obtained. Subgroup analyses were performed based on preoperative thoracic: lumbar curve ratio as well as lumbar curve magnitude. RESULTS: Overall, the patients showed statistically significant improvement in both trunk shift and L4-pelvis obliquity at final follow-up. The uninstrumented lumbar curves trended toward improvement over time, but did not reach statistical significance (p = 0.107). SRS-30 scores were statistically significantly improved in multiple domains. CONCLUSION: Selective thoracic fusion is an excellent treatment option in most double curve patterns. Balance in the coronal plane is predictably achieved at 2-year follow-up. The lumbosacral obliquity improves more with screw technology than was previously found with hook constructs; therefore, the improvement in balance over time does not depend upon an increase in the uninstrumented lumbar curve. LEVEL OF EVIDENCE: IV.

Successful Ponseti-treated Clubfeet at Age 2 Years: What Is the Rate of Surgical Intervention After This?

BACKGROUND: In recent decades, nonoperative Ponseti casting has become the standard of care in the treatment of idiopathic clubfoot. However, the rate of recurrence, even after successful Ponseti treatment is not insignificant. The purpose of this study was to determine the future rate, timing, and type of surgery needed in patients whose idiopathic clubfeet treated by Ponseti casting were considered successful at the age of 2 years. METHODS: Inclusion criteria for this retrospective study were patients under 3 months with idiopathic clubfoot treated exclusively by Ponseti casting, who had successful outcomes at 2 years of age without surgery, and who had at least 5 years of follow-up. The total number of surgical interventions in the age range 2 to 5 and above 5 years, the number and type of procedures performed, and the timing of surgery were reviewed. RESULTS: Three hundred thirty-six patients with a total of 504 clubfeet fulfilled the inclusion criteria. One hundred twenty-two of these 336 patients (36.3%) eventually underwent surgical intervention. Between 2 and 5 years of age, 79 patients (23.5%) with 104 feet (20.6%) underwent surgery. The most common procedures performed between 2 and 5 years were limited (a la carte) in scope: tibialis anterior tendon transfer, posterior release, plantar fascia release, and repeat tendo-Achilles lengthening. At age above 5 years, 53 patients (20.1%) with 65 feet (16.9%) underwent surgery. Ten of these 53 patients had already undergone surgery between 2 and 5 years of age. The procedures most commonly performed were similar. CONCLUSIONS: In patients with idiopathic clubfoot who reached 2 years of age with successful outcomes from Ponseti cast treatment, ∼35% eventually underwent surgical intervention, mostly limited (a la carte), to regain or maintain a plantigrade foot. The most commonly performed procedures include tibialis anterior tendon transfer, posterior capsular release, plantar fascia release and repeat tendo-Achilles lengthening, either in isolation or in combination. However, before considering surgery, the need for these procedures can, and should, be minimized by recasting recurrent deformities using Ponseti method. LEVEL OF EVIDENCE: Level III.

Objective Measurement of Brace Wear in Successfully Ponseti-Treated Clubfeet: Pattern of Decreasing Use in the First 2 Years.

PURPOSE: Once Ponseti correction of a clubfoot is achieved and 3-month full-time bracing treatment is completed, part-time bracing treatment for 12 hours at night for 2 to 4 years is considered necessary to maintain a successful outcome. This study objectively documents the amount of daily orthosis wear time in those who maintained correction at age 2 years and, in so doing, determines how well patients' caretakers comply with the prescribed brace program. METHODS: Patients <3 months old with idiopathic clubfeet when Ponseti treatment was initiated, who successfully maintained correction at age 2 years without surgery and who had complete objective brace wear data, were included. The foot abduction orthoses had a temperature data logger embedded in a shoe. Six 3-month time intervals were monitored in every patient as follows: full time: 0 to 3; night time: 4 to 6, 7 to 9, 10 to 12, 13 to 15, and 16 to 18 months. The families were not informed that hours of brace wear were being measured. RESULTS: One hundred twenty-four patients with 187 clubfeet were included. During the 0- to 3-month interval, wear time averaged 19.8 hr/d. After this period of full-time use, the night-time brace wear decreased over each of the subsequent five intervals: 11.9, 9.6, 8.6, 7.9, and 7.7 hours. By the 18-month period of brace wear, 1 of 3 patients wore the orthoses less than 6 hours per day, and nearly 1 of 2 patients wore the orthoses less than 8 hours per day. DISCUSSION: In patients evaluated at age 2 years whose clubfeet had successful nonsurgical treatment, night-time brace wear varied greatly and decreased over each 3-month period measured. By the second year of bracing treatment, nearly half of the patients wore them 8 hours or less. LEVEL OF EVIDENCE: Level IV case series.

