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Purpose The use of vertebral body tethering (VBT) for the treatment of main thoracic deformities in adolescent idiopathic scoliosis patients is becoming increasingly more common, but limited data exist on its safety and efficacy in thoracolumbar deformities. We aimed to evaluate the postoperative outcomes of patients with thoracolumbar (TL) deformities that were treated with VBT. Methods We assessed clinical and radiographic data from twenty-eight consecutive patients that were surgically managed with VBT, all of whom exhibited a TL deformity with at least two years (mean: 44.7 ± 14.5 months) of postoperative follow-up. Standard radiographic parameters were extracted from left hand wrist and standing posterior–anterior and lateral spine radiographs at various timepoints. Outcome variables were assessed based on preoperative Lenke Classification and included: deformity measures, complications, surgical revisions, and postoperative success. Results The mean age at the time of instrumentation was 13.4 ± 1.3 years, with an average preoperative Sanders Stage of 4.6 ± 1.4. A significant reduction in preoperative deformities was observed at most postoperative timepoints. A perioperative complication was observed in three patients and surgical revision was required in another four patients. A suspected broken tether was observed in sixteen patients, most of which occurred at the apex of the lumbar deformity. Only one patient required surgical revision due to a suspected broken tether. We observed an overall success rate of 57%, regardless of Lenke Classification. Conclusions These data indicate that VBT can successfully correct TL deformity patterns in 57% of patients without an increase in the rate of perioperative complications, suspected broken tethers, or surgical revisions.

Purpose The purpose of the study was to evaluate the effect of skeletal age and lesion size, location, and grade on the success of nonoperative treatment for juvenile osteochondritis dissecans (OCD). It is hypothesized that skeletal maturity, including a combination of maturation phenotypes, correlates with nonoperative lesion healing. Methods The clinical and radiographic data on 52 patients aged 7–20 years treated for OCD of the distal femur between 2010 and 2019 were retrospectively reviewed. Knee radiographs were assessed for number of lesions present and lesion location, size, and stage. Assessments of skeletal maturation were performed on all antero-posterior knee radiographs using the Roche, Wainer, and Thissen (RWT) method. Patients were categorized as healed if they demonstrated no pain on clinical examination. The relationship between skeletal maturity and nonoperative lesion healing was determined using Spearman rank correlations on available variables. Results Neither chronological nor skeletal age was associated with surgical status (Rho = 0.03, n.s., and Rho = 0.13, n.s., respectively) or the healing status of nonoperatively treated OCD lesions (Rho = 0.44, n.s., and Rho = 0.03, n.s., respectively). Epiphyseal fusion status of the distal femoral physis was moderately correlated with nonoperative healing, but was not statistically significant (lateral femoral physis: Rho = 0.43, p  = 0.05; medial femoral physis: Rho = 0.43, n.s.). Lesion length correlated with surgical status (Rho = − 0.38, p  = 0.009). Conclusion The extent of fusion of the distal femoral physis (multi-stage grading) may be more strongly correlated with nonoperative healing than other markers of skeletal maturity or chronological age. Clinicians can use this as an additional radiographic sign when considering nonoperative treatment for juvenile OCD lesions in the distal femur. OCD lesion length and physeal fusion status appear to be more important for healing than patient age.

PurposeVertebral body tethering (VBT) has been reported as a safe and effective non-fusion surgical technique for the treatment of adolescent idiopathic scoliosis, but the postoperative health of the bone and soft tissues of the spine following instrumentation remains unknown. We aimed to evaluate pathoanatomy and degenerative changes of the spine in adolescent idiopathic scoliosis patients both prior to and two years following VBT. MethodsWe prospectively enrolled nine patients who underwent VBT for the treatment of progressive adolescent idiopathic scoliosis. All patients received preoperative and two-year postoperative magnetic resonance imaging of their spine; images were assessed for pathoanatomy (e.g. nucleus pulposus positioning and muscle atrophy) and degenerative changes (e.g. Schmorl nodes, endplate oedema, disc degeneration, and osteoarthritis) at each vertebral level between T1 and S1. ResultsFour patients (44%) exhibited a shift of the nucleus pulposus from an eccentric position at baseline towards midline at three or more levels, most of which were in the tethered region. Tethering did not affect preexisting fatty atrophy of multifidus. No patients exhibited postoperative Schmorl nodes, endplate oedema, or disc degeneration in either the tethered or untethered regions. Four patients (44%) presented with mild facet osteoarthritis in the lower lumbar spine, which did not change postoperatively. One patient developed moderate facet osteoarthritis at L5-S1.ConclusionsThese preliminary data indicate that VBT may not result in significant degenerative changes in either the intervertebral discs or the posterior facets two years following instrumentation.

