Does the addition of convex uniplanar screws in hybrid constructs improve 3D surgical correction in thoracic adolescent idiopathic scoliosis posterior fusion?

Purpose: Hybrid techniques using thoracic sublaminar bands have proved their efficacy in adolescent idiopathic scoliosis posterior fusion, but clinical axial correction sometimes remained disappointing. One solution found was "the frame technique" and the second alternative was the replacement of the convex sublaminar bands by periapical uniplanar screws. The goal of this study was to compare clinical and radiological outcomes of both techniques in a consecutive cohort of adolescent idiopathic scoliosis patients. Methods: All patients undergoing primary posterior fusion for thoracic adolescent idiopathic scoliosis between January 2017 and March 2020 were included. Two groups were compared: Group 1 with thoracic sublaminar bands only and Group 2 with periapical uniplanar screws. All patients underwent standing stereoradiographs. The main frontal, sagittal, and axial (apical vertebra rotation) radiological parameters of interest were analyzed. Functional outcomes were assessed using the Scoliosis Research Society 30 score. Results: A total of 147 adolescents were included (Group 1, n = 73 and Group 2, n = 74 patients). In the frontal plane, a greater reduction index was observed in Group 2 (68% versus 62%, p < 0.001) as well as a better apical axial correction (67.8% versus 46.6%, p = 0.03). The number of thoracoplasty performed was reduced (6.7% versus 20.5%, p = 0.02) in Group 2, with a significant decrease in the rate of mechanical complication. No significant loss of correction was observed during follow-up in any of the group. Conclusion: The adjunction of convex uniplanar screws at the periapical levels improved the three-dimensional surgical correction of thoracic adolescent idiopathic scoliosis treated with hybrid constructs. Level of evidence: level III, retrospective comparative study.

Distal femoral osteotomy and patellar tendon advancement for the treatment of crouch gait in patients with bilateral spastic cerebral palsy.

BACKGROUND: Crouch gait, or flexed knee gait, represents a common gait pattern in patients with spastic bilateral cerebral palsy (CP). Distal femoral extension and/or shortening osteotomy (DFEO/DFSO) and patellar tendon advancement (PTA) can be considered as viable options when knee flexion contractures are involved. Better outcomes have been reported after a combination of both, independently of the presence of knee extensor lag. In this study, we evaluated the clinical and kinematic outcomes of these procedures. PATIENTS AND METHODS: We reviewed a cohort of 52 limbs (28 patients) who were treated for crouch gait by DFEO/DFSO alone (group 1, n = 15) or DFEO/DFSO + PTA (group 2, n = 37) as a part of single event multilevel surgery (SEMLS). The mean age at surgery was 14 years, and the mean follow-up time was 18 months. The physical examination data and three-dimensional standardized gait analysis were collected and analyzed before the surgery and postoperatively. RESULTS: Overall knee range of motion improved in all limbs. The knee flexion decreased significantly in both groups at initial, mid, and terminal stance. Hip flexion significantly decreased in mid-stance for limbs in group 2. Both clinical and gait parameters were most improved in limbs who underwent DFEO/DFSO + PTA. Increased pelvic tilt was observed in both groups after surgery. CONCLUSION: Although DFEO/DFSO alone was successful in correcting knee flexion contractures, PTA has helped to improve knee extensor lag and knee extension during gait. LEVEL OF EVIDENCE: Therapeutic level IV.

Is scoliosis a source of pain?

