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Purpose: Determine peri-operative risk factors predictive for prematurely stopping surgery prior to completion of deformity correction due to intra-operative neuromonitoring changes. Methods: A single institution retrospective review of adolescent idiopathic scoliosis (AIS) patients that underwent spinal fusion for curves greater than 70°. Cases aborted due to persistent loss of IONM were compared to completed cases. Demographic, radiographic, neurologic, and surgical information was reviewed. Results: There were 453 total cases. Nine (9/453: (2%)) cases were aborted due to persistent loss of IONM, and 4 (4/453; (0.88%)) awoke with a neurologic deficit. Comparing to the 444 completed cases, pre-operative risk factors associated with case abortion were older age (15.3 vs. 13.8 years; p= 0.02), sex (male) (66.7% vs. 20.3%, p= 0.004), and larger cobb angles (87.6° vs. 79.2°; p= 0.01). Being male increased the risk of case abortion: 7.9X. Conclusion: Pre-operative risk factors for AIS case abortion due to persistent loss of IOMN are older age, males, with larger Cobb angles. Intraoperative risk factors are combined ASF/PSF and increased index procedure EBL. Independent risk factors were sex (male) and ASF/PSF which increased the risk 7.9X and 10.3X, respectively.

Background: Neuromuscular and syndromic (NMS) scoliosis patients are at higher risk of acute surgical site infections (SSIs). Despite following POSNA’s endorsed consensus-based guidelines for SSI prevention, our institutional rates of acute SSI have varied dramatically. This variability drove simultaneous strategies to lower SSI rates: the creation of a preoperative Medical Optimization Clinic (MOC) and use of antibiotic-impregnated (Abx-I) calcium sulfate beads. Methods: Patients undergoing index PSF at a single institution between 2016 and 2022 were retrospectively reviewed. Patients with ≥ 2 risk factors were included: (1) BMI < 18.5 or > 25; (2) incontinence; (3) instrumentation to pelvis; (4) non-verbal; (5) GMFCS IV/V. SSI was defined as deep infection within 90 days. We compared patients who attended MOC and received Abx-I (MOC + Abx-I) to those receiving neither intervention (control) nor a single intervention. Results: 282 patients were included. The overall infection rate was 4.26%. Higher GMFCS (p= 0.0147), non-verbal status (p= 0.0048), and longer fusions (p= 0.0298) were independently associated with infection rate. Despite the MOC + Abx-I group having larger Cobb angles (88° ± 26°), higher GMFCS levels (4.5 ± 0.9), ASA class (3 ± 0.4), and more frequent instrumentation to the pelvis (85%), they had the lowest infection rate (2.13%) when compared to the control (4.2%) or single intervention groups (5.7%, 4.6%) (p= 0.9). Conclusion: The study examined the modern infection rate of NMS patients following the implementation of two interventions: MOC and Abx-I. Despite having higher risk factors (curves (88°), GMFCS level (4.5), ASA class (3), higher % instrumentation to the pelvis (85%)), the patients treated with both interventions demonstrated the lowest infection rate (2.13%).

Purpose: This study calculated the rates of Unplanned Return to the Operating Room (UPROR) in early-onset scoliosis patients who had no previous spine surgery and underwent Magnetically Controlled Growing Rod (MCGR) implantation. Methods: We reviewed surgical, radiographic, and UPROR outcomes for EOS patients treated with the MCGR implant < 12 years + 11 months of age, had complete preop/postop major curve measurements, and had complete MCGR details. Results: 376 patients underwent MCGR implantation at a mean age of 7.7 years (1.8–12.9). Diagnoses included 106 (28%) idiopathic, 84 (22%) syndromic, 153 (41%) neuromuscular, and 33 (9%) congenital. The mean preop-cobb was 76.7° (9–145°), and an immediate postop correction was 41% (0–84%). We found that 38% (142/376) of patients experienced an UPROR prior to the maximal actuator length being achieved. UPROR occurred at mean 2 years (3 days–5 years) after initial implantation. Of the 142 patients who experienced UPROR there were 148 complications that lead to an UPROR. The most common reason for UPROR was anchor (55/148: 37%) or MCGR implant related (33/148: 22%). Wound related (22/148:15%), Neuro related 4/148: 3%), and other (34/148: 23%) accounted for the remaining UPROR occurrences. Conclusion: In conclusion, the MCGR UPROR rate was 142/376 (38%) after an average of 2 years post implantation. At 2-year follow-up, only 20% of MCGR patients had experienced an UPROR. However, between 2 and 5 years, the development of an UPROR increased precipitously with only 39% of MCGR patients remaining UPROR free at 5 years post MCGR implantation. The most common reason for UPROR was related to anchor or MCGR implant-related complications. This information can be utilized to set realistic expectations about the need and timing of future surgical procedures with patients and their families.