PurposeLittle is known about the perioperative characteristics associated with a posterior spinal fusion (PSF) in adolescent idiopathic scoliosis patients previously treated with vertebral body tethering (VBT). We aimed to determine if operative time, estimated blood loss, postoperative length of stay, instrumentation type, and implant density differed in patients that received a PSF (i.e., PSF-Only) or a PSF following a failed VBT (i.e., PSF–VBT).MethodsWe retrospectively assessed matched cohort data (PSF–VBT = 22; PSF-Only = 22) from two multi-center registries. We obtained: (1) operative time, (2) estimated blood loss, (3) postoperative length of stay, (4) instrumentation type, and (5) implant density. Theoretical fusion levels prior to the index procedure were obtained for PSF–VBT and compared to the actual levels fused.ResultsWe observed no difference in operative time, estimated blood loss, or postoperative length of stay. Instrumentation type was all-screw in PSF-Only and varied in PSF–VBT with nearly 25% of patients exhibiting a hybrid construct. There was no added benefit to removing anterior instrumentation prior to fusion; however, implant density was higher in PSF-Only (1.9 ± 0.2) than when compared to PSF–VBT (1.7 ± 0.3). An additional two levels were fused in 50% of PSF–VBT patients, most of which were added to the distal end of the construct.ConclusionsWe found that operative time, estimated blood loss, and postoperative length of stay were similar in both cohorts; however, the length of the fusion construct in PSF–VBT is likely to be two levels longer when a failed VBT is converted to a PSF.

Purpose Although several studies have reported on the application of biplanar stereo-radiographic technology in pediatric clinical practice, few have performed large-scale analyses. The manual extraction of these types of data is time-consuming, which often precludes physicians and scientists from effectively utilizing these valuable measurements. To fill the critical gap between clinical assessments and large-scale evidence-based research, we have addressed one of the primary hurdles in using data derived from these types of imaging modalities in pediatric clinical practice by developing an application to automatically transcribe and aggregate three-dimensional measurements in a manner that facilitates statistical analyses. Methods Mizzou 3D SPinE was developed using R software; the application, instructions, and process were beta tested with four separate testers. We compared 1309 manually compiled three-dimensional deformity measurements derived from thirty-five biplanar three-dimensional reconstructions (image sets) from ten pediatric patients to those derived from Mizzou 3D SPinE. We assessed the difference between manually entered values and extracted values using a Fisher’s exact test. Results Mizzou 3D SPinE significantly reduced the duration of data entry (95.8%) while retaining 100% accuracy. Manually compiled data resulted in an error rate of 1.58%, however, the magnitude of errors ranged from 5.97 to 2681.82% significantly increased the transcription accuracy ( p value < 0.0001) while also significantly reducing transcription time (0.33 vs. 8.08 min). Conclusion Mizzou 3D SPinE is an essential component in improving evidence-based patient care by allowing clinicians and scientists to quickly compile three-dimensional data at regular intervals in an automated, efficient manner without transcription errors.

All eleven-year-old girls want to do is play and be active like every other child her age. Yet, the ability to have a normal childhood for one of our patients became a concern when she and her parents noticed an abnormal lateral curvature in her spine, which was later diagnosed as adolescent idiopathic scoliosis. In February 2014, she presented with a 45° thoracic deformity with a high risk of progression. At that time, the gold standard for the treatment of her deformity was a posterior spinal fusion - a surgical treatment she nor her parents were interested in pursuing. After their initial appointment, her parents scoured the internet and discovered a new non-fusion surgical technique, known as vertebral body tethering, that might correct their daughter's deformity without the need for titanium rods in her spine. In April 2014, that same eleven-year-old girl underwent vertebral body tethering of her main thoracic deformity from T5 to L1 under the care and management of Dr. Daniel Hoernschemeyer, a pediatric orthopaedic surgeon, with the University of Missouri's Department of Orthopaedic Surgery. Today, she is a healthy young adult who is thinking more about prom than about her scoliosis.

