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Introduction: The evolution of MCGR technique has led to modifications in the configuration of the proximal construct to decrease the incidence of implant-related complications (IRC) and revision surgeries. However, there is no data characterizing the performance of the most used configurations reducing the risk of complications., Methods: 487 patients were identified from an international multicenter EOS database., Inclusion Criteria: EOS patients, primary dual MCGR, complete radiographs, and minimum of 2-year follow-up. 76 patients had incomplete X-rays, 5 had apical fusions, and 18 had inconclusive complications, leaving 388 patients for review. A digital spine template was created to document UIV; number of levels; number, type, and location of anchors; as well as implant configuration. First available postoperative and latest follow-up radiographs were reviewed by two senior surgeons and two spine fellows. UPROR due to IRC was defined as any change in proximal anchors between the postoperative and final follow-up radiographs., Results: The most common proximal construct configuration: UIV at T2 (50.0%) with 17.5% UPROR, followed by T3 (34.0%) with 12.1% UPROR; number of levels was three (57.1%) with 16.8% UPROR and two (26.0%) with 17.0% UPROR; number of proximal anchors was six (49.9%) with 14.1% UPROR and four (27.0%) with 18.3% UPROR. The most common anchors were all screws (42.0%) with 9.9% UPROR, and all hooks (26.4%) with 31.4% UPROR (P < 0.001). The construct with the lowest rate of UPROR was a UIV at T2, with six anchors (all screws) across three levels (42 cases), with 0% UPROR. Other construct combinations that yielded 0% UPROR rates were UIV of T3, six anchors (all screws) across three levels (25 cases), and a UIV of T3 with six anchors (screws and hooks) across three3 levels (9 cases)., Conclusion: Proximal anchor configuration impacts the incidence of UPROR due to IRC in MCGR. UIV at T2 and T3 compared to T4, and the use of all screws or combination of screws and hooks compared to all hooks were associated with a lower UPROR rate. The most common construct configuration was T2 UIV, three levels, six anchors, and all screws. The use of a combination of six anchors (screws or screws and hooks) across three levels with a UIV at T2 or T3 was associated with a lower UPROR rate. Additional research is needed to further evaluate the variables contributing to configuration selection and their association with IRC., (© 2024. The Author(s), under exclusive licence to Scoliosis Research Society.)

Background: Neuromuscular early-onset scoliosis (N-EOS) often presents with a long sweeping thoracolumbar scoliosis and pelvic obliquity. With severe pelvic obliquity, the ribs come into contact with the high side of the pelvis, termed rib-on-pelvis deformity (ROP). The goal of this study is to evaluate whether ROP is associated with reported pain and other health-related quality of life (HRQOL) measures. We hypothesize that ROP is associated with increased pain and negative HRQOL., Methods: A multicenter international registry was queried for all nonambulatory patients with N-EOS from 2012 to 2022. Both surgical and nonsurgical patients were included. ROP was classified as a binary radiographic assessment of preoperative (surgical patients) and most recent follow-up (nonsurgical patients) upright radiographs. Reported pain and other HRQOL measures were assessed through the 24-Item Early Onset Scoliosis Questionnaire (EOSQ-24). Patients with nonupright radiographs or EOSQ-24 questionnaires and corresponding radiographs >4 months apart were excluded., Results: Totally, 225 patients (8.4±3.1 y, 55% female) were included. The median major curve was 63.3 (IQR: 40.6 to 81.2) degrees and median pelvic obliquity was 15.5 degrees (IQR: 8.8 to 26.4). Eighty-three patients (37%) had ROP. ROP was associated with both frequency ( P <0.001) and severity ( P <0.001) of pain. ROP was associated with worse general health ( P =0.01), increased difficulty with vocalization ( P =0.02), increased frequency of shortness of breath ( P =0.002), and increased difficulty sitting upright ( P =0.04). Regarding overall EOSQ-24 domains, ROP was associated with worse general health, pain/discomfort, pulmonary function, and physical function ( P <0.01). In a subanalysis of 76 patients who underwent surgical intervention with at least 2 years of follow-up, patients with preoperative ROP experienced significantly greater improvements in both frequency ( P =0.004) and severity ( P =0.001) of pain than the patients without preoperative ROP at 2 years postoperatively., Conclusions: The overall incidence of ROP in N-EOS is about 37%. ROP is associated with greater pain and worse HRQOL through the EOSQ-24 questionnaire. Furthermore, these patients experienced a greater reduction in pain after