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Purpose: This study evaluates the relationship between existing radiographic measurements of shoulder asymmetry with novel surface topographic (ST) measurements, hypothesizing that these relationships will be weak., Methods: Data were gathered from a prospectively collected registry of patients who underwent ST scanning at a single tertiary care institution. Inclusion criteria were diagnosis of juvenile or adolescent idiopathic scoliosis, age 11-21, same-day ST and EOS radiographic evaluation. Twelve radiographic variables that evaluate shoulder height were measured, as well as curve magnitudes and vertebral axial rotation. ST data were collected using the 3dMDbody scanning system. Three ST measurements of shoulder symmetry were evaluated: ST-based AC angle (the angle between a line made between the surface of the AC joints and a line parallel to the ground), Shoulder Normal Asymmetry angle (the angle between the mirrored normals to the planes defined by the jugular notch, vertebral prominence, and AC joint), and Shoulder Volume Asymmetry Index (difference in volumes between the right and left shoulder). Univariate, followed by a stepwise multivariate linear regression was performed to evaluate the correlations of the radiographic measurements to the ST-based measurements. Correlation categories: weak (x < 0.4), moderate (0.4 ≤ x < 0.6), strong (0.6 ≤ x < 0.8), and very strong (x ≥ 0.8)., Results: 141 patients with idiopathic scoliosis were evaluated (65.2% female, mean age 15.1 years, mean BMI 20.5 kg/m 2 , with mean maximum curve 44.7 degrees). ST-based AC angle had moderate-to-strong correlations with several radiographic measurements, while ST-based Shoulder Normal Asymmetry angle and Shoulder Volume Asymmetry Index had weak or no correlation with individual radiographic measures. Multivariate models created using a combination of radiographic variables demonstrated a strongly positive correlation between radiographic variables and ST-based AC angle (R = 0.678) and moderately positive correlations with ST-based Shoulder Normal Asymmetry Angle (R = 0.488), and ST-based Shoulder Volume Asymmetry Index (R = 0.514)., Conclusion: Radiographic measurements may be acceptable stand-ins for two-dimensional ST measurements such as AC angle, but not for more complex shoulder measurements based on three dimensions. This study demonstrates the inadequacy with which radiographic assessments evaluate shoulder height asymmetry and highlights the use of ST measurements., (© 2024. The Author(s), under exclusive licence to Scoliosis Research Society.)

Competing Interests: Competing interests: None declared.

Background: Various measurements are used to evaluate hindfoot alignment and determine appropriate treatment, though the best tool is not known. Few studies have examined the relationship between these measurements in pediatric patients. This study sought to compare Hindfoot Moment Arm (HMA) and Hindfoot Alignment Angle (HAA) in evaluation of pediatric hindfoot deformity., Methods: This was a retrospective cohort study of pediatric patients by age: school-aged (7 to 10 years old), preadolescents (11 to 14), and adolescents (15 to 18). A total of 10 males and 10 females were randomly selected for each cohort from patients with available hindfoot radiographs. HMA and HAA were measured by 2 independent reviewers. Pearson correlation of HMA and HAA was performed by age cohort. Multivariable linear regression was used to investigate the association of HMA and HAA adjusting for age, sex, height, and weight., Results: Sixty participants were analyzed. Interrater reliability was found to be excellent for HMA and HAA (ICC=0.996 and 0.992, respectively). HMA was 8.7±9.4 mm in school age, 5.7±6.7 mm in preadolescents, and 2.5±13.0 mm among adolescents (P=0.153). HAA was 6.3±9.7 degrees in school age, 6.7±8.6 degrees in preadolescents, and 6.0±14.5 degrees among adolescents (P=0.983). The Pearson correlation coefficient was 0.78 (CI: 0.51-0.91) for school-aged, 0.92 (CI: 0.81-0.97) for preadolescents, and 0.86 (CI: 0.67-0.94) for adolescents. Using multivariable regression, each degree increase in HAA, increased HMA by 0.77 mm. Age, height, and weight were not found to be independent predictors of HMA., Conclusions: HMA and HAA were both found to be reliable measurements across all age cohorts. When comparing across age cohorts, neither HMA nor HAA differed significantly (P=0.153 and 0.983, respectively). Furthermore, Pearson correlation demonstrated a linear relationship between HMA and HAA. When evaluating hindfoot deformity, surgeons may assess hindfoot alignment via either HMA or HAA regardless of patient age. The authors support the use of HMA for clinical and academic purposes as HMA is considerably simpler to measure., Level of Evidence: Level III., Competing Interests: D.N.M. is a Vice president of New York Radiology Society. R.F.W. is a Paid consultant of SpineGuard, owns stock, and Medtronic Spine; Editorial board member for Spine Deformity; and Editorial board member for the Journal of Children’s Orthopaedics. S.J.E. is a paid consultant of Stryker, Paragon 28, Vilex, and Medartis; a Managerial Board member of FAI/FAO; and treasurer of AOFAS. The other authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Historically, pedicle screw accuracy measurements have relied on CT and expert visual assessment of the position of pedicle screws relative to preoperative plans. Proper pedicle screw placement is necessary to avoid complications, cost and morbidity of revision procedures. The aim of this study was to determine accuracy and precision of pedicle screw insertion via a novel computer vision algorithm using preoperative and postoperative computed tomography (CT) scans. Three cadaveric specimens were utilized. Screw placement planning on preoperative CT was performed according to standard clinical practice. Two experienced surgeons performed bilateral T2-L4 instrumentation using robotic-assisted navigation. Postoperative CT scans of the instrumented levels were obtained. Automated segmentation and computer vision techniques were employed to align each preoperative vertebra with its postoperative counterpart and then compare screw positions along all three axes. Registration accuracy was assessed by preoperatively embedding spherical markers (tantalum beads) to measure discrepancies in landmark alignment. Eighty-eight pedicle screws were placed in 3 cadavers' spines. Automated registrations between pre- and postoperative CT achieved sub-voxel accuracy. For the screw tip and tail, the mean three-dimensional errors were 1.67 mm and 1.78 mm, respectively. Mean angular deviation of screw axes from plan was 1.58°. For screw mid-pedicular accuracy, mean absolute error in the medial-lateral and superior-inferior directions were 0.75 mm and 0.60 mm, respectively. This study introduces automated algorithms for determining accuracy and precision of planned pedicle screws. Our accuracy outcomes are comparable or superior to recent robotic-assisted in vivo and cadaver studies. This computerized workflow establishes a standardized protocol for assessing pedicle screw placement accuracy and precision and provides detailed 3D translational and angular accuracy and precision for baseline comparison., (© 2024. The Author(s).)

Purpose: This study evaluates the intraoperative and short-term complications associated with robotically assisted pedicle screw placement in pediatric posterior spinal fusion (PSF) from three surgeons at two different institutions., Methods: We retrospectively reviewed 334 pediatric patients who underwent PSF with robotic-assisted navigation at 2 institutions over 3 years (2020-2022). Five thousand seventy robotically placed screws were evaluated. Data collection focused on intraoperative and early postoperative complications with minimum 30-day follow-up. Patients undergoing revision procedures were excluded., Results: Intraoperative complications included 1 durotomy, 6 patients with neuromonitoring alerts not related to screw placement, and 62 screws (1.2%) with documented pedicle breaches, all of which were revised at time of surgery. By quartile, pedicle breaches statistically declined from first quartile to fourth quartile (1.8% vs. 0.56%, p < 0.05). No breach was associated with neuromonitoring changes or neurological sequelae. No spinal cord or vascular injuries occurred. Seventeen postoperative complications occurred in eleven (3.3%) of patients. There were five (1.5%) patients with unplanned return to the operating room., Conclusion: Robotically assisted pedicle screw placement was safely and reliably performed on pediatric spinal deformity by three surgeons across two centers, demonstrating an acceptable safety profile and low incidence of unplanned return to the operating room., (© 2024. The Author(s), under exclusive licence to Scoliosis Research Society.)

