The "Risser+" grade: a new grading system to classify skeletal maturity in idiopathic scoliosis.

PURPOSE: This study aims to propose and validate a new unified "Risser+" grade that combines the North American (NA) and European (EU) variants of the classic Risser score. The "Risser+ " grade can effectively combine the North American and European Risser Classifications for skeletal maturity with adequate intra-rater/inter-rater reliability and agreement. METHODS: Agreement and reliability were evaluated for 6 raters (3-NA, 3-EU) who assessed 120 pelvic radiographs from the BrAIST trial, all female, average age 13.4 (range 10.1-16.5 years). Blinded raters reviewed x-rays at two time-points. Intra- and inter-rater agreement (RA) were established with Krippendorff's alpha (k-alpha), while intra- and inter-rater reliability (RR) were established with intraclass correlation coefficients (ICC). Acceptable agreement and reliability were set a priori at 0.80. RESULTS: Inter-RA for the second reading met study requirements (k-alpha = 0.86 [0.81-0.90]) compared to the first reading (0.72 [0.63-0.79]) while combined readings was close to target agreement (0.79 [0.74-0.84]). Removal of 20 readings demonstrating outlier tendencies increased agreement for the first, second, and combined reads (k-alpha = 0.85, 0.89, 0.87, respectively). Intra-RA was sufficient for 4 out of 6 raters (k-alpha > 0.80) and one rater from EU and NA presented subpar intra-RA (k-alpha = 0.64 and 0.74, respectively). Inter-RR met study requirements overall reads (ICC = 0.96 [0.95-0.97]) including the first (0.94 [0.92-0.95]) and second (0.97 [0.97-0.98]) reads, independently. CONCLUSIONS: The Risser+ system showed excellent reliability across multiple reads and raters and demonstrated 79% agreement overall reads and ratings. Agreement increased to over 85% when raters could distinguish Risser 0 + from Risser 5. These slides can be retrieved from electronic supplementary material.

Correction to: The "Risser+" grade: a new grading system to classify skeletal maturity in idiopathic scoliosis.

Unfortunately, the affiliation of the author Negrini S has been incorrectly published in the original version. The complete correct affiliation of this author should read as follows.

The relationship between physical activity, structural deformity, and spinal mobility in adolescent idiopathic scoliosis patients.

PURPOSE: Adolescent idiopathic scoliosis (AIS) patients experience structural spinal deformity, but the impact of AIS on physical activity is not widely studied. Reports of physical activity levels between children with AIS and their peers are mixed. This study sought to characterize the relationship between spinal deformity, spinal range of motion, and self-reported physical activity in AIS patients. METHODS: Patients aged 11-21 completed self-reported measures of physical activity using the HSS Pedi-FABS and PROMIS Physical Activity questionnaires. Radiographic measures were obtained from standing biplanar radiographic imaging. Surface topographic (ST) imaging data was obtained using a whole-body ST scanning system. Hierarchical linear regression models analyzed the relationship between physical activity, ST, and radiographic deformity while controlling for age and BMI. RESULTS: 149 patients with AIS (mean age 14.5 ± 2.0 years, mean Cobb angle 39.7° ± 18.9°) were included. In the hierarchical regression predicting physical activity from Cobb angle, no factors were significant predictors of physical activity. When predicting physical activity from ST ROM measurements, age and BMI served as covariates. No covariates or ST ROM measurements were significant predictors of physical activity levels for either activity measure. CONCLUSIONS: Physical activity levels of patients with AIS were not predicted by levels of radiographic deformity or surface topographic range of motion. Although patients may experience severe structural deformity and range of motion limitations, these factors do not appear to be associated with decreased physical activity level utilizing validated patient activity questionnaires. LEVEL OF EVIDENCE: Level II.

Bracing for infantile scoliosis: no sedation needed.