Purpose: Magnetically controlled growing rods (MCGR) have become the dominant distraction-based implant for the treatment of early onset scoliosis (EOS). Recent studies, however, have demonstrated rising rates of implant failure beyond short-term follow-up. We sought to evaluate a single-center experience with MCGR for the treatment of EOS to define the rate of MCGR failure to lengthen, termed implant stall, over time. Methods: A single-center, retrospective review was conducted identifying children with EOS undergoing primary MCGR implantation. The primary endpoint was the occurrence of implant stalling, defined as a failure of the MCGR to lengthen on three consecutive attempted lengthening sessions with minimum of 2 years follow-up. Clinical and radiographic variables were collected and compared between lengthening and stalled MCGRs. A Kaplan–Meier survival analysis was conducted to assess implant stalling over time. Results: A total of 48 children met inclusion criteria (mean age 6.3 ± 1.8 years, 64.6% female). After a mean 56.9 months (range of 27 to 90 months)follow-up, 25 (48%) of children experienced implant stalling at a mean of 26.0 ± 14.1 months post-implantation. Kaplan–Meier survival analysis demonstrated that only 50% of MCGR continue to successfully lengthen at 2 years post-implantation, decreasing to < 20% at 4 years post-implantation. Conclusion: Only 50% of MCGR continue to successfully lengthen 2 years post-implantation, dropping dramatically to < 20% at 4 years, adding to the available knowledge regarding the long-term viability and cost-effectiveness of MCGR in the management of EOS. Further research is needed to validate these findings.

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For the past 35 years, we have used halo gravity traction (HGT) to treat patients with a wide variety of underlying spinal deformities. This clinical concepts review will cover the indications, contraindications, HGT technique details, and our preferred method of dynamic HGT. Emphasis will be placed on our protocol, and recommendations that help to avoid complications. HGT is best applied by a standardized team approach intending to medically and nutritionally optimize the patient in preparation for an operative or medical/interventional treatment that will maintain and improve on the deformity correction achieved while avoiding peri- and postoperative complications.

For the past 35 years, we have used halo gravity traction (HGT) to treat patients with a wide variety of underlying spinal deformities. This clinical concepts review will cover the indications, contraindications, HGT technique details, and our preferred method of dynamic HGT. Emphasis will be placed on our protocol, and recommendations that help to avoid complications. HGT is best applied by a standardized team approach intending to medically and nutritionally optimize the patient in preparation for an operative or medical/interventional treatment that will maintain and improve on the deformity correction achieved while avoiding peri- and postoperative complications.

The purpose of this study was to determine whether pelvic fracture pattern is associated with transfusion requirements or concomitant injuries in pediatric patients. This was a single-institution, retrospective review from 1970 to 2000. Pelvic ring injuries were classified using the Orthopaedic Trauma Association system. Injury Severity Scores were assigned. Ninety patients were included in this study. There were 27 A-type (30.0%), 51 B-type (56.7%), and 12 C-type (13.3%) injuries. Mean Injury Severity Scores were 8.1 for 61 A-type, 12.7 for 61 B-type, and 23.6 for 61 C-type fractures (The purpose of this study was to determine whether pelvic fracture pattern is associated with transfusion requirements or concomitant injuries in pediatric patients. This was a single-institution, retrospective review from 1970 to 2000. Pelvic ring injuries were classified using the Orthopaedic Trauma Association system. Injury Severity Scores were assigned. Ninety patients were included in this study. There were 27 A-type (30.0%), 51 B-type (56.7%), and 12 C-type (13.3%) injuries. Mean Injury Severity Scores were 8.1 for 61 A-type, 12.7 for 61 B-type, and 23.6 for 61 C-type fractures (P<.0001). Transfusion was required for 14.8% of A-type, 18.4% of B-type, and 66.7% of C-type injuries (P=.0009). There was no significant association with the number of units transfused (P=.9614). Decreased pelvic ring fracture stability was associated with an increased need for blood transfusion, although not with the number of units. Pelvic ring fracture stability may be a marker of associated injuries. [Orthopedics. 2018; 41(5):e701–e704.]