Introduction: Early-onset scoliosis (EOS) refers to spinal curvature exceeding ten degrees in the coronal plane in patients under 10 years old. When non-operative management fails to control the curvature, surgical intervention may be indicated. In younger patients, growth-friendly instrumentation may be necessary to allow for continued spinal growth while controlling the curve, which includes magnetically control growing rods (MCGR). This paper is the first description of robotic-assisted navigation in a patient with EOS undergoing MCGR insertion with the minimally invasive placement of pedicle screws. The benefits of a trans-muscular robotic-assisted technique include minimizing the risk of autofusion of the non-instrumented area., Case Report: The 7-year-old female patient with vertebral, anal, cardiac, tracheoesophageal, renal, esophageal, and limb anomalies and a complex medical history, presented with progressive, early-onset syndromic scoliosis. She underwent various surgeries in infancy for imperforate anus, colonic atresia, and malrotation, among other issues. Over time her curve worsened, reaching 71° by age seven. Insertion of MCGR was recommended and successfully performed using robotic-assisted navigation for placement of pedicle screws. Immediately post-operatively, the patients' major curve improved to 15°. She was discharged home without complications on post-operative day 4., Conclusion: This case study exemplifies the success and safety of growth-friendly instrumentation using robotic-assisted navigation for the placement of pedicle screws., Competing Interests: Conflict of Interest: Nil, (Copyright: © Indian Orthopaedic Research Group.)

Objective: Severe spinal deformity results in restrictive pulmonary disease from thoracic distortions and lung-volume limitations. Though spirometry and body plethysmography are widely accepted tests for pulmonary function tests (PFTs), they are time-consuming and require patient compliance. This study investigates whether surface topographic [surface topography (ST)] measurements of body volume difference (BVD) and torso volume difference between maximum inhale and exhale correlate to values determined on PFTs., Methods: This study included patients with idiopathic scoliosis and thoracic/thoracolumbar curves ≥40 degrees. Patients received ST scans, clinical examinations, and EOS biplanar radiographs on the same day. PFTs were performed within 3 months of ST/radiographic analysis. Univariate linear regression analysis was used to examine relationships between BVD, PFT values, and mean curves., Results: Sixteen patients (14.6 ± 2.2 y, 69% females) with idiopathic scoliosis and mean thoracic/thoracolumbar curves of 62 degrees ± 15˚ degrees (45 degrees to 93 degrees) were assessed. BVD displayed statistically high-positive positive correlations with forced vital capacity ( R = 0.863, P < 0.0001), forced expiratory volume in 1 second ( R = 0.870, P < 0.001), vital capacity ( R = 0.802, P < 0.0001), and TLC ( R = 0.831, P < 0.0001. Torso volume difference showed similarly high positive correlations to forced vital capacity, forced expiratory volume in 1 second, vital capacity, and TLC, but not residual volume. No correlations emerged between the mean thoracic/thoracolumbar curve and BVD or PFT values., Conclusion: This study strongly endorses further investigation into ST scanning as an alternative to traditional PFTs for assessing pulmonary volumes. The noncontact and noninvasive nature of ST scanning presents a valuable alternative method for analyzing thoracic volume, particularly beneficial for patients unable to cooperate with standard PFTs., Level of Evidence: Level II-prognostic., Competing Interests: R.F.W. is a paid consultant of SpineGuard. R.H. is on the advisory board of Medtronic and Alphatec, and a paid consultant of Aspen Medical Products. H.J.H. is on the advisory board of Biomed Consulting. M.E.C. is a shareholder of Sustain Surgical. The remaining authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Retrospective case series., Objective: To characterize the change in angle of trunk rotation (ATR), axial vertebral rotation (AVR), and body surface rotation (BSR) in patients with adolescent idiopathic scoliosis (AIS) undergoing posterior spinal fusion (PSF) with en-bloc derotation across multiple postoperative visits., Summary of Background Data: Previous research has documented ATR, AVR, and BSR correction for AIS patients after surgery. However, there is a lack of evidence on the sustainability of this correction over time., Methods: This was a retrospective study from a single-center prospective surface topographic registry of patients with AIS, age 11-20 at time of surgery, who underwent PSF with en-bloc derotation. Patients with previous spine surgery were excluded. ATR was measured with a scoliometer, AVR through EOS radiographic imaging, and BSR via surface topographic scanning, Data collection occurred at: preoperative, six-week, three-month, six-month, one-year, and two-year postoperative visits. BSR and AVR were tracked at the preoperative apical vertebral level, and the level with maximum deformity, at each respective timepoint. Generalized estimating equations models were used for statistical analysis. Covariates included age, sex, and body mass index., Results: 49 patients (73.4% female, mean age 14.6±2.2 years, mean preoperative coronal curve angle 57.9°±8.5, and 67% major thoracic) were evaluated. ATR correction was significantly improved at all postoperative timepoints and there was no significant loss of correction. AVR Max and AVR Apex were significantly improved at all timepoints but there was a significant loss of correction for AVR Apex between the six-week and one-year visit (P=0.032). BSR Max achieved significant improvement at the three-month visit. BSR Apex was significantly improved at the three-month and one-year visit., Conclusion: ATR and AVR demonstrated significant axial plane correction at two-years postoperative in patients undergoing PSF for AIS. BSR did not maintain significant improvement by the two-year visit., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Pelvic fixation is commonly used in correcting pelvic obliquity in pediatric patients with neuromuscular scoliosis and in preserving stability in adult patients with lumbosacral spondylolisthesis or instances of traumatic or osteoporotic fracture. S2-alar-iliac screws are commonly used in this role and have been proposed to reduce implant prominence when compared to traditional pelvic fusion utilizing iliac screws. The aim of this technical note is to describe a technique for robotically navigated placement of S2-alar-iliac screws in pediatric patients with neuromuscular scoliosis, which (a) minimizes the significant exposure needed to identify a bony start point, (b) aids in instrumenting the irregular anatomy often found in patients with neuromuscular scoliosis, and (c) allows for greater precision than traditional open or fluoroscopic techniques. We present five cases that underwent posterior spinal fusion to the pelvis with this technique that demonstrate the safety and efficacy of this procedure., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Background: Genu valgum is a well-known feature of multiple hereditary exostoses (MHE). Though prior reports have demonstrated successful treatment with hemiepiphysiodesis, details regarding the correction rate and comparison to an idiopathic population are lacking. This study aimed to detail our institution's experience with guided growth of the knee in patients with MHE and compare this to an idiopathic population., Methods: All pediatric patients (age 18 and younger) with MHE who underwent lower extremity hemiepiphysiodesis at a tertiary care medical center between January 2016 and December 2022 were retrospectively reviewed. Preoperative and postoperative mechanical lateral distal femoral angle (mLDFA) and medial proximal tibial angle (MPTA, the primary outcomes) were measured in addition to mechanical axis deviation (MAD) and hip-knee-ankle angle (HKA). Patients were 1:2 matched based on age, sex, and physes instrumented to a cohort with idiopathic genu valgum., Results: A total of 21 extremities in 16 patients with MHE underwent hemiepiphysiodesis of the distal femur, proximal tibia, and/or distal tibia. The mean age at surgery was 11.7±2.2 years. Mean MAD corrected from zone 1.9±0.7 to -0.3±1.5, while mLDFA corrected from 83.4±2.9 to 91.7±5.2 degrees and MPTA corrected from 95.3±3.6 to 90.5±4.0 degrees in distal femurs and proximal tibias undergoing guided growth, respectively. Three extremities (14.3%) experienced overcorrection ≥5 degrees managed with observation. There were no differences in correction rates per month for mLDFA (0.54±0.34 vs. 0.51±0.29 degrees, P =0.738) or MPTA (0.31±0.26 vs. 0.50±0.59 degrees, P =0.453) between MHE and idiopathic groups. For 11 extremities in the MHE group with open physes at hardware removal, they experienced a mean recurrence of HKA of 4.0±3.4 degrees at 19-month follow-up., Conclusion: Hemiepiphysiodesis corrects lower extremity malalignment in patients with MHE at a similar rate compared with an idiopathic coronal plane deformity population. Rebound deformity of 4 degrees at 19 months after hardware removal in patients with remaining open growth plates should make surgeons conscious of the remaining growth potential when planning deformity correction., Level of Evidence: Level III., Competing Interests: D.W.G. has royalties in Arthrex Inc. and Pega Medical. D.W.G. is a consultant for Arthrex Inc. R.F.W. is a consultant for SpineGuard Co. And is on the editorial board for Children’s Orthopaedics and Spinal Deformity. E.R.D. is an Orthopediatrics consultant and an AAOS official spokesperson. The remaining authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The COVID-19 pandemic has affected healthcare worldwide since December 2019. We aimed to identify the effect of the COVID-19 pandemic on outpatient clinic and surgical volumes and peri-operative complications for pediatric spinal deformities patients., Methods: In this multi-center retrospective study, outpatient visits (in-person and virtual care) and pediatric spine surgeries volumes in four high-volume pediatric spine centers were compared between March and December 2019 and the same period in 2020. Peri-operative complications were collected and compared in the same periods. Descriptive statistics were calculated, and comparative analyses were performed., Results: During the 2020 study period, the outpatient visit (in-person and virtual care) volume decreased during local lockdown periods by 71% for new patients (p < 0.001) and 53% for returning patients (p = 0.03). Overall, for 2020, there was a 20% reduction in new patients (p = 0.001) and 21% decrease in returning patients (p < 0.001). During the pandemic, there was also 20% less overall surgical volume of adolescent idiopathic scoliosis (AIS) patients undergoing primary posterior spinal fusion, with a 70% reduction during lockdown times (p < 0.001). Complication rate and profile were similar between periods., Conclusion: There was a significant decrease in outpatient pediatric spine outpatient visits, particularly new patients, which may increase the proportion of pediatric patients with spinal deformities that present late, meeting surgical indication. This, in combination with the reduction in surgical volume of AIS over the first year of the pandemic, could result in an extended waitlist for surgeries during years to come. Complication rate was similar for both periods, suggesting it is safe to continue elective pediatric spine surgery even in a time of a pandemic., Level of Evidence: level IV., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2023.)

