Combined Anterior Thoracic Vertebral Body Tethering and Posterior Lumbar Tethering Results in Quicker Return to Sport and Activity Compared to Posterior Spinal Instrumented Fusion in Patients with Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Retrospective comparative study. OBJECTIVE: To compare patient-reported physical activity between anterior thoracic vertebral body tethering and posterior lumbar spine tethering (ATVBT/PLST) and posterior spinal instrumentation and fusion (PSIF) with minimum 2 year follow-up. METHODS: Consecutive skeletally immature patients with idiopathic scoliosis and a thoracic and lumbar curve magnitude ≥40° who underwent either ATVBT/PLST or PSIF from 2015-2019 were included. The primary outcome was rate of returning to sport. Secondary outcomes included ability to bend and satisfaction with sport performance as well as weeks until return to sport, school, physical education (PE) classes, and running. RESULTS: Ten patients underwent ATVBT/PLST and 12 underwent PSIF. ATVBT/PLST patients reported significantly faster return to sport (13.5 weeks vs 27.9 weeks, P = .04), running (13.3 weeks vs 28.8 weeks, P = .02), and PE class (12.6 weeks vs 26.2 weeks, P = .04) compared to PSIF patients. ATVBT/PLST patients reported that they had to give up activities due to their ability to bend at lower rates than PSIF patients while reporting "no changes" in their ability to bend after surgery at higher rates than PSIF patients (0% vs 4% giving up activities and 70% vs 0% reporting no changes in bending ability for ATVBT/PLST and PSIF, respectively, P = .01). Compared to PSIF patients, ATVBT/PLST patients experienced less main thoracic and thoracolumbar/lumbar curve correction at most recent follow-up (thoracic: 41 ± 19% vs 69 ± 18%, P = .001; thoracolumbar/lumbar: 59 ± 25% vs 78 ± 15%, P = .02). No significant differences in the number of revision surgeries were observed between ATVBT/PLST and PSIF patients (4 (40%) and 1 (8%) for ATVBT/PLST and PSIF, respectively, P = .221). CONCLUSIONS: ATVBT/PLST patients reported significantly faster rates of returning to sport, running, and PE. In addition, ATVBT/PLST patients were less likely to have to give up activities due to bending ability after surgery and reported no changes in their ability to bend after surgery more frequently than PSIF patients. However, the overall rate of return to the same or higher level of sport participation was high amongst both groups, with no significant difference observed between ATVBT/PLST and PSIF patients.

Rate of Refracture After Removal of Hardware in Pediatric Femur Fractures.

PURPOSE: Both flexible intramedullary nails (FINs) and plate osteosynthesis are commonly used for the treatment of femoral shaft fractures in pediatric patients. The purpose of this study is to determine the refracture rate after hardware removal in pediatric femur fractures. METHODS: This is a retrospective cohort study that utilized the Pediatric Health Information System database to determine the number of pediatric patients ages 4 to 10 who underwent surgical fixation of a femur fracture and subsequent hardware removal between the years 2015 and 2019. All patients had a minimum of a 2-year follow-up to assess for refracture. Patients with metabolic bone disease, neuromuscular conditions, bone fragility disorders, nutritional deficiencies, and pathologic fractures were excluded. RESULTS: Of the total, 2805 pediatric patients with 2881 femoral shaft fractures who underwent FIN (48.4%), plate fixation (36.1%), splinting/casting (14.9%), or external fixation (0.6%) were included. The mean age of patients with index fracture was 7.2 years (SD, 2.1) and 69% were males. Eight hundred eighty patients (60%) in the FIN group had their hardware removed compared with 693 patients (68%) in the plate fixation group ( P = 0.07), at an average of 287 ± 191 days versus 320 ± 203 days ( P = 0.03). Refracture occurred in 13 patients (1.5%) who had their hardware retained and in 21 patients (1.4%) who had their hardware removed ( P = 0.732). Among 65% of patients who underwent hardware removal, refracture occurred in 7 patients with FIN (0.8%) and 14 patients with plate fixation (2.2%) ( P = 0.04). Refracture occurred within 365 days from hardware removal in 1 patient with FIN (0.1%) and 7 patients with plate fixation (1%) ( P = 0.01). In logistic regression, patients with FIN fixation had lower odds of refracture after hardware removal compared with plate fixation (adjusted odds ratio: 0.39; 95% CI: 0.15-0.97). Age and payor status did not reach statistical significance in multivariate analysis. CONCLUSIONS: The rate of refracture after hardware removal for pediatric patients with a femoral shaft fracture was similar between patients with hardware retained and removal. However, patients with FIN had a lower rate of refracture AFTER hardware removal compared with plate fixation. This information can be helpful for advising families regarding the risks of refracture after hardware removal. LEVEL OF EVIDENCE: Level IV-retrospective cohort study.