Purpose: Pain in scoliosis is definitely a hot topic with growing popularity. The literature remains very controversial, with a pain prevalence ranging from 23% to 90%, but this can be explained by the great heterogeneity of the numerous series. The aim of this review was to report results from the literature regarding pain in relation to scoliosis regardless of the etiology. Methods: A bibliographic search in Medline and Google database from 2003 to March 2023 was performed. Relevant literature was analyzed, summarized, and discussed based on authors' experience. A 1-year prospective series of adolescent idiopathic scoliosis patients was also included to compare with the existing literature. Results: A total of 126 adolescent idiopathic scoliosis patients were included, with a mean preoperative Cobb angle of 64.5° (range, 45°-112°). Reported pain prevalence was 34.1%. Pain and no-pain groups were very different in their self-reported experience, with a very low mean visual analogue scale score of 0.5 (± 0.6) in the no pain group, while visual analogue scale averaged 5.6 (± 1.2) in the pain group (p < 0.001). No significant difference was found between groups regarding the most relevant demographic and radiological parameters. Conclusion: Evidence-based literature on "scoliosis as a source of pain" remains ambiguous. There seems to be a consensus on the lack of direct relationship between deformity magnitude and back pain intensity. A comprehensive evaluation of the patient is therefore necessary before any treatment, including medical history, clinical examination, and relevant imaging for any child with scoliosis and back pain. Level of evidence: Level VI.

Slipped Capital Femoral Epiphysis in Adolescents: Functional Outcomes and Return to Physical Activity after Surgical Treatment.

Background: Slipped capital femoral epiphysis (SCFE) represents a relatively common hip disorder in adolescents. The present retrospective study analyzes the correlation between age, severity of the slip and physeal stability and the functional outcomes, as well as the ability to return to previous physical activity (PA) of patients surgically treated with either pining in situ (PIS) or the modified Dunn (MD) procedure (anatomical reduction of the slipped epiphysis). Methods:The present research is a retrospective observational study of patients surgically treated for SCFE from 2010 to 2015. The sample was divided into two groups: those treated with PIS and those with the MD procedure. Univariate and multivariate logistic regression analyses were performed to determine the relationship between age, Loder classification (stable/unstable), as well as Southwick slip angle (severity of the slip) to return to previous PA. Furthermore, linear regression was used to investigate the association of the above predictor variables to Oxford and Harris hip scores (HHS). Results:A total of 32 patients were identified (16 treated with PIS and 16 with the MD procedure). None of the examined predictor variables (age, Southwick slip angle, Loder classification) had statistically significant effect on the ability to return to previous PA in either the in situ or Dunn group. Univariate analysis showed that higher patients' age at the time of surgery was related to worse HHS and Oxford scores in both the PIS and MD groups. Unstable hips seem to affect unfavorably the HHS. Conclusion:The present study did not reveal any relationship between the age, degree of the Southwick slip angle, the stability of the physis, and the return to PA. Exploration of additional confounding factors are warranted to better understand the physis-related impact on the functional outcomes in both groups.

Bivertebral pedicle-supralaminar autostable claw for proximal fixation of magnetic growing rods in early-onset scoliosis.

BACKGROUND: The various methods for the proximal fixation of magnetic growing rods in patients with early-onset scoliosis (EOS) are associated with high rates of mechanical complications related to material failure or proximal junctional kyphosis (PJK). The bivertebral autostable claw (BAC) has been proven reliable in adolescent idiopathic scoliosis but has not been assessed when used with magnetic growing rods. The objective of this study was to describe the operative technique and outcomes of BAC proximal fixation of magnetic growing rods in children with EOS. HYPOTHESIS: The BAC provides stable and effective proximal fixation in children with early-onset scoliosis. MATERIAL AND METHODS: This retrospective observational study included 24 patients who had surgery in 2015-2019 for early-onset scoliosis with magnetic growing rod implantation and BAC proximal fixation. Radiological variables were measured in the coronal and sagittal planes before surgery, during the early postoperative period (<3months) and at last follow-up (≥2years). RESULTS: No neurological complications were recorded. At last follow-up, four patients had radiological PJK, including one patient with clinical PJK due to material failure. DISCUSSION: BAC proximal fixation is both effective and sufficiently stable (4.2% pull-out) to withstand the forces applied during distraction sessions and daily activities in children with EOS. Moreover, the polyaxial connecting rods ensure better BAC adaptation to the local proximal kyphosis, which is often marked in this population. CONCLUSION: The BAC is a reliable proximal fixation device that is well-suited to magnetic growing rod fixation in children with EOS. LEVEL OF EVIDENCE: IV, retrospective observational cohort study.