Background: Up to 75% of patients with idiopathic scoliosis (IS) report back pain, but the exact contributors are unclear. This study seeks to assess how pain correlates with demographics, radiographic and surface topographic (ST) measurements, and patient-reported outcome measures (PROMs) in patients with IS., Methods: Patient-Reported Outcome Measurement Information System (PROMIS) Pain Interference (PI) and Scoliosis Research Society revised (SRS-22r) pain domain from an IRB approved prospectively collected registry containing patients 11 to 21 years old with IS were correlated (Spearman coefficients) with measurements from whole-body EOS radiography and ST scanning, PROMIS 1.0 PROMs, Trunk Appearance Perception Scale (TAPS), and SRS-22r domains. SRS-22r and PROMIS-PI were also compared between different sex, scoliosis severities, and primary curve locations with Mann-Whitney U or Kruskal-Wallis tests, and if significant differences were found, included with the 5 highest univariate correlated variables into stepwise multivariate linear regression models ( P <0.05 to enter, P >0.1 to remove) predicting SRS-22r pain and PROMIS-PI., Results: One hundred and forty-nine patients (14.5 ± 2.0 y, body mass index 20.6 ± 4.1 kg/m 2 , 96 (64%) female, mean major coronal curve 40 ± 19 deg, range: 10 deg, 83 deg) reported mean PROMIS-PI of 42.2 ± 10.0 and SRS-22r pain of 4.4 ± 0.6. SRS-22r self-image was the most correlated variable with both SRS-22r pain (rho=0.519) and PROMIS-PI (rho=-0.594). Five variables, none of which were ST or radiographic measures, strongly predicted SRS pain domain (R=0.711, R2=0.505, N=138). Two variables (SRS-22r self-image and SRS-22r function) were utilized by a model correlated with PROMIS-PI (R=0.687, R2=0.463, N=124)., Conclusions: SRS-22r function and self-image domains were more strongly correlated with SRS-22r pain and PROMIS-PI than any radiographic or ST measurements., Level of Evidence: Level II-retrospective study., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

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., (© 2023. The Author(s), under exclusive licence to Scoliosis Research Society.)

Purpose: Adolescent idiopathic scoliosis (AIS) is a deformity of the spine that results in external asymmetry of the torso in the shoulder, waist, and rib hump. Several patient reported outcome measures (PROMS) including the Trunk Appearance Perception Scale (TAPS) and SRS-22r self-image domain are used to measure the patient's self-perception. The purpose of this study is to investigate the relationship between objective surface topographic measurements of the torso to subjective patient self-perception., Methods: 131 AIS subjects and 37 controls participated in this study. All subjects completed TAPS and SRS-22r PROMS followed by whole body 3d surface topographic scanning. An automated analysis pipeline was used to compute 57 measurements. Multivariate linear models were developed to predict TAPS and SRS-22r self-image using each unique combination of 3 parameters and leave one out validation where the best combinations were selected., Results: Back surface rotation, waist crease vertical asymmetry and rib prominence volume were most predictive of TAPS. The final predicted TAPS values from leave one out cross validation was correlated to ground truth TAPS scores with an R value of 0.65. Back surface rotation, silhouette centroid deviation, and shoulder normal asymmetry were most predictive of SRS-22r self-image with a correlation of R = 0.48., Conclusion: Surface topographic measurements of the torso are correlated to TAPS and SRS-22r self-image scores in AIS patients and controls, with TAPS exhibiting a stronger relationship, better reflecting the patient's external asymmetries., (© 2023. The Author(s), under exclusive licence to Scoliosis Research Society.)

Study Design: Prospective cohort., Objective: To determine if distal spinal fusion level is associated with postoperative sport participation after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS)., Summary of Background Data: The concept of "saving a level" during PSF for AIS refers to minimizing the distal extent of lumbar fusion to theoretically allow for increased postoperative spinal mobility and a more predictable return to athletic activity, as well as minimizing the risk of degenerative disc disease. There are few prospective studies evaluating the correlation between distal fusion level and timing of return to sports., Materials and Methods: Adolescent patients undergoing PSF for AIS between 2009 and 2019 were approached at their presurgical visit to participate in this prospective study. Participants were followed for a minimum of 2 years after surgery. Sports participation (classified by sport type and level of competitiveness) and radiographic data were collected at the initial visit. At each postoperative visit, it was noted whether patients returned to the same sport type and level of competitiveness., Results: After an a priori power calculation was performed, a total of 106 participants were included in the analysis with a mean age of 14 ± 2 years. Distal fusion levels ranged from T11 to L4. There was no significant association between distal fusion level and return to the same level of sports participation ( P = 0.192). Of the participants, 93% returned to sports with no significant differences by distal fusion level ( P = 0.081). Distal fusion level demonstrated no difference in return to preoperative sport ( P = 0.486) or return to the same type of sport ( P = 0.247)., Conclusions: This study found no association between distal fusion level and postoperative sports participation. Even though many patients may elect to change sports, nearly all patients returned to sports, and the majority of patients returned to the same level of sports competition or higher after PSF for AIS., Competing Interests: P.D.F.: Clinical Orthopedics and Related Research: Editorial or governing board, Osso VR: Stock or stock Options, WishBone Orthopedics: Paid consultant. D.W.G.: American Academy of Orthopaedic Surgeons (AAOS): Board or committee member, AO Trauma International: Paid presenter or speaker, Arthrex, Inc: IP royalties; Paid consultant; Paid presenter or speaker, Current Opinion in Pediatrics: Editorial or governing board; Publishing royalties, financial or material support, New York County Medical Society: Board or committee member, New York State Society of Orthopedic Surgeons: Board or committee member, PatelloFemoral Foundation: Board or committee member, Pediatric Orthopedic Society of North America: Board or committee member, Pediatric Research in Sport Medicine: Board or committee member, Pega Medical: IP royalties, Wolters Kluwer Health—Lippincott Williams & Wilkins: Publishing royalties, financial or material support. J.S.B.: OrthoPediatrics: Paid consultant, Wishbone: Paid consultant. R.F.W.: Medtronic: Paid consultant, OrthoPediatrics: IP royalties, Spine Deformity Journal Editorial Board: Editorial or governing board, Springer: Journal of Children’s Orthopedics Editorial Board: Editorial or governing board. The remaining authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Posterior spinal fusion for idiopathic scoliosis is known to increase spinal height, but the impacts on weight and resulting body mass index are unknown. This study assesses body mass index, weight, and height percentile changes over time after posterior spinal fusion for idiopathic scoliosis., Methods: Body mass index, weight, and height age- and sex-adjusted percentiles for patients with idiopathic scoliosis undergoing posterior spinal fusion between January 2016 and August 2022 were calculated based on growth charts from the Centers for Disease Control for Disease Control and compared to preoperative values at 2 weeks, 3 months, 6 months, 1 year, and 2 years. The data were analyzed for normality with a Shapiro-Wilk test, and percentiles were compared with the Wilcoxon signed-rank tests., Results: On average, 12.1 ± 2.3 levels were fused in 269 patients 14.4 ± 1.9 years, and percentiles for body mass index, weight, and height preoperatively were 55.5 ± 29.4%, 57.5 ± 28.9%, and 54.6 ± 30.4%, respectively. Body mass index and weight percentiles decreased at 2 weeks (-10.7%, p  < 0.001; -4.6%, p  < 0.001, respectively) and 3 months (-6.9%, p  < 0.001; -3.2%, p  < 0.001, respectively) postoperatively. Postoperative weight loss at 2 weeks averaged 2.25 ± 3.09% of body weight (0.98 ± 4.5 kg), normalizing by 3 months. Body mass index percentile normalized at 1 year, but height percentile was increased at 2 weeks (2.42 ± 1.72 cm, p  < 0.001) and through 2 years., Conclusion: Despite initial height increase due to deformity correction, acute postoperative weight and body mass index percentile decreases postoperatively normalize by 1-year body mass index percentile. Physicians may benefit from utilizing this information when discussing the postoperative course of posterior spinal fusion with idiopathic scoliosis., Level of Evidence: 4, Retrospective Case Series., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2023.)