Mehta casting technique applied under anesthesia is standard treatment for infantile scoliosis (IIS). However, concern has been raised about frequent anesthesia in children less than three years. The development of a customized thoracolumbar sacral orthosis (TLSO) could avoid the risks of Mehta casting. To develop a bracing technique for IIS that achieves patient compliance and scoliosis correction. Nine patients with ISS were offered a custom TLSO as an alternative to Mehta casting. One patient declined due to an insurance issue. No anesthesia was required for measurement or fitting of the TLSO. A temperature sensitive monitor recorded wear time. Brace success was determined by radiographic correction and adherence to prescription of greater than 18 hours per day. Eight patients had brace treatment with mean(range): age 19(12-44) months, curve magnitude 34° (22-44°), rib vertebral angle of greater than 20° with follow-up 17(3-28) months. In brace correction was less than 15 degrees in 6 of 8 patients. Compliance monitor recorded wear: 4 patients ≥ 18 hours, 2 patients 16-18 hours, 1 had 14 hours, and 1 monitor malfunctioned and could not be read. Brace design evolved to maximize ipsilateral abdominal relief away from the lateral apical shift of the design. Foam lining was added to prevent skin irritation through the relief opening. Average number of braces per year =2.2. A customized TLSO can achieve in brace correction comparable to Mehta casting with acceptable compliance and without the need for general anesthesia, while allowing bathing and skin care.

Physeal arrest about the knee associated with non-physeal fractures in the lower extremity.

The cases of seven patients who had a physeal arrest about the knee in association with nonphyseal fractures in the lower extremity were reviewed. The patients were between ten and twelve and one-half years old at the time of injury, and the physeal arrest involved either the posterolateral part of the distal femoral physis or the anterior part of the proximal tibial physis. There was no evidence of iatrogenic trauma to the physis. Recognition of the physeal injury was delayed for an average of one year and ten months until a gross angular deformity appeared. Adolescents who have fractures of the lower extremities that do not appear to involve a physeal plate should nevertheless be evaluated and followed for possible physeal injury about the knee that can be detected only after additional growth has taken place.

Latent psoas abscess after anterior spinal fusion.

This case is presented to emphasize that late infection should be considered in all postoperative patients as a cause of pain. A psoas abscess may remain dormant for many years after an anterior spinal procedure. It should be considered in the differential diagnosis of back pain and lumbar radiculopathy after anterior spinal fusion. The lumbar nerve plexus lies within the psoas muscle, and referred pain patterns may occur in the lumbar nerve distribution. In this case, dysesthesias occurred in the distribution of the genitofemoral nerve. The diagnosis and treatment of a psoas abscess has been greatly aided by use of CT and ultrasound. Either of these modalities may be used for directed percutaneous drainage of the abscess. The presence of metal fixation devices necessitates removal of the hardware in order to ensure eradication of the infection.

Comparison of single- and dual-rod techniques for posterior spinal instrumentation in the treatment of adolescent idiopathic scoliosis.

STUDY DESIGN: Two groups of patients undergoing posterior spinal instrumentation and arthrodesis for treatment of adolescent idiopathic scoliosis were reviewed retrospectively. OBJECTIVE: To compare intraoperative concerns (operative time and blood loss), complications, and outcome in patients undergoing single or double posterior rod instrumentation for treatment of adolescent idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: The current treatment of idiopathic scoliosis includes posterior spinal instrumentation and arthrodesis. The standard configuration is a rectangular construct of dual rods connected by cross-links. Use of a single rod with multiple fixation points has been proposed as an alternative method to decrease operative time and blood loss, and to avoid late deep infections. METHODS: In this study, 21 patients underwent posterior instrumentation using a standard dual-rod construct, and 25 patients underwent posterior instrumentation using a solitary rod with multiple fixation points. Patients were assessed after a minimum 2-year follow-up period. RESULTS: No significant differences were found in blood loss, operative time, or overall frequency of long-term complications. Although not statistically significant, the trend was toward implant prominence in the double-rod group and implant failure in the single-rod group. Implant failure occurred only in instrumentations extending into the lumbar spine. There was no statistical difference in curve progression. CONCLUSIONS: Single-rod instrumentation and dual-rod constructs offered similar curve correction, blood loss, and operative time. However, single-rod instrumentation may be more prone to implant failure when extended into the lumbar spine.

Burst fractures of the fifth lumbar vertebra.

