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Purpose Early onset scoliosis (EOS) is defined as spinal curvature affecting children below 10 years of age. Non-operative treatment can consist of casting and bracing. When curvature progresses despite these treatments, operative intervention is indicated. Traditional growing rods (TGR) have been a mainstay of treatment. Unfortunately, TGR’s require planned return to the operating room every 6–9 months. Magnetic controlled growing rods (MCGR) ideally provide curve correction and allow the spine to grow without frequent surgeries. However, the ability to correct and maintain correction after MCGR has not been well-characterized. The purpose of this study is to evaluate maintenance of curve correction in patients treated primarily with MCGR and analyze the rate of complications including unplanned return to the operating room (UPROR). Methods 24 patients with EOS were retrospectively reviewed. These patients were subdivided into 4 subcategories: congenital, idiopathic, neuromuscular (NMS), and syndromic. The major curve correction (%) and T1–S1 distance were assessed utilizing scoliosis plain film radiographs over time. Complications and return to the operating room for any reason were recorded. Patients were followed until conversion to posterior spinal fusion (PSF) or most recent lengthening of MCGR. Results There were 11 male and 13 female patients averaging 8 years at the time of index surgery. The average preoperative curve angle was 61.1°. Initial curve correction with MCGR obtained at the index procedure was 46.2%, reducing the mean curve angle to 32.7° ( p  < 0.05). Curve correction at a mean 6.2 years (2.4–7.4) follow-up was 36.1°, 40.9% curve correction. 75% of patients underwent conversion to PSF during the study period 4.8 years (2.4–7.0) after initial MCGR surgery. 15% of patients were still undergoing MCGR lengthening after 6.1 years. 54.2% of patients had at least one UPROR. Conclusions For patients with EOS with curve progression, MCGRs can maintain curve correction well after 2 years. Furthermore, MCGR allowed patients to grow over time to safely delay timing to definitive fusion. On average, patients underwent conversion to PSF after 4.7 years at an average age of 13.5. Although the complication rate in the first 2 years is relatively low, 54.2% of patients underwent an UPROR. As the use of MCGR increases, surgeons should be aware of possible complications associated with this technology and counsel patients accordingly. Further research is needed to continue to evaluate the efficacy and safety of MCGR in this challenging patient population.

Adolescent idiopathic scoliosis (AIS) is associated with decreased respiratory quality of life and impaired diaphragm function. Recent hyperpolarized helium (HHe) MRI studies show alveolarization continues throughout adolescence, and mechanical forces are known to impact alveolarization. We therefore hypothesized that patients with AIS would have alterations in alveolar size, alveolar number, or alveolar septal dimensions compared to adolescents without AIS, and that posterior spinal fusion (PSF) might reverse these differences. We conducted a prospective observational trial using HHe MRI to test for changes in alveolar microstructure in control and AIS subjects at baseline and one year. After obtaining written informed consent from subjects' legal guardians and assent from the subjects, we performed HHe and proton MRI in 14 AIS and 16 control subjects aged 8-21 years. The mean age of control subjects (12.9 years) was significantly less than AIS (14.9 years, p = 0.003). At baseline, there were no significant differences in alveolar size, number, or alveolar duct morphometry between AIS and control subjects or between the concave (compressed) and convex (expanded) lungs of AIS subjects. At one year after PSF AIS subjects had an increase in alveolar density in the formerly convex lung (p = 0.05), likely reflecting a change in thoracic anatomy, but there were no other significant changes in lung microstructure. Modeling of alveolar size over time demonstrated similar rates of alveolar growth in control and AIS subjects in both right and left lungs pre- and post-PSF. Although this study suffered from poor age-matching, we found no evidence that AIS or PSF impacts lung microstructure. Trial registration: Clinical trial registration number NCT03539770.