Clubfoot Infants Initially Thought to be Idiopathic, But Later Found Not to Be. How do They do With Nonoperative Treatment?

BACKGROUND: Infants thought to be normal with idiopathic clubfeet when nonoperative treatment begins may later be found to have other complicating diagnoses. The purpose of this study was to determine the incidence of this occurrence, and to compare the clinical outcomes of these "nonidiopathic" patients with idiopathic clubfoot patients. METHODS: Infants below 3 months old with clubfeet who were thought to be normal (idiopathic) at presentation and had ≥2-year follow-up were studied. Treatment consisted of either the Ponseti method or the French physical therapy method. In total, 789 patients with 1174 clubfeet were identified. Those who were idiopathic (group 1) were compared with those later found to be nonidiopathic (group 2). The outcomes at 2 years were assessed as good (plantigrade foot±heelcord tenotomy only), fair (limited procedures), or poor (full-posteromedial release). For those feet rated good at age 2 years, outcomes were again assessed age 5 years and above. RESULTS: In total, 70 patients (8.9%) of the 789 enrolled patients were eventually found to have another disorder including neurological, syndromic, chromosomal, or spinal abnormalities. The remaining 719 idiopathic patients with 1062 clubfeet (group 1) were compared with these 70 nonidiopathic patients with 112 clubfeet (group 2). At age 2 years, in group 1 81% of the feet were rated good, 11% fair, and 8% poor, whereas in group 2 70% of the feet were rated good, 11% fair, and 19% poor (P=0.0004).With follow-up exceeding age 5 years in those rated good at age 2 years: in group 1, 73% continued to do well, but 22% rated fair, and 5% poor. In group 2, 59% continued to do well, but 31% rated fair, and 10% poor (P=0.046). CONCLUSIONS: For infants with clubfeet who were initially thought to be idiopathic, nearly 9% were later found to have a complicating disorder. Despite this, these patients' clubfeet can be expected to respond favorably to nonoperative treatment. However, they will require more surgical intervention early (by age 2 years) and later (age, 5 years and above) when compared with normal infants with idiopathic clubfeet. LEVEL OF EVIDENCE: Level IV-therapeutic, case series.

Repeat Surgical Interventions Following "Definitive" Instrumentation and Fusion for Idiopathic Scoliosis: 25-Year Update.

STUDY DESIGN: Single-institution, retrospective review of prospectively collected data on pediatric patients with adolescent idiopathic scoliosis (AIS) undergoing spinal fusion with a minimum two-year follow-up. OBJECTIVE: To determine the rate of reoperation in AIS patients undergoing spine fusion from 2008 to 2012. SUMMARY OF BACKGROUND DATA: Recent trends in the surgical treatment of AIS have included increased use of all-pedicle screw constructs, smaller implants, more posterior-only approaches, and improved correction techniques. METHODS: A retrospective review of 467 patients undergoing spinal fusion from 2008 to 2012 was performed. Demographic, clinical, radiographic, and surgical data were collected prospectively on all patients for the index procedure and any reoperations. Data were compared to previously published cohorts of patients from the authors' institution who underwent spinal fusion for AIS between 1988 and 2007. RESULTS: The rate of reoperation in this five-year cohort of patients was 9.9%. The most common indications for reoperation were infection (4.5%: 2.4% delayed infections and 2.1% acute infections), symptomatic implants (2.1%), and misplaced pedicle screws (1.7%). When compared to the 2003-2007 cohort, the rate of reoperation for acute infection and malpositioned pedicle screws increased significantly (p = .01 and p = .04), whereas the rate of reoperation for curve progression decreased (p = .01). Reoperations for acute infections and malpositioned pedicle screws also increased significantly (p = .047 and p = .042) compared with the 1988-2002 cohort, whereas the rate of reoperation for pseudarthrosis decreased (p = .002). CONCLUSION: Reoperation rates for AIS have not improved with more sophisticated implants and techniques, predominantly because of increased acute infections and malpositioned pedicle screws despite decreasing pseudarthrosis rates and curve progression. LEVEL OF EVIDENCE: Level II.

