Three-dimensional vertebral shape changes confirm growth modulation after anterior vertebral body tethering for idiopathic scoliosis.

PURPOSE: To evaluate three-dimensional (3D) vertebra and disk shape changes over 2 years following anterior vertebral body tether (AVBT) placement in patients with idiopathic scoliosis (IS). METHODS: Patients with right thoracic IS treated with AVBT were retrospectively evaluated. 3D reconstructions were created from biplanar radiographs. Vertebral body and disk height (anterior, posterior, left and right) and shape (wedging angle) were recorded over the three apical segments in the local vertebral reference planes. Changes in height and wedging were measured through 2 years postoperatively. Change in patient height was correlated with changes in the spine dimensions. RESULTS: Forty-nine patients (Risser 0-3, Sanders 2-4) were included. The mean age was 12.2 ± 1.4 years (range 8-14). The mean coronal curve was 51 ± 10° preoperatively, 31 ± 9° at first postoperative time point and 27 ± 11° at 2-year follow-up (p < 0.001). The mean patient height increased 8 cm by 2 years (p < 0.001). The left side of the spine (vertebra + disc) grew in height by 2.2 mm/level versus 0.7 mm/level on the right side (p < 0.001). This differential growth was composed of 0.5 mm/vertebral level and 1.0 mm/disk level. Evaluation of the change in disk heights showed significantly decreased height anteriorly (- 0.4 mm), posteriorly (- 0.3 mm) and on the right (- 0.5 mm) from FE to 2 years. Coronal wedging reduced 2.3°/level with 1.1°/vertebral level change and 1.2°/disk level. There was no differential growth in the sagittal plane (anterior/posterior height). Patient height change moderately correlated with 3D measures of vertebra + disk shape changes. CONCLUSIONS: Three-dimensional analysis confirms AVBT in skeletally immature patients results in asymmetric growth of the apical spine segments. The left (untethered) side length increased more than 3 × than the right (tethered) side length with differential effects observed within the vertebral bodies and disks, each correlating with overall patient height change.

Arthroscopic Shoulder Stabilization in High School Football Players.

Background: Destabilizing shoulder injuries are common in high school American football players; however, the rate of recurrent glenohumeral instability and return to play after arthroscopic labral stabilization surgery remains unknown. Purpose/Hypothesis: The purpose of this study was to determine the rate of recurrent instability on return to competitive high school football after arthroscopic shoulder labral stabilization and capsulorrhaphy procedures. It was hypothesized that the instability rate would be greater in players with more years of eligibility remaining (YER) to play at the high school level. Study Design: Case series; Level of evidence, 4. Methods: Consecutive male high school football players with at least 1 YER who sustained at least 1 anterior traumatic inseason shoulder instability episode and underwent arthroscopic stabilization between 2012 and 2017 were identified. Patients and/or families were contacted by phone to discuss (1) recurrent instability episodes and (2) return to competitive sport and/or recreational athletic activity. Statistical analysis was conducted using chi-square tests to compare recurrent shoulder instability with return to play and YER. Results: A total of 45 football players aged 14 to 17 years were included, with a mean follow-up of 4.1 years. Most patients (60%) chose not to return to competitive football, due mainly to fear of recurrent injury. Overall, the recurrent instability rate was 15.6% (7/45). The instability rate in players who returned to football was 16.7%, with 66.7% requiring revision surgery. The instability rate in patients who did not return to football was 14.8%, with no revision procedures required. In players who returned to football, the instability rate in YER group 4 was significantly higher than that in YER groups 1 to 3 (42% vs 10.5%, respectively, P = .03), with each year of play conferring an additional 10% risk of reinjury. There was a significant difference in the type of recurrent instability in players who returned to any sport versus those who did not (P = .029). Conclusion: High school football players who returned to competitive play after arthroscopic shoulder stabilization surgery experienced a higher rate of recurrent instability that was dependent on their YER. Over half of the players chose not to return to football, with fear of reinjury being the most common reason.