Purpose of Review: Robotic-assisted surgical navigation for placement of pedicle screws is one of the most recent technological advancements in spine surgery. Excellent accuracy and reliability results have been documented in the adult population, but adoption of robotic surgical navigation is uncommon in pediatric spinal deformity surgery. Pediatric spinal anatomy and the specific pediatric pathologies present unique challenges to adoption of robotic assisted spinal deformity workflows. The purpose of this article is to review the safety, accuracy and learning curve data for pediatric robotic-assisted surgical navigation as well as to identify "best use" cases and technical tips., Recent Findings: Robotic navigation has been demonstrated as a safe, accurate and reliable method to place pedicle screws in pediatric patients with a moderate learning curve. There are no prospective studies comparing robotically assisted pedicle screw placement with other techniques for screw placement, however several recent studies in the pediatric literature have demonstrated high accuracy and safety as well as high reliability. In addition to placement of pediatric pedicle screws in the thoracic and lumbar spine, successful and safe placement of screws in the pelvis and sacrum have also been reported with reported advantages over other techniques in the setting of high-grade spondylolisthesis as well as pelvic fixation utilizing S2-alar iliac (S2AI) screws., Summary: Early studies have demonstrated that robotically assisted surgical navigation for pedicle screws and pelvic fixation for S2AI screws is safe, accurate, and reliable in the pediatric population with a moderate learning curve., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Adolescent idiopathic scoliosis results in three dimensional changes to a patient’s body, which may change a patient’s range of motion. Surface topography is an emerging technology to evaluate three dimensional parameters in patients with scoliosis. The goal of this paper is to introduce novel and reliable surface topographic measurements for the assessment of global coronal and sagittal range of motion of the spine in adolescents, and to determine if these measurements can distinguish between adolescents with lumbar scoliosis and those without scoliosis. Methods: This study is a retrospective cohort study of a prospectively collected registry. Using a surface topographic scanner, a finger to floor and lateral bending scans were performed on each subject. Inter- and intra-rater reliabilities were assessed for each measurement. ANOVA analysis was used to test comparative hypotheses. Results: Inter-rater reliability for lateral bending fingertip asymmetry (LBFA) and lateral bending acromia asymmetry (LBAA) displayed poor reliability, while the coronal angle asymmetry (CAA), coronal angle range of motion (CAR), forward bending finger to floor (FBFF), forward bending acromia to floor (FBAF), sagittal angle (SA), and sagittal angle normalized (SAN) demonstrated good to excellent reliability. There was a significant difference between controls and lumbar scoliosis patients for LBFA, LBAA, CAA and FBAF (p-values < 0.01). Conclusion: Surface topography yields a reliable and rapid process for measuring global spine range of motion in the coronal and sagittal planes. Using these tools, there was a significant difference in measurements between patients with lumbar scoliosis and controls. In the future, we hope to be able to assess and predict perioperative spinal mobility changes.

Purpose: This study introduces a novel surface-topographic scanning system capable of automatically generating a suite of objective measurements to characterize torso shape., Research Question: what is the reliability of the proposed system for measurement of trunk alignment parameters in patients with adolescent idiopathic scoliosis (AIS) and controls?, Methods: Forty-six adolescents (26 with AIS and 20 controls) were recruited for a prospective reliability study. A series of angular, volumetric, and area measures were computed from topographic scans in each of three clinically relevant poses using a fully automated processing pipeline. Intraclass correlation coefficients (ICC(2,1)) were computed within (intra-) and between (inter-) raters. Measurements were also performed on a torso phantom., Results: Topographic measurements computed on a phantom were highly accurate (mean RMS error 1.7%) compared with CT. For human subjects, intra- and inter-rater reliability were both high (average ICC > 0.90) with intrinsic (pose-independent) measurements having near-perfect reliability (average ICC > 0.98)., Conclusion: The proposed system is a suitable tool for topographic analysis of AIS; topographic measurements offer an objective description of torso shape that may complement other imaging modalities. Further research is needed to compare topographic findings with gold standard imaging of spinal alignment, e.g., standing radiography., Conclusion: clinical parameters can be reliably measured in a fully automated system, paving the way for objective analysis of symmetry, body shape pre/post-surgery, and tracking of pathology without ionizing radiation., (© 2022. The Author(s).)

Axial twisting of the spine has been previously shown to be affected by scoliosis with decreased motion and asymmetric twisting. Existing methods for evaluating twisting may be cumbersome, unreliable, or require radiation exposure. In this study, we present an automated surface topographic measurement tool to evaluate global axial rotation of the spine, along with two measurements: twisting range of motion (TROM) and twisting asymmetry index (TASI). The aim of this study is to evaluate the impact of scoliosis on axial range of motion. Adolescent idiopathic scoliosis (AIS) patients and asymptomatic controls were scanned in a topographic scanner while twisting maximally to the left and right. TROM was significantly lower for AIS patients compared to control patients (69.1° vs. 78.5°, p = 0.020). TASI was significantly higher for AIS patients compared to control patients (29.6 vs. 19.8, p = 0.023). After stratifying by scoliosis severity, both TROM and TASI were significantly different only between control and severe scoliosis patients (Cobb angle > 40°). AIS patients were then divided by their major curve region (thoracic, thoracolumbar, or lumbar). ANOVA and post hoc tests showed that only TROM is significantly different between thoracic AIS patients and control patients. Thus, we demonstrate that surface topographic scanning can be used to evaluate twisting in AIS patients.

Introduction: Pediatric spinal deformity involves a complex 3-dimensional (3D) deformity that increases the risk of pedicle screw placement due to the close proximity of neurovascular structures. To increase screw accuracy, improve patient safety, and minimize surgical complications, the placement of pedicle screws is evolving from freehand techniques to computer-assisted navigation and to the introduction of robotic-assisted placement. Purpose : The aim of this review was to review the current literature on the use of robotic navigation in pediatric spinal deformity surgery to provide both an error analysis of these techniques and to provide recommendations to ensure its safe application. Methods : A narrative review was conducted in April 2021 using the MEDLINE (PubMed) database. Studies were included if they were peer-reviewed retrospective or prospective studies, included pediatric patients, included a primary diagnosis of pediatric spine deformity, utilized robotic-assisted spinal surgery techniques, and reported thoracic or lumbar pedicle screw breach rates or pedicle screw malpositioning. Results : In the few studies published on the use of robotic techniques in pediatric spinal deformity surgery, several found associations between the technology and increased rates of screw placement accuracy, reduced rates of breach, and minimal complications. All were retrospective studies. Conclusions : Current literature is of a low level of evidence; nonetheless, the findings suggest the accuracy and safety of robotic-assisted spinal surgery in pediatric pedicle screw placement. The introduction of robotics may drive further advances in less invasive pediatric spinal deformity surgery. Further study is warranted., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Roger F. Widmann, MD, reports a relationship with Medtronic. The other authors declared no potential conflicts of interest., (© The Author(s) 2021.)