A gait functional classification of adolescent idiopathic scoliosis (AIS) based on spatio-temporal parameters (STP).

BACKGROUND: Therapeutic decisions for patients with adolescent idiopathic scoliosis (AIS) are mostly based on static measurements performed on two-dimensional standing full-spine radiographs. However, the trunk plays an essential role in the human locomotion, and the functional consequences during daily activities of this specific and common spinal deformity are not factored in. RESEARCH QUESTION: Does patients with AIS have specific gait patterns based on spatio-temporals parameters measurements ? METHODS: 90 AIS patients (aged 10-18 years) with preoperative simplified gait analysis were retrospectively included for analysis between 2017 and 2020. Spatio-temporal parameters (STP) were measured on a 3-m baropodometric gaitway and included the measurement of 15 normalized gait parameters. A hierarchical cluster analysis was performed to identify group of patients based on the similarities of their gait patterns, and functional variables' inter-group differences were also measured. The subject distribution was calculated to identify the structural characteristics of the subjects according to their gait patterns. RESULTS: Three gait patterns were identified. Cluster 1 (46%) was defined by asymmetry, Cluster 2 (16%) by instability, and Cluster 3 (36%) by variability. Each cluster was significantly different from the other ones on at least 6 different parameters (p < 0.05). Furthermore, each cluster was associated with one type of curve: Lenke 1 for Cluster 1 (57.5%), Lenke 6 for Cluster 2 (40%) and Lenke 5 for Cluster 3 (43.5%). SIGNIFICANCE: Patients with severe AIS have a dynamic signature during gait identified on STP. Understanding consequences of this deformity on gait may be an interesting avenue to study the pathological mechanisms involved in their dynamic motor organization. Furthermore, these results might also be a first step to study the effectiveness of the different therapies.

Descriptive analysis of pediatric orthopedic surgical emergencies during the COVID-19 lockdown: Single-center observational study in a pandemic red-zone area in France.

INTRODUCTION: Lockdown involved strict confinement of children at home, radically affecting their way of life, with increased risk of domestic accidents and the temptation to step outside of the legal framework. The aim of the present study was to analyze the impact of lockdown on pediatric emergency turnover in a university reference center situated in a high-risk "red zone" and to describe specific management measures. HYPOTHESIS: Pediatric emergency turnover and the corresponding lesion mechanisms were altered by lockdown. MATERIALS AND METHODS: All children undergoing emergency orthopedic surgery during lockdown (group 1) were prospectively included, then retrospectively compared to series operated on during the same period in the previous 3 years. Demographic and surgical data were analyzed, and the pathway changes that were developed were detailed. RESULTS: Turnover fell by a mean 33.5%, without change in indications. The most frequent lesions were wounds (54.3%), followed by fractures (34.3%) and infections (11.4%); the upper limbs were involved in 84.6% of cases. Lockdown had been infringed in 9.7% of traumas, mainly concerning fractures (55%). Postoperative management was modulated during lockdown in 34% of cases, without complications at the time of writing. DISCUSSION: Pediatric emergency turnover decreased, without major change in lesion mechanisms. Accidents associated with lockdown infringement were rare (<10%), demonstrating good adaptation on the part of these children living in an urban area. The adapted care pathway was beneficial, and will no doubt continue to optimize management in future, with accelerated circuits and use of telemedicine. LEVEL OF EVIDENCE: IV, comparative retro-prospective study.

Is magnetic resonance imaging reliable for assessing osteosarcoma of the knee joint in children?