surgery. Clinicians and parents must be aware that ROP is possibly a pain generator, but responds positively to surgical intervention., Level of Evidence: Level III., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Posterior spinal fusion (PSF) and hip reconstruction are commonly indicated surgeries in children with cerebral palsy (CP), particularly those functioning at GMFCS levels IV and V. These are large and often painful procedures, and previous literature suggests that hip surgery is more painful than spine surgery in this patient population. The purpose of this study is to investigate pain scores and opioid use following hip and spine surgery in a large cohort of children with CP, including many patients who have undergone both types of surgery., Methods: A retrospective chart review was performed to identify children with CP who underwent hip reconstruction and/or PSF at a tertiary children's hospital between 2004 and 2022. Charts were reviewed for demographic data, pain scores, pain medication usage, duration of hospital stay, and complications., Results: Data were collected for 200 patients (101 male, 99 female) who met inclusion criteria. Eighty-seven patients underwent hip reconstruction, 62 spinal fusion, and 51 both hip and spine surgery asynchronously. Median (interquartile range) age at the time of surgery was significantly older for spinal fusion compared with hip surgery [13.1 (4.9) vs. 8.1 (5.7) y, P <0.0001]. Length of stay was significantly longer after PSF, with a median of 6 (4) days compared with 2 (1) days after hip surgery ( P <0.0001). Both maximum and average daily pain scores were similar following hip and spine surgery, with the exception that average pain scores for hip surgery were slightly higher on postoperative day 1, hip=1.73 vs. spine=1.0 ( P <0.0001). The amount of opioids used, expressed as morphine milligram equivalents (MME)/kg were similar in the hip and spine surgery groups; however, it was significantly lower in the hip surgery group on postoperative day 0, hip=0.06 versus spine=0.17 ( P <0.0001). For the 51 patients who underwent both hip and spine surgery, the amount of opioids used mirrored that for the entire group (similar MME/kg, though only statistically significantly less on POD 0 and 3), and pain scores were not significantly different between the 2 groups except in 2 circumstances. The 2 exceptions in these 51 patients both demonstrated lower pain scores in patients after hip surgery, including lower maximum pain scores on POD 1 ( P =0.041), and lower average pain scores on POD3 ( P =0.043)., Conclusions: This is the largest series to date comparing postoperative pain in children with CP after hip and spine surgery, including 51 of 200 patients who underwent both types of surgery. The results of this study demonstrate that hip surgery is not more painful than spine surgery in children with CP, and conflict with the traditional belief that hip surgery is more painful. This is important information for health care providers when counseling patients and families regarding these surgeries in children with CP., Level of Evidence: Level 3., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: This study compared shoulder balance outcomes in "rule breakers" (RB) vs. "rule followers" (RF) based on commonly utilized upper instrumented vertebrae (UIV) selection guidelines., Methods: Adolescent idiopathic scoliosis (AIS) patients (Lenke 1-4) who underwent posterior spine fusion (PSF) with minimum 2-year follow-up had radiographic measurement of shoulder balance including first rib angle (FRA), T1 tilt, coracoid process height difference (CPHD), and clavicle angle (CA) at preop, postop, 6-month, 1-year, and 2-year timepoints. Postoperative outcomes were compared between RB and RF groups defined based on the UIV selection guidelines of Rose and Lenke., Results: Among 88 patients (43 RF, 45 RB), age, gender, preoperative T1 tilt, FRA, CA, and CPHD were not significantly different between groups (p > 0.05). Immediately post-surgery, the RF group had more balanced shoulders (CPHD: 11.6 mm vs. 15.7 mm, p = 0.033; CA: 2.8° vs. 3.6°, p = 0.045; FRA: 3.4° vs. 5.1°, p = 0.009; T1 tilt: 4.7° vs. 6.1°, p = 0.045). At 2 years, no difference was observed between RF vs. RB in CA (2.3 vs. 2.2°, p = 0.857) and CPHD (8.5 vs. 8.1 mm, p = 0.791). FRA and T1 tilt were higher in RB vs. RF (FRA: 4.6 vs. 2.9°, p = 0.002; T1 tilt: 5.6 vs. 3.9, p = 0.008). Shoulder balance (CPHD < 1 cm) was achieved in 73.1% of RB and 69.9% of RF at 2-year follow-up (p = 0.216)., Conclusion: Adherence to commonly accepted UIV selection guidelines did not predict better shoulder balance. The RB group had worse shoulder balance immediately post-surgery, but also improved more over time. These results suggest the need to refine current UIV selection and management., Level of Evidence: III., (© 2024. The Author(s).)