The Lumbar Gap Measurement in Lenke 1-4C Curves.

STUDY DESIGN: Retrospective review. OBJECTIVES: To assess whether the lumbar gap (LG) measurement, which is the distance between the center sacral vertical line and the concave edge of the apical vertebra of the lumbar curve, would be a useful tool to predict the need for lumbar curve fusion in the Lenke 1-4C curves. SUMMARY OF BACKGROUND DATA: The current treatment guidelines of selective thoracic fusion in the Lenke 1-4C curves are not routinely accepted. METHODS: One hundred three adolescent idiopathic scoliosis (AIS) patients had undergone either selective thoracic fusion (STF) or both thoracic and lumbar curves fusion (TLF) for Lenke 1-4C curves. The correlations between the fusion decision making and preoperative LG, coronal balance, thoracic and lumbar Cobb, apical vertebra translation, and rotation were analyzed. The radiographic outcomes and SRS-30 of a minimum 2-year follow-up were reviewed in each group. RESULTS: A total of 51 patients (49.5%) underwent an STF, and 52 patients (50.5%) underwent a TLF. The mean LG was 22.0 ± 8.8 mm in the TLF, which was 2.3 times greater than the STF (9.6 ± 3.9 mm) (p < .0001). Only 5% of the lumbar curves were fused when the LG was 10 mm or less. Ninety percent of the lumbar curves were fused when the LG was 16 mm or greater, and 100% lumbar curves were fused with an LG of 21 mm or greater. The preoperative coronal imbalance to the left in the TLF was significantly greater than the STF. A mean 47% thoracic correction corresponded to a mean 39% spontaneous correction of the lumbar curve obtained in the SFT, which was significantly different from the TLF (56% and 65%). There were no differences in the SRS-30 scores at 2 years postoperatively between the STF and the TLF. CONCLUSION: The lumbar curve should not be fused when the LG was 10 mm or less, and very likely should be fused when the LG exceeds 20 mm in the Lenke 1-4C AIS patients. LEVEL OF EVIDENCE: Level III.

rhBMP-2 and Intramedullary Fixation in Congenital Pseudarthrosis of the Tibia.

BACKGROUND: In congenital pseudarthrosis of the tibia, use of intramedullary (IM) fixation and autogenous bone graft has long been the standard of care. This study was undertaken to determine whether the addition of rhBMP-2 to this treatment method further enhances healing potential. METHODS: Twenty-one patients with congenital pseudarthrosis of the tibia were evaluated. Fifteen of these patients had neurofibromatosis type 1 (NF1). All had IM fixation and autogenous bone graft, followed by a BMP-soaked collagen sponge wrapped around both the fracture site and bone graft. A minimum 2 years' follow-up was required. RESULTS: Follow-up averaged 7.2 years (range, 2.1 to 12.8 y). Sixteen of 21 tibias achieved bone union following the index surgery, at an average 6.6 months postoperatively. The 5 persistent nonunions occurred in NF1 patients. Further surgery was undertaken in these 5 NF1 patients, including the use of BMP. One of the 5 healed, 1 had persistent nonunion, and 3 eventually had amputation. Of the 16 patients who healed initially following the index surgery, 5 refractured (3 had NF1). Of these 5 patients, the IM fixation at the index surgery did not cross the ankle joint, and refracture occurred at the rod tip in 4. Three of these 5 patients healed following further surgery, 1 had persistent nonunion, and 1 had amputation. All of those with eventual amputation had NF1. No deleterious effects related to the use of BMP-2 were recognized in any patient. CONCLUSIONS: The addition of rhBMP-2 appears to be helpful in shortening the time required to achieve fracture union in those who healed, but its use does not insure that healing will occur. LEVEL OF EVIDENCE: Level IV-therapeutic, case series.

