How Long Can You Delay? Curve Progression While Awaiting Vertebral Body Tethering Surgery.

Background: The implications of delaying surgical intervention for patients with adolescent idiopathic scoliosis (AIS) wishing to undergo vertebral body tethering (VBT) have not yet been explored. It is important to understand how these delays can impact surgical planning and patient outcomes. Methods: This was a retrospective review that analyzed all AIS patients treated between 2015 and 2021 at a single tertiary center. Time to surgery from initial surgical consultation and ultimate surgical plan were assessed. Patient characteristics, potential risk factors associated with increased curve progression, and reasons for delay were also analyzed. Results: 174 patients were evaluated and 95 were scheduled for VBT. Four patients later required a change to posterior spinal fusion (PSF) due to excessive curve progression. Patients requiring PSF were shown to have significantly longer delays than those who received VBT. Additionally, longer delays, younger age, greater curve progression, and lower skeletal maturity were correlated with significant curve progression (≥5 degrees). Conclusions: Surgical delays for AIS patients awaiting VBT may lead to significant curve progression and necessitate more invasive procedures. Patients with longer delays experienced an increased risk of needing PSF instead of VBT. Of those requiring PSF, the majority were due to insurance denials. Optimizing surgical timing and shared decision-making among patients, families, and healthcare providers are essential for achieving the best outcomes.

Automated measurements of interscrew angles in vertebral body tethering patients with deep learning.

BACKGROUND CONTEXT: Vertebral body tethering is the most popular nonfusion treatment for adolescent idiopathic scoliosis. The effect of the tether cord on the spine can be segmentally assessed by comparing the angle between two adjacent screws (interscrew angle) over time. Tether breakage has historically been assessed radiographically by a change in adjacent interscrew angle by greater than 5° between two sets of imaging. A threshold for growth modulation has not yet been established in the literature. These angle measurements are time consuming and prone to interobserver variability. PURPOSE: The purpose of this study was to develop an automated deep learning algorithm for measuring the interscrew angle following VBT surgery. STUDY DESIGN/SETTING: Single institution analysis of medical images. PATIENT SAMPLE: We analyzed 229 standing or bending AP or PA radiographs from 100 patients who had undergone VBT at our institution. OUTCOME MEASURES: Physiologic Measures: An image processing algorithm was used to measure interscrew angles. METHODS: A total of 229 standing or bending AP or PA radiographs from 100 VBT patients with vertebral body tethers were identified. Vertebral body screws were segmented by hand for all images and interscrew angles measured manually for 60 of the included images. A U-Net deep learning model was developed to automatically segment the vertebral body screws. Screw label maps were used to develop and tune an image processing algorithm which measures interscrew angles. Finally, the completed model and algorithm pipeline was tested on a 30-image test set. Dice score and absolute error were used to measure performance. RESULTS: Inter- and Intra-rater reliability for manual angle measurements were assessed with ICC and were both 0.99. The segmentation model Dice score against manually segmented ground truth across the 30-image test set was 0.96. The average interscrew angle absolute error between the algorithm and manually measured ground truth was 0.66° and ranged from 0° to 2.67° in non-overlapping screws (N=206). The primary modes of failure for the model were overlapping screws on a right thoracic/left lumbar construct with two screws in one vertebra and overexposed images. An algorithm step which determines whether an overlapping screw was present correctly identified all overlapping screws, with no false positives. CONCLUSION: We developed and validated an algorithm which measures interscrew angles for radiographs of vertebral body tether patients with an accuracy of within 1° for the majority of interscrew angles. The algorithm can process five images per second on a standard computer, leading to substantial time savings. This algorithm may be used for rapid processing of large radiographic databases of tether patients and could enable more rigorous definitions of growth modulation and cord breakage to be established.

Does radiographic calibration affect linear radiographic measurements in a large pediatric spine registry?

PURPOSE: Large registries are increasingly at the forefront of modern pediatric spine research, with manual, centralized, trained radiographic measurement serving as the gold standard for spine research. However, there is limited data regarding the reliability of registry measurements which may be subject to differences in radiographic calibration. We undertook this study to evaluate reliability of T1-T12 height, L1-S1 height, and coronal balance measurements for a large registry of early onset scoliosis patients. METHODS: Three trained technicians from the Pediatric Spine Study Group measured 43 radiographs for T1-T12, L1-S1, and coronal balance using 3 different calibration techniques. All radiographs were AP views of patients with magnetically controlled growing rods with known diameters. The calibration techniques used a pre-export manually drawn line, a digital automatically generated computerized marker, and the diameter of a magnetically controlled growing rod. The intraclass correlation coefficient (ICC) was calculated to determine reliability. RESULTS: 1161 measurements were performed. For each of the three raters, coronal balance, T1-T12 height and L1-S1 height had excellent agreement regardless of the calibration technique (alpha 0.93-1.0). Among the parameters, coronal balance had the worst inter-rater reliability, whereas there was excellent interrater reliability regarding T1-T12 height and L1-S1 height (alpha 0.91-0.99). CONCLUSION: There was excellent agreement among reviewers and between the 3 different calibration techniques. While calibration using rod diameter served as the gold standard, this data shows that other standard calibration methods were adequate and achieved excellent reliability for registry radiographs.