Objective: Pulmonary function can be impaired in patients with adolescent idiopathic scoliosis (AIS). Maximal voluntary ventilation (MVV) has been shown to be more strongly correlated with major coronal curve, and a more easily obtained measurement of pulmonary function, than forced vital capacity (FVC). We evaluated changes in pulmonary function using these 2 measures in patients with AIS in relation to changes in major coronal curves over time., Methods: Forty-seven patients with AIS with thoracic curves ≥10 degrees performed pulmonary function tests using the Carefusion MicroLoop Spirometer at enrollment and 1 year later. Major coronal curve worsening >5 degrees was considered curve progression., Results: At enrollment, 47 patients had a mean major coronal curve of 38 degrees (range: 10 to 76 degrees). One year later, 17 patients had undergone posterior spinal fusion, 9 had curve progression >5 degrees, and 21 had no progression. MVV and major coronal curve were negatively correlated (r = -0.36, P = 0.01) at enrollment. After fusion, the major coronal curve improved by a mean of 41 degrees, and MVV improved by 23% (P < 0.01), but FVC did not improve significantly (6%, P = 0.29). In stable curves, MVV improved 12% (P = 0.01) and FVC improved 9% (P = 0.007). In patients without surgery whose curves progressed an average of 11 degrees, there was no significant change in MVV or FVC (P > 0.44)., Conclusion: This is the first study using office-based spirometry in an orthopaedic clinic showing improved pulmonary function with posterior spinal fusion and growth in patients with AIS. It is notable that MVV improved after spinal fusion, but FVC did not, as MVV appears to be a more sensitive measurement for the assessment of pulmonary function in these patients., Level of Evidence: Level II., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Children with neuromuscular early onset scoliosis (EOS) receive numerous radiographic studies both from orthopaedic and other specialties. Ionizing radiation doses delivered by computed tomography (CT) are reportedly 100 times higher than conventional radiography. The purpose of this study was to evaluate the number of radiographic studies ordered for neuromuscular EOS patients during their care., Methods: Retrospective review at a tertiary children's hospital from January 2010 to June 2021 included all patients with neuromuscular EOS followed by an orthopaedic specialist for a minimum of 3 years. Patients were excluded if the majority of their nonorthopaedic care was provided by outside institutions., Results: Eighteen patients met inclusion criteria with mean follow up of 6.4±2.3 years. A total of 1312 plain radiographs and 35 CT scans were performed. Of the plain radiographs, 34.7% were ordered by orthopaedic providers and 65.3% (857/1312) were ordered by other providers. Of the CT scans, 4 were ordered by orthopaedic providers, while 88.5% (21/35) were ordered by other providers. An average of 74.7 (range: 29 to 124) radiographs and 1.9 (range: 0 to 9) CT scans ordered over the course of each patient's treatment for an average of 13.0±6.0 radiographs and 0.3 CT scans per year., Conclusions: With an average of 75 radiographs and 1.9 CT scans performed per patient, consideration for steps to limit exposure to ionizing radiation should be made a particularly high priority in this unique subset of patients. This requires interdisciplinary coordination as 65% of the radiographs and over 80% of the CT scans were ordered by nonorthopaedic providers., Level of Evidence: Level III., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To characterize the frequency of incidental dural tears in pediatric spine surgery, their treatment, complications, and results of long-term follow-up., Methods: A retrospective review of all pediatric patients who underwent a posterior spinal fusion (PSF) between 2004-2019 at a tertiary children's hospital was conducted. Electronic medical records were reviewed for patient demographics, intra-operative data, presence of an incidental dural tear, repair method, and patient outcomes., Results: 3043 PSFs were reviewed, with 99 dural tears identified in 94 patients (3.3% overall incidence). Mean follow-up was 35.7 months (range 0.1-142.5). When the cause of the dural tear was specified, 69% occurred during exposure, 5% during pedicle screw placement, 4% during osteotomy, 2% during removal of implants, and 2% during intra-thecal injection of morphine. The rate of dural tears during primary PSF was significantly lower than during revision PSF procedures (2.6% vs. 6.2%, p < 0.05). 86.9% of dural tears were repaired and/or sealed intraoperatively, while 13.1% had spontaneous resolution. Postoperative headaches developed in 13.1% of patients and resolved at a mean of 7.6 days. There was no difference in the incidence of headaches in patients that were ordered bedrest vs. no bedrest (p > 0.99). Postoperative infections occurred in 9.5% of patients and 24.1% patients were identified to have undergone a revision surgery., Conclusions: Incidence of intra-operative dural tears in pediatric spine surgery is 3.3%. Although complications associated with the dural tear occur, most resolve over time and there were no long-term sequelae in patients with 2 years of follow up., Level of Evidence: Level IV., (© 2024. The Author(s).)