Background: Surgical navigation improves pedicle screw insertion accuracy and reliability. Robotic-assisted spinal surgery and screw placement has not been fully assessed in pediatric patients with spine deformity undergoing posterior spinal fusion. The purpose of this study was to describe the learning curve for robotically assisted pedicle screw placement in pediatric patients., Methods: A retrospective review on a consecutive series of the first 19 pediatric patients who underwent posterior spinal fusion by a single surgeon using robotic navigation was performed. Demographics, curve parameters, pedicle diameter, vertebral rotation, and additional outcome measures were recorded. Screw position was assessed with calibrated intraoperative 3-dimensional fluoroscopic images. All complications of planned and placed robotically placed screws were recorded., Results: A total of 194 left-sided screws were planned as robot-assisted. One hundred sixty-eight of the robotically planned screws (86.6%) were placed with robot assistance; 29 robotically planned screws (15.0%) were abandoned or converted to freehand. The mean time per robotically placed screw was 3.6±2.4 minutes. Fifteen breaches (8.9%) and 1 anterior perforation occurred with 2 critical (>2 to 4 mm) breaches, 1 was associated with a durotomy, and both occurred in the first case. There were no intraoperative/postoperative neuromonitoring changes and no sequela from the durotomy. Six breaches occurred in the first case. The odds ratio of obtaining a breach in screws with a matched trajectory was 0.275 (95% confidence interval: 0.089-0.848)., Conclusions: Screw time and accuracy improved and the number of breaches decreased after 10 cases. This series had 2 critical breaches (between 2 and 4 mm) on the first case. Overall, excluding the 2 critical breaches, 98.8% of robotically executed screws were placed without a critical breach, which is comparable to previous pediatric deformity studies. Caution should be exercised during the initial training period to avoid complications as experience and training lead to an improved understanding of surgical planning, skive, and soft-tissue pressure on the end-effector all of which can impact accuracy of robotically assisted pedicle screw placement., Level of Evidence: Case Series, IV., Competing Interests: D.R.L. and R.F.W. are consultants for Medtronic and they were not paid for their involvement in this study, which may result in a potential conflict of interest bias. However, the retrospective nature of the study resulted in independent researchers conducting independent data analysis and manuscript writing limits this potential for bias. One author has a consulting fee range of $1.00 to $ 10,000 (B) and the second has not received any compensation for research, education or consulting. The remaining authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: K-wireless robotic pedicle screw instrumentation with navigation is a new technology with large potential. Barriers to adoption are added registration time with robotic-navigated system and reliable screw positioning. Understanding the learning curve and limitations is crucial for successful implementation. The purpose of this study was to describe a learning curve of k-wireless robotic assisted pedicle screw placement with navigation and compare to conventional techniques., Methods: A retrospective review of prospectively collected data of 65 consecutive adult patients underwent robotic-navigated posterior spinal fusion by a single spine surgeon. Registration, screw placement, and positioning times were recorded. All patients underwent intra-operative 3D fluoroscopy and screw trajectory was compared to pre-operative CT., Results: A total of 364 instrumented pedicles were planned robotically, 311 (85.4%) were placed robotically; 17 screws (4.7%) converted to k-wire, 21 (5.8%) converted to freehand, and 15 (4.1%) planned freehand. Of the 311 robotically placed pedicle screws, three dimensional fluoroscopic imaging showed 291 (93.5%) to be GRS Grade A in the axial plane (fully contained within the pedicle) and 281 (90.4%) were GRS Grade A in the sagittal plane. All breached screw deviations from plan were identified on 3D fluoroscopy during surgery and repositioned and confirmed by additional 3d fluoroscopy scan. Reasons for conversion included morphology of starting point (n=18), soft tissue pressure (n=9), hypoplastic pedicles (n=6), obstructive reference pin placement (n=2), and robotic arm issues (n=1). Seventeen (5.5%) critical breaches (≥2-4 mm) were recorded in 11 patients, 9 (2.9%) critical breaches were due to soft tissue pressure causing skive. Two patients experienced 6 (1.9%) critical breaches from hypoplastic pedicles, and 3 (0.9%) unplanned lateral breaches were found in another patient. One patient (0.3%) experienced skive due to morphology and spinal instability from isthmic spondylolisthesis. Imaging showed 143 screws placed medially to plan (1.2±0.9 mm), 170 lateral (1.2±1.1 mm), 193 screws caudal (1.0±0.6 mm) and 117 cranial (0.6±0.5 mm). No adverse clinical sequelae occurred from implantation of any screw., Conclusions: The learning curve showed improvement in screw times for the first several cases. Understanding the learning curve and situations where the robotic technique may be suboptimal can help guide the surgeon safe and effectively for adoption, as well as further refine these technologies., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/jss-20-687). DRL reports research support from Medtronic, during the conduct of the study; royalties from K2M- Stryker, royalties from NuVasive, ownership interest from Woven Orthopedic Technologies, ownership interest from Vestia Ventures MiRus Investment LLC, investment interest from ISPH II, LLC, outside the submitted work. RFW reports personal fees from Medtronic, outside the submitted work, and fee for Service Consultant to OrthoPediatric Company Spine Division. RFM is on the editorial board Spine Deformity Journal, editorial board of The Journal of Children’s Orthopaedics, and a consultant reviewer for the Journal of Pediatric Orthopaedics. The other authors have no conflicts of interests to declare., (2021 Journal of Spine Surgery. All rights reserved.)

Background: An updated analysis of the pediatrics section of the Orthopaedic In-Training Examination (OITE) is helpful for resident education and preparation for the OITE. The purpose of this study is to provide an updated evaluation of the pediatric category of the OITE, and to explore trends in question topics and taxonomy compared with the previously published analysis from 2011 to 2014., Methods: Five years (2015-2019) of OITE questions, answers, and references were reviewed. The number of pediatric questions per year was recorded, and questions were subcategorized based on topic tested. The presence or absence of imaging or a clinical photograph was noted. Each question was also assigned a cognitive taxonomy level, based on a previously published classification system., Results: The percentage of pediatric questions on the 2015-2019 OITEs averaged 11.4% compared with 12.6% from 2011 to 2014 (P=0.349). The 3 most commonly tested pediatric topics were general trauma (17.8%), elbow trauma (13.2%), and genetic disorders/syndromes (11.2%). There was a significant increase in questions that required diagnosis and interpretation (27.6% vs. 8%, P<0.001) and a slight but not significant decrease in the questions requiring simple knowledge recall (26.3% vs. 35.5%, P=0.120) and decisions about management (46.1% vs. 56.5%, P=0.077). Overall, 65% of questions utilized clinical photographs or imaging studies compared with 62% from 2011 to 2014 (P=0.621). The most common references were the Journal of Pediatric Orthopaedics, Journal of American Academy of Orthopaedic Surgeons, and Journal of Bone and Joint Surgery. Textbooks were cited less frequently than in the past., Conclusions: While the percentage of pediatric questions on the OITE has remained consistent over time, the percentage of questions requiring diagnosis and interpretation has increased. In addition, questions testing genetic disorders/syndromes have become more prevalent in recent years. The most commonly cited resources were high-impact journal articles, with textbooks cited less frequently than in previous years., Clinical Relevance: Knowledge of the most frequently tested topics and resources cited may assist orthopaedic residents in preparing for the OITE and orthopaedic faculty to focus didactic sessions on the most commonly tested topics.

Study Design: Cross-sectional survey., Objective: To determine the prevalence of back pain in American children and adolescents, with a focus on anatomic region, duration, severity, and treatment patterns, and to investigate for any predictive variables., Summary of Background Data: No study has examined the prevalence of back pain in American children and adolescents in the last 15 years. Because the prevalence of back pain varies greatly by country and year of investigation, previous studies are not generalizable., Methods: A United States epidemiologic cross-sectional survey-based investigation was performed in children and adolescents ages 10 and 18 years old, equally split by age and sex, and representing census-weighted distributions of state of residence, race/ethnicity, and health insurance status. Prevalence of back pain was evaluated and described., Results: In total, 1236 (33.7%) participants reported experiencing back pain within the last year and 325 (8.9%) reported severe back pain within the last year. Prevalence of back pain increased with age and was significantly more common in females, P < 0.001 for both. Treatment for back pain was sought by 505 (40.9%) of the participants with pain, of which physical therapy was the most common. Invasive procedural treatment (e.g., injections, surgery) were rare and comprised only 61 (1.6%) of study participants. In addition, government insurance and lack of insurance coverage was associated with low treatment seeking behavior compared to private insurance users (P = 0.010 and P = 0.006, respectively)., Conclusion: Despite how commonly it presents, the majority of young patients with back pain do not report procedural treatment such as injections or surgery. However, because many American children and adolescents seek treatment, future research on the etiology, treatment, and prevention of back pain in children and adolescents is essential to reducing a common and financially demanding problem., Level of Evidence: 4.