Long-Term Outcomes at Skeletal Maturity of Combined Pelvic and Femoral Osteotomy for the Treatment of Legg-Calve-Perthes Disease.

Surgical treatment for Legg-Calve-Perthes disease (LCPD) is recommended for older children with moderate to severe disease. We sought to determine whether double osteotomies lead to improved radiologic outcomes compared to reported non-operative outcomes. Patients older than 6 years of age diagnosed with LCPD lateral pillar B or C who were treated with pelvic and femoral osteotomies were included. Radiologic outcomes and leg-length discrepancies were assessed using the Stulberg classification and were compared with the current literature. Fifteen hips in fourteen patients were treated with double osteotomy for LCPD, and seven had lateral pillar C disease (47%). The mean age at surgery was 8.6 years (range, 7.2-10.4) and the mean age at follow-up was 20.2 years (range, 14.2-35.6). At a mean 11.6-year follow-up (range: 6.3-25.2), double osteotomy resulted in 40% of patients having Stulberg I/II scores, 27% having Stulberg III scores, and 33% having Stulberg IV/V scores. The mean leg-length discrepancy was 1.4 cm in lateral pillar C patients compared to 0.8 cm in lateral pillar B patients. Four patients underwent additional surgeries, including two who required total hip arthroplasty. Double osteotomy as an alternative surgical procedure for the treatment of LCPD did not show improved outcomes when compared to historic non-operative cohorts.

Investigating racial disparities in quality-of-life years after pediatric hematopoietic stem cell transplant.

BACKGROUND: While racial disparities in the clinical outcomes of hematopoietic stem cell transplant (HSCT) patients have been explored, racial disparities in quality of life (QoL) during the re-adjustment phase after transplant are yet to be investigated in pediatric patients. The objective of this study was to examine the role of patient race in QoL at least 2 years after pediatric HSCT. PROCEDURE: We conducted a retrospective chart review of patients under 21 years of age at diagnosis who received an allogeneic transplant at our institution between January 2007 and December 2017. Patient QoL was assessed using the Pediatric Quality-of-Life Inventory Generic Score Scales (PedsQL TM 4.0) at least 2 years post transplant. Patient demographic, treatment, and transplant outcome data were obtained for subsequent analysis, where patient race was categorized as either Black, White, Hispanic, or Native American. RESULTS: Data were collected on 86 pediatric patients who underwent HSCT. Forty patients (46.5%) were non-Hispanic White, 29 (33.7%) Hispanic, 10 (11.6%) Black, and seven (8.1%) Native American. Where preliminary analyses indicated a difference in QoL by patient race, there were no significant differences in physical, emotional, social, and school functioning by patient race after adjusting for transplant characteristics (age at transplant, sex, diagnosis, donor type, and conditioning regimen) and determinants of socioeconomic status (insurance type, estimated household income). CONCLUSIONS: Pediatric patients had comparable QoL, regardless of race, at a median of 3 years after HSCT in our study cohort.

Minimum 5-Year Results of Elongation Derotation Flexion Casting for Early Onset Scoliosis: The Story Is Not Over Until Skeletal Maturity.

BACKGROUND: Early conservative treatment for patients with idiopathic infantile scoliosis (IIS) with elongation derotation flexion (EDF) casting and subsequent serial bracing has become widely utilized. However, the long-term outcomes of patients treated with EDF casting are limited. METHODS: We performed a retrospective chart review of all patients who had undergone serial elongation derotation flexion casting and subsequent bracing for scoliosis presenting at a single large tertiary center. All patients were followed for a minimum of 5 years or until surgical intervention. RESULTS: Our study included 21 patients diagnosed with IIS and treated with EDF casting. At a mean 7-year follow-up, 13 of the 21 patients were considered successfully treated with a mean final major coronal curvature of 9 degrees compared to a pretreatment coronal curve of 36 degrees. These patients, on average, began casting at 1.3 years old and spent 1 year in a cast. Patients that did not have substantial improvement began casting at mean 4 years old and remained in a cast for 0.8 years. Three patients initially had substantial improvement with the correction to <20 degrees at a mean age of 7; however, their curves worsened in adolescence with poor brace compliance. All 3 patients will require surgical intervention. Of the patients not successfully treated with casting, 7 required surgery at a mean 8.2 years of age, 4.3 years after initiation of casting. A significant predictor of treatment failure was older age of cast initiation ( P <0.001). CONCLUSIONS: EDF casting can be an effective cure for IIS patients if initiated at a young age with 15 of 21 patients successfully treated (76%). However, 3 patients had a recurrence in adolescence resulting in an overall success rate of only 62%. Casting should be initiated early to maximize the likelihood of treatment success and periodic monitoring should be continued through skeletal maturity as recurrence during adolescence can occur.