Study Design: Retrospective case series. Background: Previous studies report that 5% to 17% of pedicle screws placed in children are malpositioned. Knowledge of the long-term effects of malpositioned screws is limited. We sought to further characterize risk factors for malpositioned pedicle screws in order to establish a more proactive role in limiting future complications. Objective: We undertook this study to answer the following: 1) Is the rate of freehand pedicle screw malpositioning higher in children with spinal deformity, particularly at the apical concavity? 2) At what vertebral levels do freehand pedicle screws have the highest rates of malpositioning? 3) In which direction (medial or lateral) do freehand pedicle wall violations occur most often? Methods: Incidental postoperative computed tomographic (CT) exams were retrospectively reviewed in 85 pediatric patients (605 screws) treated with posterior spinal fusion using freehand pedicle screw technique. Of the screws imaged, 355 were in patients without deformity and 250 in patients with deformity. Breaches were categorized as mild (&lt;2 mm), moderate (2–4 mm), or severe (>4 mm). Results: Screws in pediatric deformity patients were more frequently malpositioned by 2 mm or more than were screws in patients without deformity (26% vs. 19%, p =.02). In patients with deformity, no higher rate of screw malposition was detected at the apical region. Overall, the highest rates of severe screw malposition were between T3 and T8. Pedicle breaches were more commonly in a medial direction compared with lateral (74% vs. 26%, p &lt;.0001). However, severe breaches within the T3–T8 region were more often directed lateral than medial (92% vs. 8%, p =.0001). Conclusions: The clinical significance of asymptomatic pedicle screw breaches in children has not yet been determined. In this study, screws at the apical concavity were no more likely to be malpositioned than those at other sites. Efforts to reduce pedicle screw malposition would likely be most effective at the T3–T8 levels. Level of Evidence: Level IV, Therapeutic Study. See the Guidelines for Authors for a complete description of the levels of evidence.

Retrospective case series.

This study evaluated the complications associated with the treatment of clavicle fractures in adolescents. All cases of clavicle fractures were identified during an 8-year period between January 2005 and January 2013. During the study period, 153 clavicle fractures occurred in patients between the ages of 14 and 17 years who were treated at the authors’ center. Medical records and radiographs were reviewed to determine injury mechanism, fracture pattern, treatment, and complications. Injury severity was assessed as high, medium, and low. Patients with medial or distal metaphyseal fractures and intra-articular fractures were excluded. Of the 153 clavicle fractures, 23 (15.0%) were treated surgically. Compared with the fractures treated nonsurgically, the surgical fractures had greater shortening (mean, 2.0 vs 0.9 cm; This study evaluated the complications associated with the treatment of clavicle fractures in adolescents. All cases of clavicle fractures were identified during an 8-year period between January 2005 and January 2013. During the study period, 153 clavicle fractures occurred in patients between the ages of 14 and 17 years who were treated at the authors’ center. Medical records and radiographs were reviewed to determine injury mechanism, fracture pattern, treatment, and complications. Injury severity was assessed as high, medium, and low. Patients with medial or distal metaphyseal fractures and intra-articular fractures were excluded. Of the 153 clavicle fractures, 23 (15.0%) were treated surgically. Compared with the fractures treated nonsurgically, the surgical fractures had greater shortening (mean, 2.0 vs 0.9 cm; P<.001) and were more likely to be comminuted (65.2% vs 23.1%; P<.001). Complications occurred in 21.7% of fractures treated surgically, including refracture (n=2), implant removal for prominence (n=2), and nonunion with implant failure (n=1). One complication was associated with intramedullary nailing, whereas the other 4 complications occurred in clavicles treated with plate fixation. In the non-surgical group, no patients sustained a refracture or malunion who required delayed surgical intervention. Pediatric fellowship-trained orthopedic surgeons treated 78 displaced fractures, resulting in 8 (10.3%) surgeries. Nonpediatric orthopedic specialists treated 46 displaced fractures, 15 (32.6%) of which were treated surgically (P=.0035). [Orthopedics. 2015; 38(4):e287–e291.]

Study Design: Retrospective, comparative case series from the study group database. Objectives: The primary objective was to report the neurologic injury rate for rib-based distraction surgery and determine whether preoperative diagnosis affects this rate. The secondary objective was to describe these injuries and outcome. Summary of Background Data: Posterior distraction-based systems are commonly used to treat early-onset scoliosis. General complication rates for these surgeries are high; however, there are few reports in the literature on neurologic injury after rib-based distraction surgery. p ]MethodsThis was a retrospective review of the Children’s Spine Study Group database from 2004 to 2013. The researchers used the chi-square test to compare the distributions of proportions between diagnoses. Results: A total of 524 patients were identified and treated with rib-based distraction surgery. The preoperative diagnoses consisted of 222 congenital/structural, 163 neuromuscular, 63 syndromic, 67 idiopathic, and 9 unknown. There were 9 neurologic injuries (7 clinical and 2 neuromonitoring alerts) for a neurologic injury rate of 1.7%. Using the Classification for Early-Onset Scoliosis, 8 patients were classified as congenital and 1 as neuromuscular. The neurologic injury rate in the congenital curves group was 3.6% and was 0.34% in non-congenital curves (p =.005). The proportion of injured patients with an additional secondary diagnosis was 3.82%, compared with 0.82% patients with only a primary diagnosis (p =.01). Eight injuries occurred at initial implantation and 1 at revision surgery. Most were brachial plexus (n = 5) with no complete spinal cord injuries. Four patients required return to surgery and 1 needed intraoperative intervention. At 4.2 years’ follow-up, 7 of 9 patients had full resolution of symptoms and 2 patients had residual upper extremity weakness. p ]ConclusionsThe rate of neurologic injury for patients treated with rib-based distraction surgery was 1.7%. Most injuries occurred with congenital diagnoses and they were more likely in patients with additional secondary diagnoses. These injuries were predominantly to the brachial plexus and generally resolved.