Purpose: Scoliosis, chest wall deformities and pulmonary involvement are common features of Marfan syndrome (MFS). We aimed to assess the impact of spinal and chest wall deformities on pulmonary function in paediatric MFS patients with a surgically managed spinal deformity., Methods: In this multicentre retrospective study, spirometry, lung volumes and radiographic imaging were performed on 26 MFS patients between the ages of seven and 18 years who were undergoing planned spinal fusion surgery for spinal deformity. A correlation analysis assessed the relationship between radiographic measurements of spinal and chest wall deformities and predicted total lung capacity (TLC), forced vital capacity (FVC) and the ratio between forced expiratory volume in one second and FVC (FEV1/FVC)., Results: In total, 18 patients (70%) had impaired pulmonary function. Thoracic kyphosis (mean 19.3°; -32° to 54°) had a strong positive correlation with FEV1/FVC (r = 0.65; p < 0.001). Significant decrease in FEV1/FVC below 80% occurred at kyphosis under 15° (p = 0.004). Kyphosis had a moderate negative correlation with FVC (r = -0.43; p = 0.03). Chest wall deformity had a strong negative correlation with FEV1/FVC (r = -0.61; p = 0.001). The magnitude of the thoracic curve (mean 55.2°; 28° to 92°) had a significant moderate negative correlation with TLC (r = -0.45; p = 0.04)., Conclusion: In MFS, three factors correlate with decreased pulmonary function measures: hypokyphosis, increasing chest wall deformity and increasing coronal curve magnitude. Hypokyphosis and increased chest wall deformity correlated with diminished FEV1/FVC; increasing thoracic spinal curvature with diminished TLC. Further analysis with a larger cohort will help better define the relationship between these deformities and pulmonary function in this unique population., Level of Evidence: IV., (Copyright © 2020, The author(s).)

Background: Blade plates are frequently used for internal fixation following proximal femoral varus rotational osteotomy to treat hip dysplasia in children with cerebral palsy. Recently, cannulated blade plates with the option for a proximal locking screw have demonstrated ease of insertion and low complication rates. Although there are two commonly used blade plates with a proximal screw option, no comparison of their biomechanical profiles has been undertaken., Questions/purposes: Our study sought to compare the structural properties under axial loading, as well as the biomechanical contribution of a proximal screw, of two different 90° cannulated blade plates designed for pediatric proximal femurs. Plate A has a hole distal to the blade designed to attach a plate inserter, through which a 3.5-mm non-locking cortical screw could be placed. Plate B has a threaded hole distal to the blade designed to accept a 3.5-mm locking screw., Methods: Plate A and plate B were inserted into 33 left pediatric synthetic proximal femurs. Axial loading to failure of plate A with and without a proximal screw was compared to that of plate B with and without a proximal screw. An additional 10 samples using plate B, with and without a proximal locking screw, were tested in tension to quantify the effect of the proximal screw on pullout strength., Results: Plate B failed at a higher axial load than plate A. The addition of a proximal screw did not affect the axial load to failure for either plate. Pullout testing revealed that blade plates fixed with the proximal screw failed in tension at a significantly higher load (856.3 ± 120.9 N) than those without proximal fixation (68.1 ± 9.3 N, p  < 0.001)., Conclusions: Plate B failed at a higher axial load in biomechanical testing, likely related to differences in its design. The addition of a proximal screw did not increase the axial loading properties of the blade plate construct but did increase the pullout strength by a factor of 12. These results may be used to influence implant selection and post-operative rehabilitation following proximal femoral osteotomies in children., Competing Interests: Conflict of InterestJoseph J. Ruzbarsky, MD, Ishaan Swarup, MD, Matthew R. Garner, MD, Kathleen Meyers, MS, Folorunsho Edobor-Osula, MD, Roger Widmann, MD, and David M. Scher, MD, report that OrthoPediatrics provided some of the blade plates used in this study. David M. Scher, MD, also reports receiving personal fees as a consultant from OrthoPediatrics, during the conduct of this study., (© Hospital for Special Surgery 2019.)

Background: Prior reports suggest that osteoarticular infections may be increasing over time., Questions/purposes: We sought to determine if incidence rates, median in-hospital costs, and length of stay (LOS) of osteomyelitis, septic arthritis (SA), and combined infections have changed over time for pediatric patients, and how they compare to previously reported rates., Methods: The Kids' Inpatient Database (KID), a US national sample of pediatric hospital discharge records from 1997, 2000, 2003, 2006, 2009, and 2012, was used to determine yearly estimated counts of infections in children 20 years of age or younger. US census data was used to calculate yearly incidence rates. Trend tests using linear contrast analysis were used to compare estimated median LOS and inflation-adjusted median costs over time for each type of infection., Results: From 1997 through 2012, the incidence rate of osteomyelitis increased from 7.9 to 10.5 per 100,000, SA was unchanged from 5.3 to 5.2 per 100, and combined infections increased from 0.8 to 1.3 per 100,000. Median LOS from 1997 to 2012 showed no significant change for osteomyelitis (5.0 to 4.9 days), SA (4.4 to 4.1 days), or combined infections (6.5 to 6.8 days). Median in-hospital costs from 1997 to 2012 increased for osteomyelitis ($7735 to $11,823), SA ($5041 to $10,574), and combined infections ($12,691 to $16,260)., Conclusion: In pediatric patients, the estimated incidence rate of SA appeared stable, while rates of osteomyelitis and combined infections increased. These estimated rates fall within previously reported ranges. Despite stable LOS, costs have increased over time., Competing Interests: Conflict of InterestGabriella Safdieh, MD, Jason Silberman, BA, Joseph Nguyen, MPH, Shevaun Doyle, MD, John Blanco, MD, David Scher, MD, Daniel Green, MD, MS, Roger Widmann, MD, and Emily Dodwell, MD, MPH, FRCSC, declare that they have no conflict of interest. Joseph Nguyen, MPH, reports grants from Clinical Translational Science Center (CTSC), National Center for Advancing Translational Sciences (NCATS), outside the submitted work.

Background: Infants previously treated for developmental dysplasia of the hips (DDH) are routinely imaged with ultrasound initially and reimaged with an anteroposterior (AP) pelvis X-ray at 6 months of age to assess for dysplasia. It has become convention to transition from ultrasound to AP X-ray at 6 months of age, but no study has demonstrated that ultrasound is inadequate at this age., Question/purpose: The purpose of this study was to confirm that ultrasound for the 6-month DDH evaluation is a feasible alternative to the standard X-ray., Patients and Methods: Thirty-one 5- to 7-month-old infants undergoing AP pelvis X-ray related to previous Pavlik harness treatment for DDH or to a history of breech presentation were prospectively enrolled. All patients were imaged with an AP pelvis X-ray and bilateral hip ultrasounds. Three senior orthopedic surgeons unfamiliar with the patient histories evaluated both types of imaging for standard measures of hip dysplasia, including acetabular index (AI), alpha angle, and bony rim percent coverage of the femoral head. Pearson correlation coefficients were calculated for the X-ray and ultrasound measures., Results: Good quality ultrasound images were obtained in all patients, despite the presence of the ossific nucleus in 66% of the hips. All three reviewers correctly diagnosed the one dislocated hip via both X-ray and ultrasound. There were no false negatives on ultrasound, and none of the patients with negative ultrasounds required treatment during the mean 26 months of follow up. An increased AI on X-ray was correlated with lower percent coverage of the femoral head on ultrasound., Conclusions: Ultrasound is a technically feasible DDH imaging modality that can be used as an alternative to X-ray for 6-month-olds., Competing Interests: Conflict of InterestAlison Kitay, MD, Roger F. Widmann, MD, Shevaun M. Doyle, MD, Huong T. Do, MA, and Daniel W. Green, MD, declare that they have no conflicts of interest.

Imaging plays in important role in the evaluation of the acutely limping child. The decision-making process about initial imaging must consider the level of suspicion for infection and whether symptoms can be localized. The appropriateness of specific imaging examinations in the acutely limping child to age 5 years is discussed with attention in each clinical scenario to the role of radiography, ultrasound, nuclear medicine, computed tomography, and magnetic resonance imaging. Common causes of limping such as toddler's fracture, septic arthritis, transient synovitis, and osteomyelitis are discussed. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment., (Copyright © 2018 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Background: There is no standardized complication classification system that has been evaluated for use in pediatric or general orthopaedic surgery. Instead, subjective terms such as major and minor are commonly used. The Clavien-Dindo-Sink complication classification system has demonstrated high interrater and intrarater reliability for hip-preservation surgery and has increasingly been used within other orthopaedic subspecialties. This classification system is based on the magnitude of treatment required and the potential for each complication to result in long-term morbidity. The purpose of the current study was to modify the Clavien-Dindo-Sink system for application to all orthopaedic procedures (including those involving the spine and the upper and lower extremity) and to determine interrater and intrarater reliability of this modified system in pediatric orthopaedic surgery cases., Methods: The Clavien-Dindo-Sink complication classification system was modified for use with general orthopaedic procedures. Forty-five pediatric orthopaedic surgical scenarios were presented to 7 local fellowship-trained pediatric orthopaedic surgeons at 1 center to test internal reliability, and 48 scenarios were then presented to 15 pediatric orthopaedic surgeons across the United States and Canada to test external reliability. Surgeons were trained to use the system and graded the scenarios in a random order on 2 occasions. Fleiss and Cohen kappa (κ) statistics were used to determine interrater and intrarater reliabilities, respectively., Results: The Fleiss κ value for interrater reliability (and standard error) was 0.76 ± 0.01 (p < 0.0001) and 0.74 ± 0.01 (p < 0.0001) for the internal and external groups, respectively. For each grade, interrater reliability was good to excellent for both groups, with an overall range of 0.53 for Grade I to 1 for Grade V. The Cohen κ value for intrarater reliability was excellent for both groups, ranging from 0.83 (95% confidence interval [CI], 0.71 to 0.95) to 0.98 (95% CI, 0.94 to 1.00) for the internal test group and from 0.83 (95% CI, 0.73 to 0.93) to 0.99 (95% CI, 0.97 to 1.00) for the external test group., Conclusions: The modified Clavien-Dindo-Sink classification system has good interrater and excellent intrarater reliability for the evaluation of complications following pediatric orthopaedic upper extremity, lower extremity, and spine surgery. Adoption of this reproducible, reliable system as a standard of reporting complications in pediatric orthopaedic surgery, and other orthopaedic subspecialties, could be a valuable tool for improving surgical practices and patient outcomes.