Purpose The treatment of operative double major pediatric spinal deformities (e.g., Lenke 3 or 6) with bilateral vertebral body tethering (VBT) can be significantly more challenging when compared to other deformity patterns (e.g., Lenke 1) or treatment with a posterior spinal fusion. We aimed to identify preoperative and perioperative characteristics that were associated with successful postoperative outcomes in patients treated with both a thoracic and thoracolumbar (e.g., bilateral) tether. Methods We retrospectively assessed radiographic and clinical data from patients enrolled in a large multi-center study who had a minimum postoperative follow-up of two years. Standard radiographic parameters were extracted from standing spine and left hand-wrist radiographs at various timepoints. We classified patients based on their preoperative deformity pattern (Primary Thoracic [T P ] vs. Primary Thoracolumbar [TL P ]) and assessed: (1) deformity balance, (2) tilt of the transitional vertebra, and (3) postoperative success. Results We analyzed data from thirty-six patients (T P : 19 and TL P : 17). We observed no relationship between deformity balance at first erect and postoperative success ( p  = 0.354). Patients with a horizontal transitional vertebra at first erect were significantly ( p  = 0.001) more likely to exhibit a successful outcome when compared to those who exhibited a tilted transitional vertebra (83% vs. 62%). Patients who had TL P were also more likely to exhibit a successful outcome when compared to patients who exhibited T P (76% vs. 50%). Conclusion These data indicate that double major deformities can be successfully treated with VBT, particularly for those who exhibit TL P .

Opioid medications ate commonly prescribed after pediatric orthopaedic surgery, but there is a critical need to optimize prescribing practice. This study identifies socioeconomic characteristics, surgical characteristics, and patient reported psychological factors influencing postoperative opioid use in this population and found that post-operative opioid use in this pediatric orthopaedic population is multifactorial. Physicians should consider implementing protocols for initial opioid prescriptions to cover two to three days following common orthopaedic surgeries for most pediatric patients.

Introduction: Posterior spinal fusion (PSF) is the gold standard procedure for curve correction in Adolescent Idiopathic Scoliosis (AIS). Enhanced recovery protocols (ERPs) have been found to decrease pain and hospital length of stay (LOS) resulting in decreased total hospital charges. Methods: We identified all adolescent idiopathic scoliosis patients treated with a posterior spinal fusion at our children's hospital between 2015-2019. Length of stay, pain scores, and hospital direct costs were calculated to determine the pathway's efficacy. Results: Hospital LOS was reduced by 26% and post-op pain scores did not significantly change when using the Team Integrated Enhanced Recovery (TIGER) protocol (P<0.05). Total hospital costs decreased by 7.9%, daily contribution margins increased 7.9%, and daily net income increased 10.6% after TIGER protocol implementation. Conclusion: TIGER protocol resulted in decreased hospital LOS as well as direct costs for the hospital without increasing postoperative pain scores.

Achondroplasia is the most common skeletal dysplasia. This form of dwarfism is caused by a point mutation in the fibroblast growth factor receptor 3 (FGFR3) gene, leading to inhibition of endochondral ossification for these patients. This results in a normal trunk height but shortened limbs. The discoid meniscus may be an important associated finding to better understand the common complaints of leg pain for these patients. Although the incidence for a discoid meniscus is between 3% and 5% for the general population, it is unknown with achondroplasia. This case series includes 4 patients, with ages ranging from adolescence to early adulthood, with symptoms of knee pain that were not attributable to some of the more common findings seen in this patient population. Typically, patients with achondroplasia who experience knee pain are evaluated for more common and well-known etiologies such as genu varum, ligamentous instability, and neurogenic claudication. However, the authors propose that symptomatic discoid lateral meniscus should be added to the differential diagnosis for lower-extremity pain in the achondroplasia population. A thorough history and physical examination, in combination with magnetic resonance imaging, can aid in making the diagnosis. Treatment with arthroscopic debridement, saucerization of the meniscus, and repair for unstable injuries has yielded good outcomes for this patient population. [ Orthopedics. 2016; 39(3):e498–e503.]