Radiographic and perioperative outcomes following anterior thoracic vertebral body tethering and posterior lumbar spine tethering: a pilot series.

BACKGROUND AND CONTEXT:  In patients with adolescent idiopathic scoliosis (AIS) of main thoracic and lumbar spine regions, combined anterior thoracic vertebral body tethering and posterior lumbar spine tethering (ATVBT/PLST) is a novel non-fusion treatment option for growth modulation and conservation of motion. METHODS:  Fourteen patients with AIS who underwent ATVBT/PLST with at least 2-year follow-up were included. Primary outcomes included quality of life as assessed by SRS-22 instruments, radiographic analysis, and revision operations. We secondarily reported perioperative metrics and post-operative opiate morphine equivalents (OME). Clinical success was defined as patients who achieved skeletal maturity with ≤ 30° curve magnitude of both their main thoracic and thoracolumbar/lumbar curves and who did not undergo posterior spine instrumentation and fusion (PSIF). RESULTS: Patients had a mean age of 11.6 years (range 10-14 years), majority were girls (92%), and mean follow-up was 3.0 years (range 2-4.8 years). All patients were skeletally immature with a Risser ≤ 2. Included curves were Lenke 1C, 3C, or 6C. Mean preoperative curve magnitudes were 53° ± 8° (range 45°-65°) main thoracic and 49° ± 9° (range 40°-62°) thoracolumbar/lumbar curves. At most recent follow-up, patients had a mean main thoracic curve of 29° ± 8° (range 15°-40°) and a mean thoracolumbar/lumbar curve of 20° ± 15° (range 4°-35°). 50% required a revision operation. Cable breakage occurred in 43%, which did not always require revision. One patient progressed to thoracic fusion, but no patient underwent lumbar fusion. Patients had a mean SRS-22 outcome score of 4.2 ± 0.4. CONCLUSIONS: ATVBT/PLST is a potential alternative to spine fusion for select immature patients with AIS at a minimum 2-year follow-up. ATVBT/PLST potentially offers motion conservation at the cost of a higher revision rate. Further study and reporting of results are necessary to refine indications and techniques, which in turn will improve outcomes of this procedure. LEVEL OF EVIDENCE: Level IV-Case series without comparative group.

Perioperative Outcomes of Open Anterior Vertebral Body Tethering and Instrumented Posterior Spinal Fusion for Skeletally Immature Patients With Idiopathic Scoliosis.

BACKGROUND: Correcting adolescent idiopathic scoliosis (AIS) without fusion can be achieved with anterior vertebral body tethering (AVBT). However, little is known about the perioperative outcomes, pain control, and clinical outcomes in patients undergoing AVBT compared with instrumented posterior spinal fusion (IPSF). METHODS: In this retrospective cohort study, we compared pediatric patients with AIS who underwent either AVBT or IPSF. Inclusion criteria were based on the AVBT group, which included primary thoracic idiopathic scoliosis, Risser ≤1, curve magnitude 40 to 70 degrees, age 9 to 15, no prior spine surgery, index surgery between 2014 and 2019, and minimum 2-year follow-up. Patient demographics, perioperative metrics, pain visual analog scale scores, opiate morphine equivalent usage, cost data, and radiographic outcomes were compared. RESULTS: We identified 23 patients who underwent AVBT and 24 matched patients in the IPSF group based on inclusion criteria. Patients undergoing AVBT and PSF were similar in age (12±1 y vs. 13±1 y, P =0.132) and average follow-up time (3.8±1.6 y vs. 3.3±1.4 y, P =0.210). There were 23 female patients (87%) in the AVBT group and 24 female (92%) patients in the IPSF group. Intraoperatively, estimated blood loss (498±290 vs. 120±47 mL, P <0.001) and procedure duration (419±95 vs. 331±83 min, P =0.001) was significantly greater in the IPSF group compared with AVBT. Length of stay was lower in the AVBT group compared with PSF (4±1 vs. 5±2 d, P =0.04). PSF patients had significantly greater total postoperative opiate morphine equivalent use compared with AVBT (2.2±1.9 vs. 5.6±3.4 mg/kg, P <0.001). Overall direct costs following PSF and AVBT were similar ($47,655+$12,028 vs. $50,891±$24,531, P =0.58). Preoperative radiographic parameters were similar between both the groups, with a major thoracic curve at 51±10 degrees for AVBT and 54±9 degrees for IPSF ( P =0.214). At the most recent follow-up, IPSF patients had greater curve reduction to a mean major thoracic curve of 11±7 degrees (79%) compared with 19±10 degrees (63%) in AVBT patients ( P =0.002). Nine patients (39%) required revision surgery following AVBT compared with 4 patients(17%) following IPSF ( P =0.09). CONCLUSIONS: In a select cohort of patients, AVBT offers decreased surgical time, blood loss, length of stay, and postoperative opiate usage compared with IPSF. Although IPSF resulted in greater deformity correction at 2-year follow-up, the majority of patients who underwent AVBT had ≤35 major curves and avoided fusion. There is optimism for AVBT as a treatment option for select AIS patients, but long-term complications are still being understood, and the risk for revision surgeries remains high. LEVEL OF EVIDENCE: Level III.