Nonoperatively Corrected Clubfoot at Age 2 Years: Radiographs Are Not Helpful in Predicting Future Relapse.

BACKGROUND: Nonoperative treatment of idiopathic clubfoot is standard. The purpose of this study was to determine if measurements made on standing lateral radiographs of successfully treated clubfeet made at 18 to 24 months of age were predictive of late recurrence. METHODS: Inclusion criteria were idiopathic clubfoot with an age at presentation of ≤3 months, nonoperative treatment resulting in a clinically plantigrade foot at 2 years of age, standing lateral radiograph of the involved foot made at 18 to 24 months of age, and a minimum age of 4 years at the time of follow-up. The radiographs were assessed for the talocalcaneal angle and the tibiocalcaneal angle, with measurements made by 2 trained practitioners. The average values of the 2 raters were used. The interobserver reliability was calculated using intraclass correlation coefficients (ICCs). A total of 211 patients with 312 clubfeet were evaluated. The average age at the time of follow-up was 8.0 years (range, 4.0 to 13.3 years). Results at the time of follow-up were rated as good (maintained plantigrade foot), fair (required limited surgery to maintain, or return to, a plantigrade position), or poor (required posteromedial release). RESULTS: Over time, 75% of the feet had a good result, 19% had a fair result, and 6% had a poor result. With regard to radiographic assessment, the ICCs were 0.97 (talocalcaneal angle) and 0.98 (tibiocalcaneal angle), demonstrating excellent agreement between the raters. The mean talocalcaneal angle differed significantly between the feet with a good clinical outcome and those with a fair outcome (28° versus 24°; p < 0.02), but did not differ significantly between those with a good versus poor outcome (28° versus 26°), or a fair versus poor outcome (24° versus 26°). There were no significant differences in the mean tibiocalcaneal angle among the groups (86°, 90°, and 84°, respectively) (p = 0.17). CONCLUSIONS: Most clubfeet that were clinically plantigrade at 2 years of age remained so, while one-fourth subsequently required some surgery for late recurrence, primarily limited procedures. The tibiocalcaneal angle and talocalcaneal angle from standing lateral radiographs made at 18 to 24 months of age were not helpful in predicting future relapse. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

What would be the annual cost savings if fewer screws were used in adolescent idiopathic scoliosis treatment in the US?

OBJECTIVE: There is substantial heterogeneity in the number of screws used per level fused in adolescent idiopathic scoliosis (AIS) surgery. Assuming equivalent clinical outcomes, the potential cost savings of using fewer pedicle screws were estimated using a medical decision model with sensitivity analysis. METHODS: Descriptive analyses explored the annual costs for 5710 AIS inpatient stays using discharge data from the 2009 Kids' Inpatient Database (Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality), which is a national all-payer inpatient database. Patients between 10 and 17 years of age were identified using the ICD-9-CM code for idiopathic scoliosis (737.30). All inpatient stays were assumed to represent 10-level fusions with pedicle screws for AIS. High screw density was defined at 1.8 screws per level fused, and the standard screw density was defined as 1.48 screws per level fused. The surgical return for screw malposition was set at $23,762. A sensitivity analysis was performed by varying the cost per screw ($600-$1000) and the rate of surgical revisions for screw malposition (0.117%-0.483% of screws; 0.8%-4.3% of patients). The reported outcomes include estimated prevented malpositioned screws (set at 5.1%), averted revision surgeries, and annual cost savings in 2009 US dollars, assuming similar clinical outcomes (rates of complications, revision) using a standard- versus high-density pattern. RESULTS: The total annual costs for 5710 AIS hospital stays was $278 million ($48,900 per patient). Substituting a high for a standard screw density yields 3.2 fewer screws implanted per patient, with 932 malpositioned screws prevented and 21 to 88 revision surgeries for implant malposition averted, and a potential annual cost savings of $11 million to $20 million (4%-7% reduction in the total cost of AIS hospitalizations). CONCLUSIONS: Reducing the number of screws used in scoliosis surgery could potentially decrease national AIS hospitalization costs by up to 7%, which may improve the safety and efficiency of care. However, such a screw construct must first be proven safe and effective.