INTRODUCTION: The study of tumor extension in knee osteosarcomas is an essential diagnostic tool that helps determine the surgical approach. Magnetic resonance imaging (MRI) is the key component in this decision-making process, but the interpretation of signals can be difficult because peritumoral edema and inflammation may be mistaken for the tumor. HYPOTHESIS: There is a discrepancy between MRI and histopathology findings in the assessment of joint involvement in pediatric osteosarcomas of the knee. MATERIALS AND METHODS: All children who underwent an extra-articular resection for an osteosarcoma of the knee between 2007 and 2016 were included. This was indicated if there was at least one of the following MRI signs: presence of articular effusion, involvement of either the peripheral capsuloligamentous structures, central pivot or patella, or lesion abutting the articular cartilage. RESULTS: Nine patients were operated on with a mean age of 13±2.7 years. There were at least two of the described signs, mainly the involvement of the peripheral capsuloligamentous structures (78%) and central pivot (56%). The histopathology confirmed that the resection margins were healthy in all cases, but the indication for extra-articular resection could have been avoided in 89% of them. DISCUSSION: MRI is the current gold standard for assessing tumor extension, but the signs contraindicating the transarticular approach remain poorly defined. Joint effusion detected by clinical or radiological assessment is the least reliable one. It seems that the tumor's proximity to the articular cartilage, as long as there is no loss of continuity in the latter, or its extension into the central pivot should no longer be considered as relevant signs. The involvement of the peripheral capsuloligamentous structure remains an indication criterion because oncologic resection is otherwise impossible, and the risk of false-negative histopathologic diagnoses is higher. Other MRI sequences could better assess the true extension into the joint space. LEVEL OF EVIDENCE: IV, retrospective study.

Benefit-risks analysis of thoracoplasty in adolescent idiopathic scoliosis treated by sublaminar bands.

INTRODUCTION: Cosmetic concerns are one of the main complaints of patients with adolescent idiopathic scoliosis (AIS). Several studies have shown a significant improvement in self-image scores after thoracoplasty. However, the effects of thoracoplasty on pulmonary function and clinical outcomes remain debated. The objective was to analyze the benefits and risks of thoracoplasty during AIS surgery using a hybrid construct with sublaminar bands. MATERIAL AND METHODS: In this monocentric prospective cohort study, 68 patients with thoracic AIS were consecutively included between 2016 and 2017. All patients had low-dose 3D radiographs. Surgical correction was performed via the posterior approach, using the posteromedial translation technique with a hybrid construct (thoracic sublaminar band and lumbar pedicle screws). A thoracoplasty was proposed in cases of severe rib hump (more than 3cm). Pulmonary function was assessed by pulmonary function tests (PFT) with forced vital capacity, forced expiratory volume in 1 second and total lung capacity). Radiographic parameters and PFT were compared between patients who had or had not had a thoracoplasty preoperatively and 2 years postoperatively. The SRS-22 score was collected at follow-up. RESULTS: The average age was 15±3 years. Nineteen patients (27%) had a thoracoplasty. The demographic, radiographic and respiratory data of the 2 groups were comparable preoperatively. The correction was similar between the groups on sagittal and coronal views. At 2 years, the PFTs were comparable to those performed preoperatively and no difference was found between the groups. None of the 12 patients who had a pleural effusion had it drained. The total SRS-22 score and the cosmetic subscore were higher in the thoracoplasty group (p<0.03). DISCUSSION: The association of a thoracoplasty with AIS surgery improves the self-image of patients without altering the PFTs at 2 years postoperatively. Given the low morbidity of thoracoplasty, it seems reasonable to offer it to patients with severe rib hump and high cosmetic demands. LEVEL OF EVIDENCE: III.

Does the use of intrawound povidone-iodine irrigation and local vancomycin powder impact surgical site infection rate in adolescent idiopathic scoliosis surgery?