Study Design: Modified Delphi consensus study., Objective: To develop consensus-based best practices for the care of pediatric patients who have implanted programmable devices (IPDs) and require spinal deformity surgery., Summary of Background Data: Implanted programmable devices (IPDs) are often present in patients with neuromuscular or syndromic scoliosis who require spine surgery. Guidelines for monitoring and interrogating these devices during the perioperative period are not available., Methods: A panel was assembled consisting of 25 experts (i.e., spinal deformity surgeons, neurosurgeons, neuroelectrophysiologists, cardiologists, and otolaryngologists). Initial postulates were based on a literature review and results from a prior survey. Postulates addressed the following IPDs: vagal nerve stimulators (VNS), programmable ventriculoperitoneal shunts (VPS), intrathecal baclofen pumps (ITBP), cardiac pacemakers and implantable cardioverter-defibrillators (ICD), deep brain stimulators (DBS), and cochlear implants. Cardiologist and otolaryngologist participants responded only to postulates on cardiac pacemakers or cochlear implants, respectively. Consensus was defined as ≥80% agreement, items that did not reach consensus were revised and included in subsequent rounds. A total of 3 survey rounds and 1 virtual meeting were conducted., Results: Consensus was reached on 39 total postulates across 6 IPD types. Postulates addressed general spine surgery considerations, the use of intraoperative monitoring and cautery, the use of magnetically controlled growing rods (MCGRs), and the use of an external remote controller to lengthen MCGRs. Across IPD types, consensus for the final postulates ranged from 94.4% to 100%. Overall, experts agreed that MCGRs can be surgically inserted and lengthened in patients with a variety of IPDs and provided guidance for the use of intraoperative monitoring and cautery, which varied between IPD types., Conclusion: Spinal deformity correction surgery often benefits from the use of intraoperative monitoring, monopolar and bipolar cautery, and MCGRs. The final postulates from this study can inform the perioperative and postoperative practices of spinal deformity surgeons who treat patients with both scoliosis and IPDs., Level of Evidence: V-Expert opinion., Competing Interests: J.T.B. has consulted for Orthopediatrics Corporation, Medtronic, Inc., and Medical Devices Business Services, Inc. T.J.G. has consulted for NuVasive. L.M.A. has consulted/served as a speaker for Medtronic, Inc. and NuVasive. R.E.F. has consulted for Medical Devices Business Services, Inc. L.Y. has consulted for Medtronic, Inc. L.C.B. has consulted for Stryker Corp., Medtronic, Inc., and SeaSpine Orthopedics Corp. C.K.H. has consulted/served as a speaker for Medtronic, Inc. V.V.D. is a proctor and consultant for the following companies: Medtronic, Inc., Edwards Lifesciences, B. Braun and Abbott Vascular. J.H.P. received royalties/license fees and is a consultant for Medtronic, Inc. D.W.P. received royalties/license fees and has consulted for SI-BONE. He has also consulted for Globus Medical, Inc. J.R.S. has consulted for Orthopediatrics and Medtronic, Inc. P.D.S. received royalties/license fees from Globus Medical and has served as a consultant for the following companies: Medical Devices Business Services, Inc., Orthopediatrics, and NuVasive. P.F.S. has consulted for NuVasive. B.Y. received royalties/license fees from NuVasive, Stryker Corp, and Globus Medical. He has also consulted for Stryker, Pacira Pharmaceuticals Inc., Medical Device Business Services, Inc., and Orthopediatrics Corp. The remaining authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Retrospective, Multicenter., Objective: Determine if posterior column osteotomies (PCO) at time of conversion from growth friendly instrumentation (GFI) to definitive fusion in early onset scoliosis (EOS) graduates impacts outcomes., Summary of Background Data: Increasing spinal rigidity following treatment of EOS with GFI can limit curve correction at time of conversion to definitive spinal fusion. PCO are often employed at the time of fusion to improve flexibility. This technique's efficacy has not been studied., Methods: EOS patients with GFI undergoing conversion to fusion were grouped by those that did or did not have PCO. Patients with inadequate radiographs, <2 years follow-up, or three-column osteotomies at time of fusion were excluded., Results: 832 patients met inclusion criteria. 