Study Design: Retrospective cohort study.Purpose: To determine whether implant density impact three-dimensional deformity correction in posterior spinal fusion (PSF) without Ponte osteotomies (POs) for patients with Lenke 1 and 2 adolescent idiopathic scoliosis (AIS).Overview of Literature: Currently, the optimal pedicle screw (PS) density for flexible moderate-sized thoracic AIS curve correction is still controversial. There are limited data regarding the impact of implant density on three-dimensional correction in PSF without the use of PO for thoracic AIS surgery.Methods: A database of patients with AIS with Lenke 1 and 2 curves treated with PSF without PO and instrumented with PSs and ≥2-year follow-up was reviewed. The preoperative, immediate, and final follow-up postoperative radiographs were analyzed. The correlation between PS density and the following factors were determined: major curve correction (MCC), correction index (CI; MCC/curve flexibility), kyphosis angle change, and rib index (RI) correction. Then, patients were divided into low-density (LD) and high-density (HD) groups according to mean PS density for the entire cohort (1.5 PS per level). Demographics and radiographic and clinical outcomes were compared between groups.Results: The study included 99 patients with Lenke 1 and 23 patients with Lenke 2 AIS. The average MCC was 67.2%. There was no correlation between screw density and these parameters: MCC (r=0.10, p=0.26), CI (r=0.16, p=0.07), change in T2–T12 kyphosis angle (r=−0.13, p=0.14), and RI correction (r=−0.09, p=0.37). Demographic and preoperative radiographic parameters were similar between the LD and HD groups. At the latest follow-up, there were no differences between the two groups in regard to MCC, CI, change in T2–T12 kyphosis angle, RI correction, and Scoliosis Research Society-30 scores (all p>0.05).Conclusions: This study revealed no significant correlation between screw density and curve correction in any planes. HD construct may not provide better deformity correction in patients with flexible and moderate thoracic AIS undergoing PSF without PO.

ObjectiveTo quantitatively determine the relationship between the contouring of the magnetically controlled growing rods (MCGR), their expansion capacity and the risk of developing proximal junctional kyphosis in early onset scoliosis (EOS).Summary of background dataMCGRs allow gradual expansion and correction of the spinal deformity in EOS while reducing the need for repeated surgeries. As the expansion of the MCGRs is controlled externally, several factors can impact the discrepancy between the intended and actual expansions of the rods. The expansion capacity of the growing rods as a function of the expanded length has been tested in experimental setups; however, no study has evaluated the role of contouring of the MCGRs on its function and long-term surgical outcome.MethodsA total of 25 EOS patients, a total of 48 MCGRs, with right thoracic curves, were studied retrospectively. All patients had two view spinal radiographs at pre-operative, after MCGR implantation, and after 6 lengthening visits. The first post-operative radiographs were used to calculate the 3D contour of the MCGR at the proximal end. 2D ultrasound images before and after lengthening visits were used to measure the rod lengthening at each visit. The relationship between the increase in the rod length and rod curvature was determined. Finally, the rod curvature was correlated to the changes in proximal junctional kyphosis (PJK) angle between the pre-operative and the most recent follow-up, i.e., after 6 visits.ResultsThe average rod 3D angle at the proximal end was 13.5° ± 9.7° [0°-37.2°]. The overall increased length after six lengthening visits for the rod at the concave side was 18.8 mm and at the convex side was 16.9 mm. 62% of the patients with a contoured rod at the proximal end developed a PJK exceeding 10° whereas in patients with a straight rod PJK occurred in 9.1%.ConclusionsContouring the MCGR impacts both the mechanics of the rod expansion and the prevalence of PJK in EOS patient population.

Purpose Body casts have a long history in the treatment of spinal deformity. Currently the use of body casts is limited to early onset scoliosis. Here, we aim to provide a brief narrative of the evolution of cast application for the management of spinal deformity. Methods A history of cast application is provided with a brief review of the orthopedic literature. The current indications for cast application and the authors’ preferred technique are described. Results Serial casting is an effective treatment method for early onset scoliosis. It may be definitive for most idiopathic curves or used to delay surgical intervention in more severe idiopathic, syndromic and even congenital curves. Conclusions Surgeons who treat children with early onset scoliosis should familiarize themselves with serial cast application techniques.