PURPOSE: Surgical site infection (SSI) is a major complication after adolescent idiopathic scoliosis (AIS) surgery, with an incidence ranging from 0.5 to 7%. Intraoperative wound decontamination with povidone-iodine (PVP-I) irrigation and/or vancomycin powder in adult spinal surgery has gained attention in the literature with controversial results. The aim of this study was to investigate the impact of using intrawound PVP-I irrigation and local vancomycin powder (LVP) on the incidence of early SSI in AIS surgery. METHODS: All AIS patients who underwent posterior spinal fusion between October 2016 and December 2019 were retrospectively reviewed. The incidence of early SSI was reported and compared between 2 groups defined by the treating spinal surgeons' preferences: group 1-intrawound irrigation with 2L of PVP-I and application of 3 g LVP before closure and control group 2-patients that did not receive either of these measures. RESULTS: Nine early cases of SSI (2.9%) were reported among the 307 AIS posterior spinal fusion patients. Incidence of SSI in group 1 (2/178 = 1.1%) was significantly lower than in group 2 (7/129 = 5.4%; p = 0.04). There were no adverse reactions to the use of PVP-I and LVP in our study. At latest follow-up, rate of surgical revision for mechanical failure with pseudarthrosis was significantly lower in group 1 (2/178 = 1.1%) than in group 2 (9/129 = 7.0%; p = 0.01). CONCLUSION: Intraoperative use of intrawound PVP-I irrigation and vancomycin powder is associated with a significant reduction of early SSI after AIS spine surgery. LEVEL OF EVIDENCE IV: Retrospective study.

Study of the latency of transcranial motor evoked potentials in spinal cord monitoring during surgery for adolescent idiopathic scoliosis.

OBJECTIVE: An increase in the latency of a motor evoked potential might be as significant as a decrease in amplitude to predict a significant and clinically symptomatic neurological injury in spinal surgery for adolescent idiopathic scoliosis. The aim of the study was to investigate the impact of monitoring of latency of motor evoked potentials during spinal surgery for adolescent idiopathic scoliosis by describing intraoperative data. METHODS: Preoperative recordings of 50 patients undergoing posterior spinal fusion for idiopathic scoliosis were studied. Latencies of appearance of the motor evoked potential curves on the right and left side were recorded for each group of muscles at several key moments during the procedure (basal, before the first implant, before and after corrective maneuvers). RESULTS: Mean latencies were approximately the same in each muscle group on the right and the left side, before and after correction. There was no significant increase in latency during surgery. Overall results showed that the measured latency did not differ significantly between the two age groups (p=0.07). Negative correlation between height and the means of latencies was recorded in the abductor pollicis brevis and abductor digiti minimi (r=0.4; p=0.009), rectus femoris (r=0.4; p=0.01), tibialis anterior (r=0.4; p=0.007), and abductor hallucis (r=0.5; p=0.0004). No significant correlation was found between age and intraoperative parameters. CONCLUSION: Intraoperative latency could be a reliable intraoperative monitoring criteria with low variability, that might be used to predict postoperative motor deficits in surgery for adolescent idiopathic scoliosis.

Post-traumatic Radioulnar Synostosis in Distal Forearm Fractures in Children: A Report of 2 Cases.

CASES: Two pediatric cases of post-traumatic distal radioulnar synostosis are reported, accompanied by a literature review summarizing evidence on the management of these conditions. Radioulnar synostosis is a rare complication of distal forearm fractures, which impairs upper-extremity function. The numerous surgical procedures that have been described to treat this condition in adults typically involve synostosis resection and an interposition graft to reduce recurrence. The optimal treatment in children has not been established. CONCLUSIONS: Post-traumatic radioulnar synostoses are rare conditions in pediatric patients who can be successfully treated with surgical excision of the synostoses and without the use of interposition grafting.

S2-Alar-iliac screw fixation for paediatric neuromuscular scoliosis: Preliminary results after two years.