Retrospective, comparative case series from the study group database.

Juvenile osteochondritis dissecans (OCD) lesions of the knee are a common cause of knee pain in skeletally immature patients.The authors sought to determine lesion healing rates, the risk factors associated with failure to heal, and the clinical outcomes for patients who underwent internal fixation for unstable OCD lesions. A retrospective review was conducted of all patients who underwent internal fixation of OCD lesions from 1999 to 2009. Using validated scoring systems, clinical outcome and functional activity were evaluated at the follow-up. The study group comprised 19 patients (20 knees). Mean patient age was 14.5 years (range, 12–17 years). Mean clinical follow-up was 7 years (range, 2–13 years). Mean radiographic follow-up was 2.5 years (range, 0.5–9 years). Fourteen (70%) lesions were grade 3 and 6 (30%) were grade 4. Eleven knees had lateral condyle lesions and 9 had medial lesions. Bioabsorbable fixation was used in 13 knees, metal fixation was used in 5 knees, and 2 knees were fixed with a combination of methods. Osseous integration was evident in 15 (75%) of 20 knees at final follow-up. The 5 unhealed lesions were lateral condylar lesions. Mean Tegner activity scores improved from 3.3 preoperatively to 5.6 at final follow-up. Mean Lysholm and International Knee Documentation Committee scores were 86.8 and 88.7, respectively, at final follow-up. Further operative intervention was required in 11 knees, with 50% of patients undergoing removal of hardware and 15% requiring subsequent osteochondral allograft transplantation. The authors recommend bioabsorbable fixation for symptomatic stable lesions and metal compression screws with staged removal for unstable lesions.

Slipped capital femoral epiphysis (SCFE) is a hip disorder of adolescence, which has the potential for profound implications into adulthood. SCFE patients are at risk of early joint degeneration and subsequent need for arthroplasty. The rate at which arthroplasty is required is not precisely known, but is estimated to be approximately 45 by 50 years after a slip. The femoral neck and shaft displace anteriorly and rotate externally relative to the femoral epiphysis, which remains fixed in the acetabulum. Stabilization of the physis is the goal of acute management. Despite such efforts, accelerated joint degeneration may occur over time. This progression is due to avascular necrosis, chondrolysis, or following years of femoroacetabular impingement. Total hip arthroplasty (THA) and total hip resurfacing (THR) are options for end-stage hip arthritis due to SCFE. THR is technically more challenging, with very limited ability to address deformity-related issues of impingement, decreased hip offset, and trochanteric malposition. THR, as in any metal on metal arthroplasty, may be associated with local metal sensitivity or systemic metal toxicity. Given the limited utility and potential risks, THR is currently not recommended in the majority of cases. THA, although historically demonstrating poor long-term implant performance in the young patient, has become a more reliable option recently. The potential benefits of THA are considerable, even for the young patient with end-stage hip degeneration. Certain cemented and many cementless stem designs show good long-term survival, as do current cementless cups. Advances in bearing surfaces promise to minimize wear and extend implant longevity. Ceramic on ceramic, metal on highly cross-linked polyethylene, and ceramic on highly cross-linked polyethylene bearing couples offer promise.

Recently, much attention has been focused on the prevention of arthritis after slipped capital femoral epiphysis SCFE. Little, however, is published on which subset of SCFE patients eventually require hip replacement, how soon arthroplasty is required, and the long-term outcomes after arthroplasty.

The children with congenital heart disease CHD have an increased risk of developing scoliosis. Many children with CHD may benefit from surgical intervention for scoliosis. However, there is uncertainty about the safety of spinal fusion in children with heart disease. The purpose of this study is to assess whether spinal fusion is safe and effective for children who have CHD.

Motocross is a nationally organized sport that is growing in popularity. The distribution and severity of motocross injuries in the pediatric population is not known. We hypothesize a high rate of musculoskeletal injuries requiring hospitalization andor surgical intervention.

To describe our experience with surgical intervention for symptomatic intraarticular vascular malformations of the knee in patients with peripheral vascular malformations including Klippel-Trénaunay syndrome (KTS).

Scheuermann's kyphosis is a condition characterized by increased posterior rounding of the thoracic spine in association with structural deformity of the vertebral elements. Currently, there is debate over whether anterior procedures are necessary in the surgical treatment of Scheuermann's kyphosis.