Eleven patients with burst fractures of the fifth lumbar vertebra were reviewed. The results of nonoperative treatment were compared with that of immediate surgery and stabilization with pedicle screw fixation. Five patients were treated nonoperatively and six patients underwent pedicle screw instrumentation and spinal fusion. Five patients had neurologic injury associated with their L5 burst fracture. Nonoperative treatment yielded excellent results in young patients with minimal canal compromise. Neurologic deficits responded more predictably to surgical decompression than to conservative treatment and internal fixation with pedicle screws restores spinal stability and allows early mobilization.

Surgical treatment of congenital kyphosis.

STUDY DESIGN: In this study, 26 cases of congenital kyphosis and kyphoscoliosis treated surgically were retrospectively reviewed. OBJECTIVE: To assess the clinical outcomes and surgical indications for posterior only versus anteroposterior surgery in the child. SUMMARY OF BACKGROUND DATA: Congenital kyphosis usually is progressive without surgical intervention. Current recommended treatment includes posterior arthrodesis for deformities of less than 50 degrees to 60 degrees, and anterior release or decompression, anterior fusion, and posterior instrumented arthrodesis for large deformities and cord compression. METHODS: Cases involving myelodysplasia, spinal dysgenesis, and skeletal dysplasia were excluded from the study. Kyphoscoliosis was included if the kyphotic deformity was greater than the scoliotic deformity. Patients were grouped by age and surgical technique. The patients in group P1 underwent posterior arthrodesis at an age younger than 3 years, and those in group P2 underwent the procedure at an age older than 3 years. The patients in group AP1 underwent anterior and posterior procedures at an age younger than 3 years, and those in group AP2 underwent the procedures at an age older than 3 years. The preoperative deformity, complications, and postoperative deformity correction were analyzed. There were nine Type 1 (failure of formation), nine Type 2 (failure of segmentation), and eight Type 3 (mixed) deformities. Four patients had associated spinal dysraphism. Three patients with Type 1 deformities had clinical or radiographic evidence of cord compression. RESULTS: In Group P1, five patients at an average age of 16 months underwent posterior arthrodesis alone for an average kyphotic deformity of 49 degrees. The immediate postoperative correction improved over a period of 6 years and 9 months by an additional 10 degrees, resulting in a final deformity of 26 degrees. Pseudarthrosis developed in two patients, requiring fusion mass augmentation or anterior arthrodesis. Neither patient was instrumented. In Group P2, five patients at an average age of 13 years and 7 months underwent posterior arthrodesis with instrumentation for kyphotic deformity of 59 degrees. Approximately 30 degrees of intraoperative correction was achieved safely using compression instrumentation and positioning. No further correction occurred with growth. The final residual kyphotic deformity was 29 degrees after a follow-up period of 4 years and 5 months. In Group AP1, seven patients underwent anterior release or vertebra resection for deformity correction and posterior arthrodesis for an average kyphotic deformity of 48 degrees at the age of 16 months. There were no iatrogenic neurologic injuries. The final residual kyphotic deformity was 22 degrees after a follow-up period of 6 years and 3 months. In Group AP2, nine patients underwent anterior release or decompression with posterior arthrodesis for kyphotic deformity of 77 degrees at the age of 11 years and 6 months. The deformity was corrected to 37 degrees, with no significant loss over a follow-up period of 5 years and 2 months. There were two postoperative neurologic complications. CONCLUSIONS: After reviewing their experience, the authors made the following observations: 1) The pseudarthrosis rate was low even without routine augmentation of fusion mass if instrumentation was used; 2) gradual correction of kyphosis may occur with growth in patients younger than 3 years with Types 2 and 3 deformities after posterior fusion, but appears to be unpredictable; 3) the risk of neurologic injury with anterior and posterior fusion for kyphotic deformity was associated with greater age, more severe deformity, and preexisting spinal cord compromise.

Hip disease in adults with Down syndrome.

The life expectancy of patients with Down syndrome has increased significantly in recent years. Hip abnormalities occur in children with this syndrome but little is known about their natural history in later life. In 65 adults with Down syndrome we found hip abnormalities in 28%, and this was statistically correlated with walking ability. A subgroup of 18 patients was followed by serial examination; this showed that hip instability occurred in adulthood and became worse with time. In some patients, hip instability started after skeletal maturity.

Extrapleural thoracoscopic anterior spinal fusion: a modified video-assisted thoracoscopic surgery approach to the pediatric spine.