BACKGROUND: Correcting pelvic obliquity is among the main goals of surgery for neuromuscular scoliosis. Spino-pelvic fixation must be stable and capable of withstanding the considerable mechanical forces applied at the lumbo-sacral junction. Selection of the best anchoring option is therefore crucial. S2-alar-iliac (S2AI) screws, which are used in adults, are less often chosen in the French paediatric spinal-surgery community. The objective of this study was to report our preliminary experience with S2AI screws used in the treatment of paediatric patients with neuromuscular scoliosis. HYPOTHESIS: Pelvic anchoring by means of S2AI screws is reliable and technically feasible in non-ambulatory children with neuromuscular scoliosis. MATERIALS AND METHODS: Consecutive non-ambulatory patients who underwent scoliosis surgery with S2AI screw fixation to the pelvis between 2016 and 2018 were retrospectively included. The surgical procedure consisted in either posterior spinal fusion (PSF) or magnetic growing rod (MGR) implantation. In all patients, radiographs were obtained before surgery, within 3 months after surgery, and at last follow-up; and low-dose computed tomography (CT) was performed before and after surgery. RESULTS: We included 25 patients with a mean age of 13.8±4.0 years, 18 managed by PSF and 7 by MGRs. Screw diameters ranged from 7.5 to 9.5mm and all screws were at least 60mm in length. The diameters and lengths were the same on both sides in 16 (89%) patients in the PSF group and in all patients in the MGR group. At last follow-up after a mean of 35.5±3.0 months, pelvic obliquity was corrected in all 23 patients with this abnormality before surgery. Complications consisted of lateral cortical screw breakthrough in 8 (32% of screws) patients and screw malposition in 2 (8% of screws) patients. No clinically significant complications related to the fixation material were recorded. DISCUSSION: The results of our study demonstrate the feasibility of S2AI screw fixation in paediatric patients with neuromuscular scoliosis. Pelvic asymmetry and dysmorphism do not contra-indicate the procedure but must be evaluated before surgery. Further work is needed to assess the potential long-term consequences on pain and growth of screw passage through the sacro-iliac joints. LEVEL OF EVIDENCE: IV, retrospective study.

Surgical outcomes of spinal osteochondroma in children: A multicentre observational study.

BACKGROUND: Spinal osteochondroma (or exostosis) is a rare benign tumour whose clinical manifestations are delayed due to their slow growth and location. Few studies have addressed the characteristics and the diagnostic and therapeutic peculiarities of spinal osteochondroma in children. The objective of this multicentre observational study was to assess the outcomes of a cohort of children after surgery for spinal osteochondroma. HYPOTHESIS: Surgical excision of spinal osteochondroma in children is not followed by complications or recurrences. MATERIAL AND METHODS: We included consecutive children who had surgery between 2010 and 2018 at any of eight participating centres to remove spinal osteochondromas. The cause, clinical manifestations, and location of the lesions were collected. The surgical outcomes were evaluated after at least 2 years' follow-up. RESULTS: We identified 22 patients who had surgery to remove 26 spinal osteochondromas at a mean age of 12.8±2.6 years. Among them, 7 had a solitary osteochondroma (SO group) and 15 had hereditary multiple osteochondromas (HMO group). At diagnosis, 72% of patients had clinical signs (spinal pain, n=4; one or more lumps, n=5; and neurological manifestations, n=3). In the HMO group, the diagnosis was made during routine MRI screening for tumours involving the spinal canal. Most osteochondromas involved the cervical spine (n=13), with no difference between the two groups (p=0.9). The lamina was the most common location but 54% of the tumours were growing within the canal (92% in the HMO group). After a mean follow-up of 5.2±4.4 years, no patients had experienced any recurrences or complications related to the disease or treatment. DISCUSSION: Surgical excision of spinal osteochondromas in children is effective, with no medium-term recurrences. Our results also confirm the low peri-operative morbidity, even when the canal is involved, and the absence of any effect at last follow-up on spinal alignment. All patients with neurological manifestations at diagnosis made a full recovery. LEVEL OF EVIDENCE: IV, retrospective observational cohort study.

How does magnetically controlled growing rods insertion affect sagittal alignment in ambulatory early onset scoliosis patients?