175 (21%) patients had PCO. Age at index surgery was younger (6.6 vs. 7.4 y, P =0.0009) and the mean duration of GFI was greater (6.2 vs. 5.5 y, P =0.009) in the PCO group. Prior to fusion, curve magnitude was similar between the groups (PCO=61.9 degrees, no PCO=59.3 degrees, P=0.18). On average 4.4 osteotomies (range: 1 - 12) were performed for the PCO group and EBL (PCO=820 cc vs no PCO=752 cc, P<0.01) and surgical time (PCO=403 min vs no PCO=349 min, P<0.01) were greater. Postoperatively, mean curve correction (PCO=16.6, no PCO=14.4 degrees, P=0.18) was similar. Accounting for preoperative curve magnitude, there was a relationship between number of PCOs and curve correction (P=0.04). There was no relationship between degrees of correction per osteotomy and duration of GFI (P=0.12). Postoperative complications at 2 years were similar (PCO=25% vs no PCO=27%, P=0.63)., Conclusion: EOS graduates achieve minimal correction at time of conversion regardless of whether PCOs are performed. PCOs increase EBL and operative time but have a similar complication rate. More PCOs resulted in more correction, though less than that anticipated in a previously uninstrumented spine., Level of Evidence: III., Competing Interests: Although the authors have no disclosures related to the study, please find the Conflicts of Interests as follows: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: This purpose of this study was to assess the impact of patient and implant characteristics on LIV selection in ambulatory children with EOS and to assess the relationship between the touched vertebrae (TV), the last substantially touched vertebrae (LSTV), the stable vertebrae (SV), the sagittal stable vertebrae (SSV), and the LIV., Methods: A multicenter pediatric spine database was queried for patients ages 2-10 years treated by growth friendly instrumentation with at least 2-year follow up. The relationship between the LIV and preoperative spinal height, curve magnitude, and implant type were assessed. The relationships between the TV, LSTV, SV, SSV, and the LIV were also evaluated., Results: Overall, 281 patients met inclusion criteria. The LIV was at L3 or below in most patients with a lumbar LIV: L1 (9.2%), L2 (20.2%), L3 (40.9%), L4 (29.5%). Smaller T1 - T12 length was associated with more caudal LIV selection (p = 0.001). Larger curve magnitudes were similarly associated with more caudal LIV selection (p = < 0.0001). Implant type was not associated with LIV selection (p = 0.32) including MCGR actuator length (p = 0.829). The LIV was caudal to the TV in 78% of patients with a TV at L2 or above compared to only 17% of patients with a TV at L3 or below (p < 0.0001)., Conclusions: Most EOS patients have an LIV of L3 or below and display TV-LIV and LSTV-LIV incongruence. These findings suggest that at the end of treatment, EOS patients rarely have the potential for selective thoracic fusion. Further work is necessary to assess the potential for a more selective approach to LIV selection in EOS., Level of Evidence: III., (© 2024. The Author(s).)

Purpose: Post-operative coronal decompensation (CD) continues to be a challenge in the treatment of adolescent idiopathic scoliosis (AIS). CD following selective spinal fusion has been studied. However, there is currently little information regarding CD following Vertebral Body Tethering (VBT). Thus, the goal of this study is to better understand the incidence and risk factors for CD after VBT., Methods: Retrospective review of a prospective multicenter database was used for analysis. Inclusion criteria were patients undergoing thoracic VBT, a minimum 2-year follow-up, LIV was L1 or above, skeletally immature (Risser ≤ 1), and available preoperative and final follow-up AP and lateral upright radiographs. Radiographic parameters including major and minor Cobb angles, curve type, LIV tilt/translation, L4 tilt, and coronal balance were measured. CD was defined as the distance between C7PL and CSVL > 2 cm. Multiple logistic regression model was used to identify significant predictors of CD., Results: Out of 136 patients undergoing VBT, 94 patients (86 female and 6 male) met the inclusion criteria. The mean age at surgery was 12.1 (9-16) and mean follow-up period was 3.4 years (2-5 years). Major and minor curves, AVR, coronal balance, LIV translation, LIV tilt, L4 tilt were significantly improved after surgery. CD occurred in 11% at final follow-up. Lenke 1A-R (24%) and 1C (26%) had greater incidence of CD compared to 1A-L (4%), 2 (0%), and 3 (0%). LIV selection was not associated with CD. Multivariate logistic regression analysis yielded 1A-R and 1C curves as a predictor of CD with the odds ratio being 17.0., Conclusion: CD occurred in 11% of our thoracic VBT patients. Lenke 1A-R and 1C curve types were predictors for CD in patients treated with VBT. There were no other preoperative predictors associated with CD., (© 2024. The Author(s), under exclusive licence to Scoliosis Research Society.)