Video assisted thoracoscopic surgery (VATS) has recently been developed as an alternative to thoracotomy for anterior spinal surgery. We report a case in which an extrapleural dissection was combined with VATS to further improve this approach.

Wagner multiple K-wire osteosynthesis to correct coxa vara in the young child: experience with a versatile 'tailor-made' high angle blade plate equivalent.

In 1978, Wagner described a technique using multiple Kirschner wires (K-wires) to stabilize an intertrochanteric osteotomy performed for the correction of coxa vara in small children. Multiple K-wires are used to create a custom high-angle blade plate for valgus osteotomy. The authors have evaluated a retrospective series of 17 Wagner intertrochanteric osteotomies that were performed in 10 children with coxa vara between the ages of 1 year and 8 years. The neck-shaft angle was corrected from 93.5 degrees to 129.5 degrees at long-term follow-up, and the Hilgenreiner epiphyseal angle was corrected from 71 degrees to 37.6 degrees at long-term follow-up. Revision surgery was performed on five hips with inadequate initial surgical correction. Complications included a single broken K-wire, a femur fracture after hardware removal, and one hip developed avascular necrosis postoperatively.

Bracing for scoliosis in 2014: state of the art.

Bracing is currently the primary method for treating moderate idiopathic scoliosis (IS) during the developmental phase of growth. Following a lengthy debate, during which researchers and authors questioned the role of bracing in the treatment of IS due to inconsistent evidence, the Bracing in Adolescent Idiopathic Scoliosis Trial study have provided a high level of evidence to the value of bracing and may have convinced most of those who were skeptic. However, although some guidelines have been published, there remains no standard for constructing scoliosis orthoses and no standard treatment protocol. The Scoliosis Research Society criteria were established to provide a framework by which to research bracing and adolescent idiopathic scoliosis, and the Society on Scoliosis Orthopedic and Rehabilitation Treatment criteria were published to guarantee a minimum level of expertise for MDs and CPOs involved in the brace treatment. However, very few contemporary papers follow both sets of criteria, and the extensive variety of braces makes it difficult to determine if one is superior to another. The aim of this paper is to provide an overview of state-of-the-art brace treatment, highlighting commonly used braces and their history, biomechanical concept, and results, as reported in published literature. Specific focus is placed on European (i.e., Chêneau and derivatives, Dynamic Derotating, Lyon, PASB, Sforzesco, TLI, TriaC) and North American (i.e. Boston, Charleston, Milwaukee, Providence, Rosenberger, SpineCor, Wilmington) designs. Details about different building techniques are also reported, along with recently developed tools that are designed to monitor compliance.

Patellar sleeve fracture: demonstration with MR imaging.

PURPOSE: To demonstrate the magnetic resonance (MR) imaging characteristics of patellar sleeve fracture, a cartilaginous avulsion from the lower pole of the patella occurring during forceful contraction of the quadriceps muscle against a partially flexed knee. MATERIALS AND METHODS: The authors evaluated radiographs and MR images from three children with suspected sleeve fractures. RESULTS: Radiographs showed small bone fragments avulsed from the lower patella in two children and no bone abnormality in one. MR imaging demonstrated separation of most of the cartilaginous lower patella in all children, definite intraarticular extension in one, and possible intraarticular extension in another. CONCLUSION: MR imaging can help determine the need for surgery by depicting the extent of cartilaginous injury and displacement of fracture fragments.

Unicameral bone cyst in the scapula of an adolescent.

Unicameral bone cysts of the scapula have been reported mainly in adult patients. The atypical location of the unicameral bone cyst in a 12-year-old girl presented a diagnostic dilemma. Curettage proved to be an effective method for both diagnosis and treatment of this benign lesion.

MRI demonstration of occult purely chondral fractures of the tibia: a potential mimic of meniscal tears.

We report the case of a 12-year-old boy with bilateral, purely chondral fractures of the tibia. The patient had Crohn's disease treated with systemic corticosteroids. MR images of the knee were initially interpreted to show a bucket-handle tear of the lateral meniscus. However, arthroscopic evaluation revealed purely chondral fractures of the tibial plateau without meniscal damage. Re-evaluation of the MR study identified the chondral fracture of the lateral tibial articular cartilage detected arthroscopically. This purely chondral fracture of the tibial plateau represented a rare finding in the symptomatic knee that mimicked a meniscal tear by history, physical exam, and MR imaging.