Background: Temporary, implant-mediated hemiepiphysiodesis (ie, guided growth) is an effective and popular treatment method for lower extremity angular deformities. The purpose of this study was to retrospectively evaluate the safety profile of 3 different implants used to correct lower extremity angular deformities in pediatric patients., Methods: We retrospectively reviewed a consecutive series of pediatric patients with lower extremity angular deformities who underwent implant-mediated guided growth by 2 surgeons at our institution between 2004 and 2014. Implants were selected according to surgeon preference and included the Biomet peanut plate, Orthofix eight-plate, and Pega Medical hinge plate. Medical records and radiographs were reviewed to assess deformity correction, implant integrity, and complications., Results: During the study period, 115 plates (63 Biomet peanut plates, 30 Orthofix eight-plates, and 22 Pega Medical hinge plates) were implanted in 52 patients (24 males, 28 females). Average age at implantation was 11.7 years (12.3 y in males, 11.1 y in females). Average length of follow-up was 18.4 months. There was no significant difference in rate of deformity correction between the implant types (P=0.08).Three broken screws (2.6%) were observed, all of which involved cannulated screws in peanut plates. Four peanut plates (6.3%) had an implant-related complication: 3 broken screws and 1 screw pullout. Three eight-plates (10.0%) had screw pullout. No complications were observed within either the hinge plate or solid screw groups. Implant-related complications were significantly associated with increased body weight and cannulated screw use (P=0.02 and 0.03, respectively), but not bone age, sex, plate type, or rate of deformity correction. No deep infections, premature growth arrests, or plate breakages were observed., Conclusions: Implant-mediated guided growth is a safe technique for pediatric lower extremity angular deformity correction with a low complication rate. This study demonstrated that overweight patients had a significantly higher rate of implant-related complications. Screw breakages were only observed with cannulated screws in peanut plates. Thus, we recommend using solid, noncannulated screws in overweight children who are at an increased risk of implant failure., Level of Evidence: Level IV-retrospective case series.

Background: Recent data have shown an increase in youth sports participation at younger ages, which may be linked to greater musculoskeletal injury risk. The Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS) is a validated 8-item instrument designed to quantify the activity of children between 10 and 18 years old. Normative data on pediatric and adolescent activity level are unknown., Purpose: To establish normative activity-level data for American youth and to determine if there is a natural decrease in activity level during adolescence., Study Design: Cross-sectional study; Level of evidence, 3., Methods: A cross-sectional investigation was performed among 2002 US children and adolescents equally split by sex and age and representing census-weighted distributions of state of residency, race/ethnicity, and health insurance status. Respondents completed the HSS Pedi-FABS, as well as survey questions on demographics and sports participation. Normative data were reported with descriptive statistics. Linear regression analysis was performed to determine if there was an effect of age on activity level during adolescence., Results: A total of 2002 respondents completed the survey; the mean age of the respondents at the time of survey completion was 14.0 ± 2.6 years. Mean weekly amount of reported physical activity was 9.3 ± 8.4 hours. HSS Pedi-FABS scores were normally distributed with a mean of 15.4 ± 8.5 points (out of 30 possible points). There was a modest but statistically significant decrease in HSS Pedi-FABS activity scores with increasing age ( r = -0.175, P < .001), corresponding to a linear decrease in activity scores by 27% on average from age 10 to 18 years., Conclusion: The current study provides baseline normative data for activity level in a census-weighted representative population sample of 2002 American youth through the use of a validated activity score (HSS Pedi-FABS). There was a modest but statistically significant decrease in activity scores with increasing age. These results will aid future research by providing normative, representative population-level activity data and will help to quantify the natural rate of decreased activity during adolescence.

Background: Percutaneous epiphysiodesis using transphyseal screws (PETS) has been associated with implant failure, implant prominence, angular deformities, and delayed growth inhibition., Questions/purposes: The aim of this study was to assess the complication rate and efficacy (defined as actual growth inhibition divided by expected growth inhibition) of PETS and to identify factors associated with improved efficacy., Methods: Patients who underwent distal femoral and/or proximal tibial PETS between January 2007 and June 2014 were identified. Complications, efficacy, and final limb-length discrepancy (LLD) were calculated using multipliers and inhibition rates based on previous growth. Associations between efficacy and screw insertion angle (SIA), body mass index, and number of threads crossing the physis were calculated., Results: Eight-two patients (126 treated physes) were included. The mean pre-operative LLD was 27.7 mm (SD = 7.5). Following epiphysiodesis, 15 had temporary pain (18%), five had temporary effusion (6.1%), four had broken implants (4.9%), four developed mild angulation (4.9%), and three had failed epiphysiodesis requiring revision (3.7%). Thirty-one underwent screw removal ( n  = 31, 38%). Mean LLD at maturity was 17.3 mm (SD = 5.8 mm). Mean efficacy at the distal femur was 97% (SD = 46%), at the proximal tibia was 108% (SD = 66%) and was 103% (SD = 57%) overall. Increased screw threads across the lateral proximal tibial physis (Spearman's correlation coefficient = 0.67; 95% CI = 0.40-0.94) and higher BMI (Spearman's correlation coefficient = 0.55; 95% CI = 0.34-0.77) were positively associated with increased efficacy., Conclusions: The efficacy of PETS may be more favorable than previously reported. Only 3.7% had serious complications requiring revision epiphysiodesis, lower than previous reports. Attention to sufficient screw threads across the physis may be important in optimizing PETS results.

Background: EOS low-dose biplanar X-ray used with tantalum bead implantation is an appealing imaging modality to evaluate limb length and physeal growth due its relatively low radiation exposure, excellent inter- and intra-observer reliability, and minimal magnification/shrinkage error., Questions/purposes: The purpose of this study was to establish the error in total length and inter-bead distances using EOS and tantalum beads due to variable positioning in the EOS gantry, by assessing variation in measurements made on the same subject repeatedly positioning by one positioner (intra-positioner measurement error) and variation in measurements made on the same subject with positioning by multiple positioners (inter-positioner measurement error)., Methods: Tantalum bead markers were placed about the distal femoral physis of a cadaveric lamb femur. Three investigators positioned the femur in the EOS gantry 10 times, totaling 30 EOS scans. Total limb length and inter-bead distances were measured on AP and lateral views; mean and standard error were calculated. A random effects analysis of variance for nested data was used to determine the proportion of variation due to differences between positioners and differences between positioning by the same positioner., Results: Intra-positioner measurement error ranged from 0.01 to 0.06 mm. Inter-positioner measurement error ranged from 0.00 to 0.09 mm., Conclusions: EOS has relatively low radiation and allows standing assessment of limb length and alignment. In this study, length measurements and inter-bead distances demonstrated minimal error due to positioning in the EOS gantry, documenting that there is minimal error from positioning, minimal magnification/shrinkage error, and exceptional inter and intra-rater reliability. EOS is the preferred method for length and angular measurements, and with tantalum beads, is ideal for measuring growth about the physis.