PURPOSE: The importance of sagittal alignment restoration in early onset scoliosis (EOS) management has rarely been investigated to date. The aim was to report the influence of magnetically controlled growing rods (MCGR) insertion on the sagittal alignment of EOS patients. METHODS: All consecutive ambulatory patients operated with MCGR rods between 2011 and 2018 were retrospectively included in four institutions. Standing biplanar radiographs were performed preoperatively, in the early postoperative period and at latest follow-up. Global and local sagittal parameters, spinal global shape and harmony were investigated. RESULTS: A total of 37 ambulatory EOS patients were included (mean age at surgery 8.5 (± 2) years). 70% had a balanced construct postoperatively. Both MaxTK (- 17°, p = 0.02) and MaxLL (- 15°, p = 0.001) were significantly reduced, particularly at the instrumented levels. The number of vertebrae included in the lumbar lordosis significantly increased (+ 2 levels, p = 0.02), as well as the thoraco-lumbar inflexion point (+ 2 levels, p < 0.001) and the kyphosis apex (+ 1 level, p < 0.001). Overall mechanical failure rate was 40.5%, and radiological PJK was observed in 43% of the patients, with 11 remaining asymptomatic. Patients with initial hyperkyphosis (> 50°) developed more complications (62% vs. 28%, p = 0.04). CONCLUSION: MCGR insertion flattened the spine in EOS, at both instrumented and non-instrumented levels. Overall spinal harmony was modified, with a cranial shift of the thoraco-lumbar inflexion point and the thoracic kyphosis apex, associated with a lengthening of the lumbar lordosis. The rate of complication remained high, some explanations being found in the radiological changes reported such as the preoperative location of the TK apex. LEVEL OF EVIDENCE: IV.

Langenskiöld classification of tibia vara: a multicenter study on interrater reliability.

Since 1952, when Langenskiöld introduced his six-stage classification on roentgenographic morphologies of tibia vara, this method has been used extensively in Orthopaedic studies. Different studies have tried to determine the reliability of this method. Although there are scarce reports of major variability in using Langenskiöld classification, but the question still remains, as to whether using expert subspecialists and MRI would improve its reliability. The aim of this study is to evaluate inter-rater reliability of Langenskiöld classification using simple radiograph and MRI, by expert raters. This is a cross-sectional multicenter study, involving patients from 4 tertiary pediatric orthopedic centers in France and Iran. Radiograph and MRI (T1, T2, fat saturation) of the affected knees were independently classified by 12 academy members from France and Iran: six pediatric fellowship orthopedic surgeons and six musculoskeletal radiologists. All data were analyzed afterwards by an independent researcher. Mean weighted kappa for agreement based on radiograph and MRI was 0.47 and 0.45, respectively. Mean percent of total agreement was 46.6 and 40.8% in the same order. Kappa statistics for the new grouping were 0.53 and 0.46 for roentgenograms and MRIs, respectively. The new regrouping was proposed so that each group would need a different treatment strategy. Fleiss kappa statistics for group B (stages 2 and 3), rose from (0.33 and 0.09) to 0.44. These values for group C (stages 4 and 5) rose from (0.42 and 0.11) to 0.54. This study concludes that Langenskiöld's classification when used by experts, still has a moderate inter-rater reliability at best. This variability is most at stages 2, 3, and 4; and can cause different treatment approaches. Use of MRI does not have a significant effect on its reliability. Regrouping the stages improved the inter-rater reliability. Level of evidence: III.

Is anterior subcapital shortening osteotomy a reliable and reproducible technique in the treatment of severe slipped capital femoral epiphysis?

INTRODUCTION: Proximal femoral shortening osteotomies are becoming the treatment of choice for severe slipped capital femoral epiphysis (SCFE) to reduce the risk of femoroacetabular impingement. The reported rates of complication seem reasonable, but these are single-operator series with surgeons highly experienced in this technique. The purpose of this study was to assess how surgeon experience impacted the outcomes of anterior subcapital shortening osteotomy (ASSO) in severe SCFE. HYPOTHESIS: The hypothesis was that ASSO is a reproducible technique that is accessible to junior surgeons. MATERIALS AND METHODS: All ASSOs performed for severe SCFE (slipangle > 40°) between 2015 and 2019 were retrospectively reviewed. All osteotomies were performed by surgeons with less than 4 years' experience (senior residents), who were trained by a senior surgeon experienced in this technique (Group 1). The incidence of femoral head avascular necrosis (AVN) and complications were analyzed and compared to a historical control cohort (Group 2). RESULTS: A total of 62 SCFEs (37 unstable and 25 stable) were analyzed. Both groups had similar demographic data and SCFE characteristics. The mean operative times were statistically comparable in both groups. The rates of AVN in unstable SCFEs and in the overall series were comparable in both groups (18.9% vs. 13.3%, p=.55 and 12.9% vs. 9.7%, p=.6). These rates were comparable in the stable forms (4.0% vs. 5.4%; p=1). However, the preoperative MRI in Group 1 showed that 42.8% of unstable hips that developed AVN were already hypoperfused before surgery. The overall rate of complication showed no significant difference between the 2 groups (26% vs. 17%, p=.16). DISCUSSION: Although ASSO is a technically demanding procedure, it is reliable and reproducible. The main risk factor for developing AVN remains the unstable nature of SCFE and not the surgeon's experience. It can be performed by trained junior surgeons, but not in an emergency setting, with the possibility of assistance from a more experienced surgeon. LEVEL OF EVIDENCE: IV; retrospective case study.