Radiographic Assessment of Shoulder Position in 619 Idiopathic Scoliosis Patients: Can T1 Tilt Be Used as an Intraoperative Proxy to Determine Postoperative Shoulder Balance?

BACKGROUND: The purpose of this study is to assess radiographic shoulder measures from the preoperative to the postoperative time period, specifically to determine whether T1 tilt could be used as an intraoperative proxy for shoulder balance determination. This study focused on radiographic shoulder measures of 619 adolescent idiopathic scoliosis patients who underwent spinal deformity surgery. METHODS: A prospective, multicenter database of adolescent idiopathic scoliosis was queried to identify all patients who had undergone spinal deformity surgery with >2 years of follow-up postoperatively. Radiographic analysis focused on measures of shoulder balance: T1 tilt, clavicle angle, and radiographic shoulder height. RESULTS: A total of 619 patients were included in this analysis. Mean age at surgery was 14.8 years with 83% female. Mean preoperative curve size was 58.0 degrees. Mean T1 tilt preoperatively was -0.10 degrees and postoperatively 2.42 degrees. Mean clavicle angle preoperatively was -1.39 degrees and postoperatively 0.79 degrees. Mean radiographic shoulder height preoperatively was -7.04 mm and postoperatively 1.63 mm. All 3 radiographic parameters demonstrated reasonable correlation preoperatively and postoperatively to each other. To assess the viability of T1 tilt as an intraoperative proxy for shoulder balance, standardized ratios between the variables were created. Analysis of these ratios demonstrated little or no relationship preoperatively to postoperatively, hence the relationship of T1 tilt to radiographic shoulder height does not remain constant. CONCLUSIONS: Analysis of the relationship of T1 tilt to radiographic shoulder height from preoperative to postoperative did not demonstrate consistency. Lenke 3 and 6 curve patterns demonstrated preoperative to postoperative correlation, both with nonstructural proximal thoracic curves; however, for the remaining curve patterns T1 tilt cannot be used as an intraoperative proxy for shoulder balance. LEVEL OF EVIDENCE: Level IV.

A radiographic scoring system to assess healing in congenital pseudarthrosis of the tibia.

The aim of this study was to determine whether an established radiographic union scoring system for tibial fracture healing (RUST) is reliable when used in neurofibromatosis (NF1) patients with congenital pseudarthrosis of the tibia (CPT) treated by intramedullary fixation. Four individuals reviewed 36 sets of radiographs from 12 NF1 patients with CPT (preoperative, and 6 months and 1 year postoperative). Intraobserver reliability (κ-value 0.89) and interobserver reliability (κ-value 0.76) were high. The modified RUST scoring system is a useful tool when faced with the challenge of postoperative radiographic evaluation of the tibia in NF1 patients with CPT.

A glimpse into Texas Scottish Rite Hospital's educational, clinical care, and research development.

This article describes four areas of pediatric orthopaedic education, research, and clinical care undertaken at Texas Scottish Rite Hospital (TSRH) over the past 25 years. These areas include the weekly preoperative conferences, the evolution of the limb lengthening and deformity correction program, the development of the TSRH instrumentation system, and the evolution of the clubfoot treatment program.