Introduction: Bone morphogenetic protein (BMP) is considered off-label when used to augment spinal arthrodesis in children and adolescents. There is a paucity of longer-term information on BMP use in this population. The purpose of this study was to determine the rate of BMP utilization in pediatric spinal arthrodesis, assess factors associated with BMP use in this population, and evaluate long-term outcome., Methods: Spinal arthrodeses in patients 18 years and younger performed in New York State between 2004 and 2014 were identified through the Statewide Planning and Research Cooperative System database. All cases had a minimum 1-year follow-up. The primary outcome was revision arthrodesis. The primary outcome, as well as short-term and longer-term complications were identified using time-to-event analysis. Multivariable Cox proportional hazards models were used to assess the association between BMP and outcomes., Results: Of 7312 children and adolescents who underwent spinal arthrodesis, 462 (6.7%) received BMP. Utilization spiked between 2008 and 2010 when (8.6%) of cases received BMP, but subsequently BMP use returned to pre-2008 levels (2004 to 2007: 5.3%; 2011 to 2014: 5.5%). BMP was more likely to be used in children who were older (P=0.027), white and with higher mean family income (P<0.001 for race and income). BMP was more likely to be used for revision surgery, 2 to 3 level fusions, and spondylolisthesis (P<0.001 for all). Revision rates did not differ based on BMP utilization status. Patients receiving BMP did not have increased risk of short-term complications although at 5-year follow-up, BMP was associated with a statistically significant increased risk of mechanical complications (hazard ratio 1.48; 95% confidence interval, 1.02-2.14)., Conclusions: Off-label use of BMP for pediatric spinal arthrodesis increased until 2008 and now appears to be decreasing. Racial/ethnic minorities and lower socioeconomic status patients are less likely to receive BMP. The rate of revision after spinal arthrodesis does not differ between those treated with and without BMP. Further long-term studies are required to delineate appropriate guidelines for BMP utilization in children., Level of Evidence: Level III.

The youngest children, particularly in the first year of life, are the most vulnerable to physical abuse. Skeletal survey is the universal screening examination in children 24 months of age and younger. Fractures occur in over half of abused children. Rib fractures may be the only abnormality in about 30%. A repeat limited skeletal survey after 2 weeks can detect additional fractures and can provide fracture dating information. The type and extent of additional imaging for pediatric patients being evaluated for suspected physical abuse depends on the age of the child, the presence of neurologic signs and symptoms, evidence of thoracic or abdominopelvic injuries, and social considerations. Unenhanced CT of the head is the initial study for suspected intracranial injury. Clinically occult abusive head trauma can occur, especially in young infants. Therefore, head CT should be performed in selected neurologically asymptomatic physical abuse patients. Contrast-enhanced CT of the abdomen/pelvis is utilized for suspected intra-abdominal or pelvic injury. Particular attention should be paid to discrepancies between the patterns of injury and the reported clinical history. Making the diagnosis of child abuse also requires differentiation from anatomical and developmental variants and possible underlying metabolic and genetic conditions. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment., (Copyright © 2017 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

The primary goal in the management of adolescent idiopathic scoliosis is to prevent the progression of spinal deformity either with the use of a brace or with surgery. The goals of surgery, if indicated, are to correct the spinal deformity safely and to preserve overall spinal balance and as many motion segments as possible, which maximizes the long-term health of a patient's spine. Recently, tremendous advances have been made in the surgical techniques that are used to correct adolescent idiopathic scoliosis, and improved tools have allowed surgeons to perform spinal deformity surgery as safely and with as few complications as possible. Surgeons should be aware of recent evidence that demonstrates the efficacy of bracing in patients who have adolescent idiopathic scoliosis. In addition, surgeons should understand recent advances in spinal deformity surgery with regard to fusion level selection, implant placement, three-dimensional deformity correction, and techniques that are used to minimize perioperative complications.

Study Design: Single-institution, retrospective case series., Objective: To determine whether the microbiology of deep surgical site infections (SSIs) after spinal fusion surgery for deformity has changed over the last decade at our institution., Summary of Background Data: SSI after pediatric spinal deformity surgery results in significantly increased patient morbidity and health care costs. Although risk factors are multifactorial, prophylactic and treatment antibiotic coverage is based in part on historical epidemiologic data, which may evolve over time., Methods: This study represents a retrospective review of clinical and microbiology records of patients less than 21 years old who underwent spinal deformity surgery at a single institution between 2000 and 2012. Patients were included who underwent index surgery at our institution and developed a deep SSI. Patients with growth-preserving spine constructs were excluded., Results: The overall incidence of deep SSI was 3.6% (39/1094). The incidence of deep SSI following primary surgery was 3.3% (34/1034) and 8.3% (5/60) following revision surgery. The incidence of deep SSI varied by primary diagnosis: idiopathic (1.0%), neuromuscular (14.3%), syndromic (5.3%), congenital (5.7%), and kyphosis (0.0%). The most common inciting pathogens were Staphylococcus epidermidis (26%), methicillin-sensitive Staphylococcus aureus (MSSA, 18%), Propionibacterium acnes (P. acnes; 18%), and Escherichia coli (18%). Sixteen of the 18 (89%) gram-negative infections occurred in neuromuscular patients (P = 0.006). Between 2000 and 2006 and between 2007 and 2012, MSSA occurred in 2/18 (11%) and 5/21 (24%) of cases (P = 0.41), methicillin-resistant S. aureus occurred in 1/18 (6%) and 3/21 (14%) (P = 0.61), and P. acnes occurred in 3/18 (17%) and 4/21 (19%) (P = 1.0)., Conclusion: The epidemiology of deep SSI following spinal fusion for deformity in pediatric patients at our institution has not changed significantly during 13 years. Prophylactic antibiotic coverage for both gram-positive and gram-negative organisms may be indicated for patients with primary neuromuscular diagnoses., Level of Evidence: 4.

Background: Anterior cruciate ligament (ACL) tears are becoming more common in the skeletally immature population as participation in high-risk sports continues to grow. This presents a challenge for the treating surgeon as ACL reconstruction in this patient set has the added aim of preservation of the growth plate anatomy. The purpose of this investigation is to report on 4 patients who developed growth arrest following ACL reconstruction and offer a review of the available literature., Methods: Four skeletally immature patients (2 male and 2 female) were identified who underwent ACL reconstruction at mean age of 14.2 years (range, 13.5 to 14.8 y) and developed growth arrests. Bone ages at the time of reconstruction were 14 and 16 years for the boys and 13 years 6 months and 14 years for the girls. All patients had a transphyseal reconstruction with a hamstring autograft. Standard postoperative care was provided including clinical and radiographic follow-up at regular intervals. Clinically significant postoperative physeal arrest was confirmed on MRI or CT scan. Detailed chart review examined demographics, operative variables, and postoperative subjective and objective clinical measures., Results: Two patients developed tibial recurvatum; 2 patients developed genu valgum. Three patients required further surgery. One patient underwent distal femoral-guided growth procedure, 2 underwent proximal tibial epiphysiodesis, and 1 patient was skeletally mature at presentation and did not require deformity correction., Conclusions: This report of 4 patients demonstrates that growth arrest following ACL reconstruction in skeletally immature patients is a real concern and highlights the importance of careful preoperative evaluation and discussion with patients and family members. We routinely obtain long-leg AP and lateral hip-to-ankle films on skeletally immature patients before performing an ACL reconstruction and then at 6 and 12 months postoperatively or every 6 months until the growth plates are closed to assess leg lengths and lower extremity alignment., Level of Evidence: Level IV-therapeutic study, case series.

Background: Low-dose biplanar radiography (EOS) is an appealing imaging modality for use in children given its low radiation and ease of use. The goal of this study was to determine the accuracy and reliability of EOS compared with CT scanogram for measurement of leg length and to assess interrater and intrarater reliability of measured interbead distances for EOS and CT scanogram after insertion of tantalum beads into lamb femurs., Methods: Tantalum beads (0.8 mm) were inserted into the cortex on both the medial and lateral sides of 10 skeletally immature lamb femurs. CT scanogram and EOS imaging were obtained. Measurements of total length and distance between bead pairs were recorded on anteroposterior and lateral views by 2 orthopaedic surgeons on 2 separate occasions. Pearson correlations were performed for statistical comparisons., Results: EOS measurements showed near-perfect correlation to those of CT scanogram (r>0.96, P<0.001). Intrarater reliability was excellent for all measurements with EOS (r>0.98, P<0.001) and CT scanogram (r>0.99, P<0.001) as was interrater reliability for EOS (r>0.98, P<0.001) and CT scanogram (r>0.99, P<0.001)., Conclusions: EOS is comparable with CT scanogram in the assessment of limb length and the distance between 2 radiopaque markers. Reliability was excellent for all measurements. The combination of EOS imaging and tantalum bead implantation may be an effective way to evaluate physeal growth following procedures such as epiphysiodesis and physeal bar resection., Level of Evidence: Level II—diagnostic