Current best practice guidelines recommend a plastics-style multilayer wound closure for high-risk pediatric spine surgery. However, plastic surgery closure of spinal incisions remains controversial. This study investigates surgeon perceptions and practice patterns regarding plastic surgery multilayered closure (PMC) in pediatric spine surgery. All surgeons in an international pediatric spine study group received a 30-question survey assessing incisional closure practices, frequency of plastic surgery collaboration, and drain management. Relationship to practice size, setting, geographic region, and individual diagnoses were analyzed. 87/178 (49%) surgeons responded from 79% of participating sites. Plastics utilization rates differed by diagnosis: neuromuscular scoliosis 16.9%, early onset scoliosis 7.8%, adolescent idiopathic scoliosis 2.8% (P < 0.0001). Plastics were used more for early onset scoliosis [odds ratio (OR) 18.5, 95% confidence interval (CI): 8.5, 40.2; P < 0.001] and neuromuscular scoliosis [OR 29.2 (12.2, 69.9); P < 0.001] than adolescent idiopathic scoliosis. Plastics use was unrelated to practice size, setting, or geographic region (P ≥ 0.09). Respondents used plastics more often for spina bifida and underweight patients compared to all other indications (P < 0.001). Compared to orthopaedic management, drains were utilized more often by plastic surgery (85 vs. 21%, P = 0.06) and for longer durations (P = 0.001). Eighty-nine percent of surgeons felt plastics increased operative time (58 ± 37 min), and 34% felt it increased length of hospitalization. Surgeons who routinely utilize plastics were more likely to believe PMC decreases wound complications (P = 0.007). The perceived benefit of plastic surgery varies, highlighting equipoise among pediatric spine surgeons. An evidence-based guideline is needed to optimize utilization of plastics in pediatric spine surgery., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Retrospective, Multicenter., Objective: Assess curve progression and occurrence of revision surgery following tether breakage after vertebral body tethering (VBT)., Summary of Background Data: Tether breakage after VBT is common with rates up to 50% reported. In these cases, it remains unknown whether the curve will progress or remain stable., Methods: Adolescent and juvenile idiopathic scoliosis patients in a multicenter registry with ≥2 year-follow-up after VBT were reviewed. Broken tethers were listed as postoperative complications and identified by increased screw divergence of >5° on serial radiographs. Revision procedures and curve magnitude at subsequent visits were recorded., Results: Of 186 patients who qualified for inclusion, 84 (45.2%) patients with tether breakage were identified with a mean age at VBT of 12.4±1.4 years and mean curve magnitude at index procedure of 51.8°±8.1°. Tether breakage occurred at a mean of 30.3±11.8 months and mean curve of 33.9°±13.2°. Twelve patients (12/84, 14.5%) underwent 13 revision procedures after VBT breakage, including 6 tether revisions and 7 conversions to fusion. All tether revisions occurred within 5 months of breakage identification. No patients with curves <35° after breakage underwent revision. Revision rate was greatest in skeletally immature (Risser 0-3) patients with curves ≥35° at time of breakage (Risser 0-3: 9/17, 53% vs. Risser 4-5: 3/23, 13%, P=0.01).Curves increased by 3.1° and 3.7° in the first and second year, respectively. By two years, 15/30 (50%) progressed >5° and 8/30 (26.7%) progressed greater than 10°. Overall, 66.7% (40/60) reached a curve magnitude >35° at their latest follow-up, and 14/60 (23.3%) reached a curve magnitude greater than 45°. Skeletal maturity did not affect curve progression after tether breakage (P>0.26), but time to rupture did (P=0.048)., Conclusion: While skeletal immaturity and curve magnitude were not independently associated with curve progression, skeletally immature patients with curves ≥35° at time of rupture are most likely to undergo additional surgery. Most patients can expect progression at least 5° in the first two years after tether breakage, though longer-term behavior remains unknown., Level of Evidence: III., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Skeletal dysplasias are a group of genetic conditions defined by atypical bone or cartilage growth and development. Skeletal abnormalities include short stature, limb deformity, joint contracture, and spinal deformity. Over 90% of disorders have a known genetic mutation that can definitively determine the diagnosis. As patients may present with a primary spinal concern, a careful clinical and radiographic evaluation can allow the physician to develop a working diagnosis to guide additional evaluation. Spinal manifestations include scoliosis and kyphoscoliosis, cervical instability, cervical kyphosis, thoracolumbar kyphosis, spinal stenosis, and atypical vertebral body morphology. An understanding of the affected conditions, prevalence, and natural history of these radiographic findings aids the orthopaedic surgeon in establishing a diagnosis and guides appropriate orthopaedic care., (Copyright © 2024 by the American Academy of Orthopaedic Surgeons.)