Congenital band syndrome with pseudarthrosis of the radius and ulna and impending vascular compromise: a case report.

BACKGROUND: Although amniotic band syndrome is relatively rare, reports of pseudarthrosis in conjunction with amniotic band syndrome are even rarer, as are reports of impending vascular compromise in the neonatal period. Careful serial examinations and timely surgical intervention can successfully avoid the catastrophic event of limb loss. We report on a case of upper extremity amniotic band syndrome with pseudarthrosis of the radius and ulna that was complicated by vascular compromise in a neonate. METHODS: Chart and radiographic data for this single case were reviewed and reported retrospectively. RESULTS: A 1-day-old neonate born at 28 3/7 weeks of gestational age was transferred to our institution for increased swelling to the forearm distal to a congenital band associated with an underlying radius and ulna pseudarthrosis. Although the forearm and hand were soft and viable initially, severe edema and swelling occurred after fluid resuscitation, and on the fourth day of life, the patient underwent simple band releases at bedside with 2 longitudinal incisions over the radius and ulna. Circulation was restored, and the pseudarthrosis healed with no further surgical intervention. Successful delayed reconstruction of the band with Z-plasties was performed when the baby was 7 months of age. CONCLUSIONS: In this case, a relatively simple, straightforward procedure that is familiar to most pediatric orthopaedists salvaged a compromised neonatal limb with amniotic band syndrome and allowed healing of a pseudarthrosis, allowing more complex reconstruction to be performed in a delayed, elective manner. Careful observation is necessary in the neonatal period of the baby with a severe band; a viable, well-perfused, compressible extremity may still be at risk.

Does higher anchor density result in increased curve correction and improved clinical outcomes in adolescent idiopathic scoliosis?

STUDY DESIGN: Retrospective review of prospectively collected data. OBJECTIVE: To determine whether anchor density is associated with curve correction and patient-reported outcomes. SUMMARY OF BACKGROUND DATA: There is limited information as to whether anchor density affects the results of adolescent idiopathic scoliosis surgery. METHODS: A total of 952 patients with adolescent idiopathic scoliosis met inclusion criteria (Lenke 1, 2, and 5 curves) with predominantly screw constructs (no. of screws/no. of total anchors >75%). Anchor density was defined as the number of screws, hooks, and wires per level fused, with less than 1.54 considered low density. Analysis of covariance was undertaken to determine association of anchor density with percent curve correction, Scoliosis Research Society (SRS), and Spinal Appearance Questionnaire (SAQ) scores, controlling for flexibility, fusion length, demographics, and surgeon. RESULTS: High- compared with low-anchor density was associated with increased percent curve correction in Lenke 1 curves at 1 year (69% vs. 66% correction, P = 0.0022), controlling for percent preoperative curve flexibility, length of fusion, and sex (model, P < 0.0001). Similar associations held at 2-year follow-up and for Lenke 2 curves. Decreased thoracic kyphosis was found with increased anchor density for Lenke 1 and 2 curve patterns. There were no associations found between anchor density and Lenke 5 curves. For Lenke 1 curve patterns at 2 years postoperatively, in the high- versus low-anchor density cohorts, there were statistically higher SRS Activity (4.3 vs. 4.2, P = 0.019), Appearance (4.3 vs. 4.1, P = 0.0005), Satisfaction (4.5 vs. 4.3, P = 0.028), and Total scores (4.3 vs. 4.2; P = 0.024). Similarly, the SAQ Appearance score at 1 year similarly was improved in the high-anchor density group (high: 14.1 vs. low: 15.0, P = 0.03) for Lenke 1 curve patterns only. CONCLUSION: For Lenke 1 and 2 curve patterns, improved percent correction of major coronal curve was noted in the high-screw density cohort. Although statistical significance was reached, it is unclear whether screw density resulted in clinically significant differences in patient-reported outcomes.