Lumbosacral fusion in children and adolescents using the modified sacral bar technique.

Between 1986 and 1995 10 patients who were 9 to 18 years of age underwent posterior spinal fusion and instrumentation to the pelvis for correction of spinal deformity using the modified sacral bar technique at the authors' institution. Etiologies of the spinal deformity included congenital scoliosis, cerebral palsy, myelomeningocele, neurofibromatosis, and postlaminectomy kyphosis. Indications for pelvic instrumentation were progressive scoliosis of the lower lumbar spine, pelvic obliquity greater than 15 degrees, and dysraphic posterior elements. Five of the patients had prior spinal surgery. Five patients had a prior or a planned pelvic osteotomy. Nine of the patients achieved lumbosacral fusion without an additional procedure. Major complications included loss of pelvic fixation in two patients, and a dural leak and a wound infection in another patient with myelomeningocele. Mean scoliotic curve correction was from 71.9 degrees to 34.5 degrees at final followup. Lumbar lordosis essentially was unchanged. Pelvic obliquity was corrected from a mean of 20.5 degrees preoperatively to a mean of 7.6 degrees at final followup. The modified sacral bar technique was selected for fusion to the sacrum because of planned or prior pelvic osteotomies, prior posterior spinal fusion and instrumentation, sacral dysraphism, or local anatomic anomalies. The modified sacral bar technique proved to be an effective technique in these patients.

Excision of the radial head in patients younger than 18 years.

We evaluated the results of an excision of the radial head in 25 patients (27 operated-on elbows) younger than 18 years with stiff painful radiocapitellar joints. The mean age was 14.2 years (range, 4.6-17.8 years) with average follow-up of 7.8 years. Analysis of the results with a postoperative elbow score revealed excellent or good results in 19 of the 27 elbows of patients. Skeletal maturity of the patient did not alter the results based on the rating scale. Revision surgery to remove appositional bone growth was needed in six of the 12 posttraumatic cases and one of 15 developmental elbows. Cubitus valgus, wrist pain, and ulnar neuropathy were not clinical problems at follow-up examination. Excision of the radial head was beneficial for 70% of patients younger than 18 years with stiff, painful radiocapitellar joints. Results were not improved in patients who had reached skeletal maturity.

Segmental spinal dysgenesis: early neurologic deterioration and treatment.

Segmental spinal dysgenesis is a rare congenital condition of the lumbar or thoracolumbar spine that can be associated with significant progressive or permanent neurologic defects, including paraplegia. In the past, both bracing and surgery have been recommended. Of the seven children we have seen with this problem, three have lost motor function between presentation and the time of surgery. Our experience suggests that to prevent catastrophic neurologic deterioration, surgery is indicated once the diagnosis is made.

Occipitocervical fusions in children. Retrospective analysis and technical considerations.

This report presents a retrospective analysis of the authors' experience with occipitocervical fusions in children and adolescents during the last 2 decades. A description of an operative technique devised by the senior author (JEH), and a comparison of the results using this and other methods of fusion are given. Twenty-three patients underwent occipitocervical fusion. Fifteen of the patients were operated on using the authors' technique. To achieve stable fixation of the distal cervical vertebra a threaded Kirschner wire was passed transversely through the spinous process; occipital fixation was achieved by the traditional method of wiring corticocancellous bone graft to the skull through burr holes. The occipital wires then were wrapped around the Kirschner wire and the graft was cradled in the resulting nest. Halo immobilization was used in 10 patients for an average of 12.5 weeks (range, 6-24 weeks). Twenty-two patients achieved successful fusion at an average followup of 5.8 years (range, 1-14.33 years). Several complications, including transient quadriplegia in one patient, pseudarthrosis in two (one of which persists), hardware fixation failure in one, unintended distal extension of the fusion, pneumonia, wound infection, halo pin infection, skin breakdown under the halo vest, hydrocephalus, cerebrospinal fluid leak, and traumatic fusion fracture were encountered. Results using the technique described herein are comparable with or better than the results reported in the previous literature, and the results of the patients in this series in whom the technique was not used.