Intrawound Vancomycin Powder Reduces Delayed Deep Surgical Site Infections Following Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Retrospective. OBJECTIVE: Evaluate whether the use of vancomycin powder (VP) placed in the surgical site prior to wound closure prevents delayed deep surgical site infections (DDI). SUMMARY OF BACKGROUND DATA: DDI after posterior spinal fusion (PSF) in adolescent idiopathic scoliosis (AIS) patients remains a significant major complication. The use of VP to prevent acute surgical site infection has been reported but the impact on DDI is unknown. METHODS: AIS patients treated over the past 20 years with PSF/instrumentation from a large muti-center registry were reviewed. Patients were divided into two groups: intraoperative vancomycin powder placed in the wound (VP) or no antibiotics placed in the wound (NVP). DDI was defined as an infection that occurred >90 days after surgery and required surgical intervention in the operating room. Patients who developed a DDI had secondary verification of VP use or not. Chi square and Kaplan-Meier (K-M) survivorship analyses were used to compare demographics and incident rate of DDI between groups. RESULTS: 4145 cases met inclusion for this study. A total of 43 DDI cases were identified (1.0%). The incidence of DDI for the VP group was 0.2% (4/2111), and 1.9% (39/2034) in the NVP group (P<0.001). Given the difference in follow-up for the 2 groups a Cumulative Survival and Kaplan-Meier analysis revealed the VP group had significantly better "survival" (no DDI) than the NVP group (P<0.001). CONCLUSION: DDIs are significant, adverse events that can greatly complicate patient recovery after PSF for AIS, including rehospitalization. This study found that patients who received VP intraoperatively were 10 times less likely to develop a DDI than those who did not receive VP. Although other advances/changes in surgical techniques may contribute to the significant decrease in infections found in the more recent VP cohort, VP should be considered as a prophylactic measure.

Intermediate Outcomes of Medial Ulnar Collateral Ligament Reconstruction Using Gracilis Allograft in Adolescent Patients.

Background: Autograft palmaris has been the primary choice for the reconstruction of the medial ulnar collateral ligament (UCL) in the elbow. Agenesis of the palmaris tendon is not rare, and outcomes of allograft reconstruction in the breadth of athlete types found in the adolescent population are lacking. Hypothesis: Allograft tendon reconstruction of the medial UCL in the young elbow would have low failure rates and satisfactory outcome scores. Study Design: Case series; Level of evidence, 4. Methods: The records of patients who underwent allograft medial UCL reconstruction (UCLR) by a single surgeon between 2009 and 2019 were reviewed. Patient-reported outcome scores in adolescent patients obtained at a minimum 4-year follow-up (for intermediate assessment) were recorded, with no exclusion according to sex or sport type. Outcomes included the Timmerman-Andrews score, the Single Assessment Numeric Evaluation (SANE), and the Conway-Jobe score. Results: Of 29 patients who underwent allograft UCLR, 10 adolescents (40% women; mean age at surgery, 15.8 years [age range, 15-17 years]) met the inclusion criteria and were included in the study. The mean follow-up was 8 years (range, 4.3-11.9 years). There were 4 overhead athletes (baseball, water polo) and 6 impact sports athletes (motocross, gymnastics, wrestling, and soccer). The mean SANE score was 86.3, and the mean subjective Timmerman-Andrews score was 92.5. The Conway-Jobe score was "excellent" in 7 of 10 participants; nonetheless, 3 elected not to return to sport (2 for reasons unrelated to the elbow). No patients experienced loss of range of motion, contracture, or ulnar nerve neuropathy. There was 1 patient with early failure (10%) who required revision reconstruction . Conclusion: Allograft reconstruction for medial UCL instability in adolescent patients from sport and trauma mechanisms demonstrated excellent patient-reported functional scores in this study. If the patient and surgeon desire to avoid autograft morbidity or agenesis of the palmaris longus, allograft tendon UCLR appears viable for both the throwing and the high-impact adolescent athlete, regardless of sex.

Breaking the Rules in Three Dimensions: What to Expect After a Thoracic-only Fusion With Structural Thoracic and Thoracolumbar Curves.