Posterior vertebral column resection for pediatric rigid spinal deformity.

INTRODUCTION: Surgery for pediatric spinal deformity may involve vertebral osteotomies in complex cases. Vertebral column resection (VCR) is the most technically demanding procedure, with the severest morbidity. It can use a double anterior and posterior approach (APVCR), though a single posterior approach (PVCR) is gaining in popularity. HYPOTHESIS: PVCR provides effective correction with acceptable morbidity in children. METHOD: A single-center retrospective series included spinal deformities treated by PVCR. Surgical data and global pelvic-spinal balance parameters were analyzed. RESULTS: Sixteen PVCRs were performed in 13 patients, with a mean age of 14.1±2.8 years. Mean operative time was 411±54minutes. Mean preoperative rigid principal Cobb angle was 74.3°. Mean correction was 64.3% postoperatively, without significant correction loss at last follow-up. Mean blood loss was 941±221ml. The cell-saver enabled 92.3% autologous transfusions, with 53.4% homologous transfusions. Transient monoplegia and permanent psoas deficit were observed during the postoperative period. Radiologic follow-up found 4 non-unions requiring revision. CONCLUSION: PVCR provided major correction of rigid spinal deformity in children. Complications mainly comprised mechanical or neurological incidents. LEVEL OF EVIDENCE: IV, non-comparative cohort study.

Halo-gravity traction followed by definitive fusion in severe early onset scoliosis: results of a trunk analysis based on biplanar 3D reconstructions.

PURPOSE: Definitive fusion can be considered in early onset scoliosis (EOS) around triradiate cartilage closure. Halo-gravity traction (HGT) is an old strategy that can help lengthen and balance the spine before fusion. The postoperative changes of the trunk have never been investigated to date with modern imaging. The goal of this study was to analyze the 3D radiological outcomes, and the associated pulmonary function, of a cohort of severe EOS patients treated by definitive posterior fusion prepared by HGT. METHODS: All consecutive EOS patients with severe (> 85°) and stiff (flexibility < 25%) curves, treated by HGT followed by posterior fusion, were followed. 3D radiological measurements and pulmonary function were assessed. RESULTS: Forty-nine EOS patients underwent fusion, with a mean follow-up of 4 years (± 1). Age at surgery averaged 13.5 years old. HGT protocol reached on average 41% of body weight. Mean preoperative 3D Cobb angle was 95° (± 10) and final correction averaged 68.4% after surgery. 3D T4T12 kyphosis was reduced after surgery (11°, p < 0.01), while the apical vertebral rotation was improved by 27.8% (p = 0.06). 3D thoracic volume increased after surgery (p = 0.02), with a 3D T1T12 height gain averaging 3.7 cm (± 2). Both parameters were significantly correlated with total lung capacity improvement. Seven complications (14.2%) were reported, and 5 patients (10.6%) underwent unplanned revision. CONCLUSION: HGT is a safe and efficient strategy to prepare posterior fusion in severe EOS patients. The 3D trunk analysis demonstrated significant postoperative gains in thoracic and spinal lengths, as well as in thoracic volume. LEVEL OF EVIDENCE: IV.