Sex and fiber type independently influence AMPK, TBC1D1, and TBC1D4 at rest and during recovery from high-intensity exercise in humans.

Women and men present different metabolic responses to exercise, yet whether this phenomenon results from differences in fiber type (FT) composition or other sex-specific factors remains unclear. Therefore, our aim was to examine the effects of sex and FT independently on AMP-activated protein kinase (AMPK), acetyl-CoA carboxylase (ACC), Tre-2/BUB2/CDC1 domain family (TBC1D)1, and TBC1D4 in response to acute exercise. Segregated pools of myosin heavy chain (MHC) I and MHC IIa fibers were prepared from vastus lateralis biopsies of young trained men and women at rest and during recovery (0 min, 45 min, 90 min, or 180 min) from high-intensity interval exercise (6 × 1.5 min at 95% maximum oxygen uptake). In resting MHC I vs. IIa fibers, AMPKα2, AMPKγ3, and TBC1D1 were higher and TBC1D4 expression was lower in both sexes, along with higher phospho (p)-TBC1D1Ser660 and lower p-TBC1D4Thr642. Women expressed higher ACC than men in MHC IIa fibers and higher AMPKß1, AMPKß2, TBC1D1, and TBC1D4 in both FTs. Immediately after exercise, p-AMPKαThr172 increased only in MHC IIa fibers, whereas p-ACCSer221 increased in both FTs, with no change in p-TBC1D1Ser660 or p-TBC1D4Thr642. During recovery, delayed responses were observed for p-AMPKαThr172 in MHC I (45 min), p-TBC1D4Thr642 in both FTs (45 min), and p-TBC1D1Ser660 (180 min). FT-specific phosphorylation responses to exercise were similar between men and women. Data indicate that sex and FT independently influence expression of AMPK and its substrates. Thus failing to account for sex or FT may reduce accuracy and precision of metabolic protein measurements and conceal key findings.NEW & NOTEWORTHY This investigation is the first to compare muscle fiber type (FT)-specific analysis of proteins between the sexes, providing comprehensive data on AMP-activated protein kinase (AMPK), acetyl-CoA carboxylase (ACC), Tre-2/BUB2/CDC1 domain family (TBC1D)1, and TBC1D4 before and in the hours following high-intensity interval exercise (HIIT). Expression and phosphorylation of specific AMPK isoforms, ACC, TBC1D1, and TBC1D4 were shown to be FT dependent, sex dependent, or both, and TBC1D1 showed an unexpected delay in FT-dependent phosphorylation in the time period following HIIT.

Extraordinary fast-twitch fiber abundance in elite weightlifters.

Human skeletal muscle fibers exist across a continuum of slow → fast-twitch. The amount of each fiber type (FT) influences muscle performance but remains largely unexplored in elite athletes, particularly from strength/power sports. To address this nescience, vastus lateralis (VL) biopsies were performed on World/Olympic (female, n = 6, "WCF") and National-caliber (female, n = 9, "NCF"; and male, n = 6, "NCM") American weightlifters. Participant accolades included 3 Olympic Games, 19 World Championships, 25 National records, and >170 National/International medals. Samples were analyzed for myosin heavy chain (MHC) content via SDS-PAGE using two distinct techniques: single fiber (SF) distribution (%) and homogenate (HG) composition. The main finding was that these athletes displayed the highest pure MHC IIa concentrations ever reported in healthy VL (23±9% I, 5±3% I/IIa, 67±13% IIa, and 6±10% IIa/IIx), with WCF expressing a notable 71±17% (NCF = 67±8%, NCM = 63±16%). No pure MHC IIx were found with SF. Secondary analysis revealed the heavyweights accounted for 91% of the MHC IIa/IIx fibers, which caused a correlation between this FT and body mass. Additionally, when compared to SF, HG overestimated MHC I (23±9 vs. 31±9%) and IIx (0±0 vs. 3±6%) by misclassifying I/IIa fibers as I and IIa/IIx fibers as IIx, highlighting the limitation of HG as a measure of isoform distribution. These results collectively suggest that athlete caliber (World vs. National) and/or years competing in the sport determine FT% more than sex, particularly for MHC IIa. The extreme fast-twitch myofiber abundance likely explains how elite weightlifters generate high forces in rapid time-frames.