Predictors of Total Hip Arthroplasty Following Pediatric Surgical Treatment of Developmental Hip Dysplasia at 20-Year Follow-Up.

Long-term outcomes of surgical treatment for pediatric developmental dysplasia of the hip (DDH) are not well defined. The purpose of this study was to report long-term radiographic and clinical outcomes, survivorship free of total hip arthroplasty (THA), and predictors of subsequent THA following childhood treatment of DDH. This study was a single-institution retrospective review of hips treated for DDH with closed or open reduction at a minimum 10-year follow-up. 107 patients (119 hips) were included with a mean patient age of 3.3 years at childhood treatment. At mean 30.5 years follow-up, 24 hips had undergone THA (20%). Mean patient age at time of THA was 33.5 years. None of the hips treated with closed reduction alone required THA, whereas 8 hips treated with open reduction (25%) underwent THA. Hips with patient age > 4 years at the time of treatment had lower survivorship at 35 years follow-up (50% vs. 85%; p < 0.001). Additionally, femoral osteotomy (OR 2.0, p < 0.001), and previous treatment elsewhere (27% vs. 16%; p < 0.01) were associated with subsequent THA. Early referral and appropriate intervention may prove important, as age and prior treatment were predictive of subsequent THA.

At Mean 30-Year Follow-Up, Cervical Spine Disease Is Common and Associated with Thoracic Hypokyphosis after Pediatric Treatment of Adolescent Idiopathic Scoliosis.

Patients with adolescent idiopathic scoliosis (AIS) often have reduced sagittal thoracic kyphosis (hypokyphosis) and cervical lordosis causing an uneven distribution of physiologic load. However, the long-term consequences of hypokyphosis in AIS patients have not been previously documented. To evaluate whether uneven load distribution leads to future complications in patients with AIS, we conducted a retrospective chart review and subsequently surveyed 180 patients treated for idiopathic scoliosis between 1975 and 1992. These patients all had a minimum follow-up time of 20 years since their treatment. We observed a ten-fold increase in the incidence of anterior cervical discectomy and fusion (ACDF) compared to reported rates in the non-pathologic population. Out of the 180 patients, 33 patients met the criteria and returned for follow-up radiographs. This population demonstrated a statistically significant increased rate of cervical osteoarthritis and disc degeneration. Overall, our study suggests that hypokyphosis in patients with AIS presents with increased rates of cervical spine degeneration and dysfunction, suggesting that these patients may require additional follow-up and treatment.

Reconstruction of Distal Nasal Defects Using Free Cartilage Batten Grafting With Secondary Intention Healing: A Retrospective Case Series of 129 Patients.

BACKGROUND: Surgical defects of the distal nose can pose significant reconstructive challenges. Free cartilage batten graft (FCBG) with secondary intention healing is an underreported yet effective repair option with cosmetically and functionally satisfying outcomes. OBJECTIVE: To share the authors' experience using FCBG with secondary intention healing on multiple nasal subunits, including a detailed evaluation of wound/graft characteristics and design modifications to optimize success with this single-stage approach. METHODS: A retrospective study of 129 patients who underwent FCBG with secondary intention healing after Mohs surgery from 2011 to 2018, using statistical analysis of numerous outcome measures graded independently by 2 fellowship-trained Mohs surgeons. RESULTS: Overall, healed wounds were graded aesthetically as follows: excellent (24%), very good (31%), good (31%), or poor (14%). Excellent/very good outcomes were seen for superficial (p < .001), small-to-medium sized wounds (p < .0001) repaired with cartilage that closely approximated the defect size (p < .05). Consistently optimal outcomes were seen in the 19 repairs involving the alar lobule (mid-ala) alone, graded excellent (47%), very good (32%), and good (21%). A majority of patients (86%) experienced mild to no alar retraction. Although 67% of all patients had some skin surface contour irregularity, only 8% of patients sought dermabrasion. Neither hematoma, infection, ear deformity, chondritis, nor graft desiccation were reported. CONCLUSION: A modified approach to FCBG with secondary intention healing provides a reliable, minimalistic, low-risk reconstructive option for mid-alar defects.