Progressive spinal curvature in juvenile idiopathic scoliosis (JIS) is challenging to treat. When conservative management fails, treatments include growing rods (GRs) or posterior spinal fusion (PSF). The purpose of this study is to compare the patient characteristics and outcomes of GR and PSF treatment of JIS. We performed a retrospective review of demographic, radiographic, and surgical data for all JIS patients requiring surgical treatment between 2012 and 2020. Patients who underwent any GR treatment were compared to PSF patients. A total of 36 patients (13 GR, 23 PSF) were reviewed. PSF patients had a larger pre-operative spinal height (p = 0.002), but similar pre-operative major curve magnitudes (p = 0.558). PSF treatment resulted in similar change in the T1-S1 length (p = 0.002), but a greater correction of the curve magnitude (p < 0.055) compared to GR patients. Eight patients initially treated with GRs later underwent definitive PSF treatment. This subset of patients had a greater spinal height before PSF (p = 0.006), but similar immediate post-PSF T1-S1 lengths (p = 0.437) and smaller changes in spinal height from PSF (p = 0.020) than primary PSF patients. At final follow-up, patients who underwent primary PSF versus PSF after GR had similar spinal heights (p = 0.842). The surgical intervention chosen to manage progressive JIS often differs based on patient characteristics. While this choice may impact immediate outcomes, the outcomes at final follow up are similar.

Purpose This purpose of this study was to assess the impact of patient and implant characteristics on LIV selection in ambulatory children with EOS and to assess the relationship between the touched vertebrae (TV), the last substantially touched vertebrae (LSTV), the stable vertebrae (SV), the sagittal stable vertebrae (SSV), and the LIV. Methods A multicenter pediatric spine database was queried for patients ages 2–10 years treated by growth friendly instrumentation with at least 2-year follow up. The relationship between the LIV and preoperative spinal height, curve magnitude, and implant type were assessed. The relationships between the TV, LSTV, SV, SSV, and the LIV were also evaluated. Results Overall, 281 patients met inclusion criteria. The LIV was at L3 or below in most patients with a lumbar LIV: L1 (9.2%), L2 (20.2%), L3 (40.9%), L4 (29.5%). Smaller T1 − T12 length was associated with more caudal LIV selection ( p  = 0.001). Larger curve magnitudes were similarly associated with more caudal LIV selection ( p  = < 0.0001). Implant type was not associated with LIV selection ( p  = 0.32) including MCGR actuator length ( p  = 0.829). The LIV was caudal to the TV in 78% of patients with a TV at L2 or above compared to only 17% of patients with a TV at L3 or below ( p  < 0.0001). Conclusions Most EOS patients have an LIV of L3 or below and display TV–LIV and LSTV–LIV incongruence. These findings suggest that at the end of treatment, EOS patients rarely have the potential for selective thoracic fusion. Further work is necessary to assess the potential for a more selective approach to LIV selection in EOS. Level of evidence III.

Reasons for the lack of treatment regimen adherence (ie, the extent to which patients follow healthcare provider-prescribed instructions1) are likely multifactorial, including health status, belief systems, social supports, economic factors, and regimen complexity.1 In chronic diseases such as pediatric asthma, socioeconomic status (SES) has been associated with readmission and has been thought to represent a marker of adherence to chronic disease management.2 The role of SES in adherence to acute processes is not well understood. All-or-nothing adherence was measured based on self-report.6 The patient variables we considered included age at surgery, sex, race, and insurance, obtained from the electronic medical record (EMR), and number of complex chronic condition (CCC) categories obtained from the Pediatric Health Information System.7 We excluded technology dependence and other congenital or genetic defects from the CCC categorization because ~90% of included patients were positive for 1 or both, presumably due to a fusion procedure and/or scoliosis diagnosis (data not shown). Factors significant for an increased risk of protocol nonadherence in the final multivariate model included any previous spinal surgery, fewer months since protocol initiation, and high census-tract percentage of individuals in poverty (Table 1).TABLE 1 Univariate Analysis of Demographic and Clinical Factors by Protocol Adherence Groups and Multivariate Analysis of Factors Associated with Protocol Nonadherence Univariate Analysisa Multivariate Analysis Variable Adherent (N=302), No. (%) Non-Adherent (N=48), No. (%) P Value Adjusted OR 95% CI P Value Patient characteristics Age at surgery, y±SD 13.4±3.8 11.7±4.9 <.01 Sex .86 Female 191 (63) 31 (65) Male 111 (37) 17 (35) Race .60 White 266 (88) 41 (85) Non-white 36 (12) 7 (15) Insurance type .31 Public 97 (32) 19 (40) Private 205 (68) 29 (60) No. complex chronic condition categoriesb .06 0 151 (50) 17 (35) 1 71 (24) 15 (31) ≥2 80 (26) 16 (33) Clinical characteristics Scoliosis diagnosis .03 Idiopathic 158 (52) 17 (35) Neuromuscular 70 (23) 17 (35) Otherc 74 (25) 14 (29) Surgical history .02 Any previous spinal surgeryd 38 (13) 17 (35) 3.2 1.7–6.2 <.01 Any previous nonspinal surgery 79 (26) 10 (21) 1.1 0.6–1.8 .82 No previous surgery 185 (61) 21 (44) Reference Months since protocol initiation, mo±SD 12.9±8.2 9.8±8.0 .02 0.95 0.92–0.98 <.01 No. assigned protocol tasks <.01 ≥4e 83 (27) 15 (31) 1.03 0.76–1.41 .84 3 200 (66) 23 (48) 0.44 0.29–0.67 <.01 2 19 (6) 10 (21) Reference Socioeconomic status Percentage individuals below poverty level .06 Highf 98 (32) 20 (42) 2.2 1.5–3.2 <.01 Medium 99 (33) 18 (37) 1.6 0.9–2.9 .08 Low 105 (35) 10 (21) Reference NOTE. OR, odds ratio; CI, confidence interval; SD, standard deviation. a Data are shown as mean±SD or number (%). b Excluding technology dependence and other congenital or genetic defect. c Includes congenital, syndromic, and other diagnoses d For multivariate analysis, comparing any previous spine surgery versus any previous non-spinal surgery: adjusted OR, 3.0; 95% CI, 1.3–7.1; P=.01. e For multivariate analysis, comparing ≥4 vs 3 assigned tasks: OR, 2.4; 95% CI, 2.0–2.9; P<.01. f For multivariate analysis, comparing high vs medium percentage individuals below poverty level: adjusted OR, 1.3; 95% CI, 1.0–1.7; P=.03.