OBJECTIVE: Despite guidelines to fuse both thoracic and thoracolumbar/lumbar (TH/L) curves in patients with structural curves in both regions, a thoracic-only fusion allows preservation of lumbar motion segments. The purpose of this study was to assess the 2-year postoperative three-dimensional (3D) radiographic and clinical outcomes of patients with double or triple major (thoracic curves >TH/L curves) structural curves who underwent a thoracic-only fusion. METHODS: A prospective adolescent idiopathic scoliosis registry was queried for double or triple major curves undergoing thoracic-only posterior fusion and a minimum 2-year follow-up. 3D reconstructions were generated from bi-planar radiographs. Paired sample t tests were used to assess differences in the coronal, sagittal, and axial planes pre and postoperatively, as well as Scoliosis Research Society Questionnaire-22 scores. Pearson correlations were utilized to identify variables related to spontaneous lumbar derotation. RESULTS: Twenty-two patients met the inclusion criteria. Both thoracic [61 ± 10 degrees to 20 ± 9 degrees ( P < 0.001)] and lumbar curves [41 ± 7 degrees to 22±7 degrees ( P < 0.001)] had significant coronal improvement and T5 to T12 kyphosis improved from 7 ± 14 degrees to 23 ± 8 degrees ( P < 0.001). The thoracic apical translation was significantly improved postoperatively (4.7 ± 1.5 to 0.5 ± 1 cm, P < 0.001), but the lumbar apical translation was unchanged (-1.7 ± 0.6 to -1.7±0.8 cm, P = 0.94). Scoliosis Research Society Questionnaire-22 scores significantly improved by 2 years postoperative. CONCLUSIONS: Unlike the 3D correction observed in nonstructural TH/L curves after thoracic-only fusion, patients with double or triple major curves demonstrated only spontaneous coronal correction of the lumbar curve, whereas the sagittal and axial planes were not significantly improved. These radiographic parameters did not negatively affect subjective or clinical outcomes at minimum 2-year follow-up. LEVEL OF EVIDENCE: Level IV-therapeutic.

Vertical Stenosis as a Morphological Risk Factor for Anterior Cruciate Ligament Ruptures in Children: A Magnetic Resonance Imaging-Based Comparison.

BACKGROUND: There are known anatomic variations that may lead to traumatic disruption of the anterior cruciate ligament (ACL) identified within adult and adolescent patients. PURPOSE/HYPOTHESIS: The purpose of this study was to compare the parameters of pediatric knees diagnosed with and without an ACL injury by magnetic resonance imaging. The hypothesis was that children with ACL abnormalities would demonstrate an equivalent notch width index (NWI), but a larger notch height index (NHI), in comparison with age-matched patients without ACL abnormalities, suggesting an association with congenital morphology. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A retrospective comparison cohort study of pediatric knees was performed by evaluating those with a confirmed ACL rupture/deficiency and those with a benign diagnosis on magnetic resonance imaging. Overall, 6 osseous and cartilaginous measurements and 3 ratios (2 newly described) were determined. They were then grouped for statistical purposes by age: children aged 5 to 11 years and adolescents aged 12 to 19 years. RESULTS: A total of 119 (49 children) consecutive patients with an ACL injury and 139 (72 children) healthy patients met inclusion criteria. The interaction between ACL status and age was significant for condylar measurements (P≤ .001), tibial spine height (P = .003), vertical space above tibial spine (P≤ .001), and NWI (P≤ .001) by 2-way analysis of variance. Although the NHI (P < 0.001) and tibial spine prominence (P = 0.039) demonstrated stenosis in the adolescent group, they did not have significant interactions with age and ACL status (P > 0.05). Regarding the transcondylar width, only the children's group had a significant difference regarding ACL status (P < .001), and the mean values in the children's group with ACL tears were nearly identical to those in the adolescent group both with and without ACL tears. The children's group with ACL tears also had a significantly larger tibial spine height compared with healthy children (P < .001). CONCLUSION: Children, similar to adolescents, demonstrated the effect of the NWI on the risk of ACL tears, but only the adolescent group demonstrated stenosis with the NHI. The morphology of the knee in a child at risk for ACL rupture was not the same as that of an adolescent when considering all dimensions, but it did seem that it was more adolescent-like than child-like at the time of an ACL rupture, refuting the idea of congenital hypoplasia as a common cause.