Study Design: Retrospective review., Objective: Our goal was to investigate the incidence of cervical degenerative disk disease (DDD) in patients with adolescent idiopathic scoliosis (AIS), before surgical intervention., Summary of Background Data: AIS is often associated with thoracic hypokyphosis and compensatory cervical kyphosis. In adults, cervical kyphosis is associated with DDD. Although cervical kyphosis has been reported in up to 60% AIS patients, the association with cervical DDD has not been reported., Materials and Methods: A retrospective review was conducted from January 2014 to December 2019 of all consecutive AIS patients. Inclusion criteria were AIS patients over 10 years of age with cervical magnetic resonance imaging and anterior-posterior and lateral spine radiographs within 1 year of each other. Magnetic resonance imaging were reviewed for evidence of cervical DDD. Severity of cervical changes were graded using the Pfirrmann classification and by a quantitative measure of disk degeneration, the magnetic resonance signal intensity ratio., Results: Eighty consecutive patients were included (mean age: 14.1 years, SD=2.5 years). Increasing cervical kyphosis was significantly correlated to decreasing thoracic kyphosis ( r =0.49, P <0.01) and increasing major curve magnitude ( r =0.22, P =0.04). Forty-five patients (56%) had the presence of DDD (grades 2-4) with a mean cervical kyphosis of 11.1° (SD=9.5°, P <0.01). More cervical kyphosis was associated with more severe cervical DDD as graded by Pfirrmann classification level ( P <0.01). Increasing cervical kyphosis was also positively associated with increasing magnetic resonance signal intensity ratio ( P <0.01). Nine patients had ventral cord effacement secondary to DDD with a mean cervical kyphosis of 22.8° (SD=8.6°) compared with 2.6° (SD=11.2°) in those who did not ( P <0.01)., Conclusions: Cervical kyphosis was significantly associated with increasing severity of cervical DDD in patients with AIS. Patients with evidence of ventral cord effacement had the largest degree of cervical kyphosis with a mean of 22.8±8.6°. This is the first study to evaluate the association between cervical kyphosis in AIS with cervical DDD., Competing Interests: D.L.S. has received royalties from Wolters Kluwer Health, Zimmer Biomet, Globus Medical, and Medtronic; consulting fees from Zimmer Biomet, Globus Medical, Top Doctors, and Orthobullets; research funding from NuVasive; has ownership interest in Zipline Medical Inc., Green Sun Medical, and Orthobullets; and has held leadership or advisory positions in the Pediatric Spine Foundation and CHLA Foundation. V.T. holds a leadership or advisory position for the Journal of Bone and Joint Surgery . K.D.I. has received consulting fees from Orthopediatrics and has served on a safety or advisory board with Medtronic. The remaining authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Parents frequently report retaining unused opioid pills following their child's surgery due to fear of untreated postoperative pain. Assessment of pain in adolescents with neurocognitive disability is challenging. We hypothesized that parents of adolescents with neurocognitive disability may report less opioid use and higher opioid pill retention., Methods: Adolescents (13-20 y) undergoing elective surgery (posterior spinal fusion, hip reconstruction, arthroscopy, tonsillectomy) were prospectively enrolled from a tertiary children's hospital from 2019 to 2020. Only adolescents prescribed opioids at discharge were included. Parents completed a preoperative survey collecting sociodemographic characteristics and two postoperative surveys at 30- and 90-d. Neurocognitive disability was determined at time of enrollment by caregiver report, and included adolescents with cerebral palsy, severe autism spectrum disorder, and discrete syndromes with severe neurocognitive disability., Results: Of 125 parent-adolescent dyads enrolled, 14 had neurocognitive disability. The median number of opioid pills prescribed at discharge did not differ by neurocognitive disability (29, interquartile range {IQR}: 20.0-33.3 versus 30, IQR: 25.0-40.0, P = 0.180). Parents of both groups reported similar cumulative days of opioid use (7.0, IQR: 3.0-21.0 versus 6.0, IQR:3.0-10.0, P = 0.515) and similar number of opioid pills used (4, IQR: 2.0-4.5 versus 12, IQR: 3.5-22.5, P = 0.083). Parents of both groups reported similar numbers of unused opioid pills (17, IQR: 12.5-22.5 versus 19, IQR: 