Purpose Appropriately measuring and classifying surgical complications is a critical component of research in vulnerable populations, including children with early-onset scoliosis (EOS). The purpose of this study was to assess the inter- and intra-rater reliability of a modified Clavien–Dindo-Sink system (CDS) classification system for EOS patients among a group of pediatric spinal deformity surgeons. Methods Thirty case scenarios were developed and presented to experienced surgeons in an international spine study group. For each case, surgeons were asked to select a level of severity based on the modified CDS system to assess inter-rater reliability. The survey was administered on two occasions to allow for assessment of intra-rater reliability. Weighted Kappa values were calculated, with 0.61 to 0.80 considered substantial agreement and 0.81 to 1.00 considered nearly perfect agreement. Results 11/12 (91.7%) surgeons completed the first-round survey and 8/12 (66.7%) completed the second. Inter-observer weighted kappa values for the first and second survey were 0.75 [95% CI 0.56–0.94], indicating substantial agreement, and 0.84 [95% CI 0.70–0.98], indicating nearly perfect agreement, respectively. Intra-observer reliability was 0.86 (range 0.74–0.95) between the first and second surveys, indicating nearly perfect agreement . Conclusion The modified CDS classification system demonstrated substantial to nearly perfect agreement between and within observers for the evaluation of complications following the surgical treatment of EOS patients. Adoption of this reliable classification system as a standard for reporting complications in EOS patients can be a valuable tool for future research endeavors, as we seek to ultimately improve surgical practices and patient outcomes. Level of evidence Level V.

Current inverse dynamics models of the upper extremity (UE) are limited for the measurement of Lofstrand crutch-assisted gait. The objective of this study is to develop, validate, and demonstrate a three-dimensional (3-D) UE motion assessment system to quantify crutch-assisted gait in children. We propose a novel 3-D dynamic model of the UEs and crutches for quantification of joint motions, forces, and moments during Lofstrand crutch-assisted gait. The model is composed of the upper body (i.e., thorax, upper arms, forearms, and hands) and Lofstrand crutches to determine joint dynamics of the thorax, shoulders, elbows, wrists, and crutches. The model was evaluated and applied to a pediatric subject with myelomeningocele (MM) to demonstrate its effectiveness in the characterization of crutch gait during multiple walking patterns. The model quantified UE dynamics during reciprocal and swing-through crutch-assisted gait patterns. Joint motions and forces were greater during swing-through gait than reciprocal gait. The model is suitable for further application to pediatric crutch-user populations. This study has potential for improving the understanding of the biomechanics of crutch-assisted gait and may impact clinical intervention strategies and therapeutic planning of ambulation.