8.0-29.0, P = 0.905) and rates of retention of unused opioids (15.4% versus 23.8%, P = 0.730)., Conclusions: The number of opioid pills prescribed did not differ by neurocognitive disability and parents reported similar opioid use and retention of unused opioid pills. Larger studies are needed to identify opportunities to improve postoperative pain control for children with neurocognitive disability., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: The Law Of Diminishing Returns (LODR) has been demonstrated for traditional growing rods, but there is conflicting data regarding the lengthening behavior of Magnetically Controlled Growing Rods (MCGR). This study examines a cohort of patients with early-onset scoliosis (EOS) with rib-to-spine or rib-to-pelvis-based MCGR implants to determine if they demonstrate the LODR, and if there are differences in lengthening behaviors between the groups., Methods: A prospectively collected multicenter EOS registry was queried for patients with MCGR with a minimum 2-year follow-up. Patients with rib-based proximal anchors and either spine- or pelvis-based distal anchors were included. Patients with non-MCGR, unilateral constructs, < 3 lengthenings, or missing > 25% datapoints were excluded. Patients were further divided into Primary-MCGR (pMCGR) and Secondary-MCGR (sMCGR)., Results: 43 rib-to-spine and 31 rib-to-pelvis MCGR patients were included. There was no difference in pre-implantation, post-implantation and pre-definitive procedure T1-T12 height, T1-S1 height, and major Cobb angles between the groups (p > 0.05). Sub-analysis was performed on 41 pMCGR and 19 sMCGR rib-to-spine patients, and 31 pMCGR and 17 sMCGR rib-to-pelvis patients. There is a decrease in rod lengthenings achieved at subsequent lengthenings for each group: rib-to-spine pMCGR (rho = 0.979, p < 0.001), rib-to-spine sMCGR (rho = 0.855, p = 0.002), rib-to-pelvis pMCGR (rho = 0.568, p = 0.027), and rib-to-pelvis sMCGR (rho = 0.817, p = 0.007). Rib-to-spine pMCGR had diminished lengthening over time for idiopathic, neuromuscular, and syndromic patients (p < 0.05), with no differences between the groups (p > 0.05). Rib-to-pelvis pMCGR neuromuscular patients had decreased lengthening over time (p = 0.01), but syndromic patients had preserved lengthening over time (p = 0.65)., Conclusion: Rib-to-spine and rib-to-pelvis pMCGR and sMCGR demonstrate diminished ability to lengthen over subsequent lengthenings., (© 2023. The Author(s), under exclusive licence to Scoliosis Research Society.)

Background: Spinal conditions, such as scoliosis and spinal tumors, are prevalent in neurofibromatosis type 1 (NF1). Despite the recognized importance of their early detection and treatment, there remain knowledge gaps in how to approach these manifestations. The purpose of this study was to utilize the experience of a multidisciplinary committee of experts to establish consensus-based best practice guidelines (BPGs) for spinal screening and surveillance, surgical intervention, and medical therapy in pediatric patients with NF1., Methods: Using the results of a prior systematic review, 10 key questions that required further assessment were first identified. A committee of 20 experts across medical specialties was then chosen based on their clinical experience with spinal deformity and tumors in NF1. These were 9 orthopaedic surgeons, 4 neuro-oncologists/oncologists, 3 neurosurgeons, 2 neurologists, 1 pulmonologist, and 1 clinical geneticist. An initial online survey on current practices and opinions was conducted, followed by 2 additional surveys via a formal consensus-based modified Delphi method. The final survey involved voting on agreement or disagreement with 35 recommendations. Items reaching consensus (≥70% agreement or disagreement) were included in the final BPGs., Results: Consensus was reached for 30 total recommendations on the management of spinal deformity and tumors in NF1. These were 11 recommendations on screening and surveillance, 16 on surgical intervention, and 3 on medical therapy. Five recommendations did not achieve consensus and were excluded from the BPGs., Conclusion: We present a set of consensus-based BPGs comprised of 30 recommendations for spinal screening and surveillance, surgical intervention, and medical therapy in pediatric NF1., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: The purpose of this study is to investigate the effect of the deformity angular ratio (DAR) on intra-operative neuromonitoring (IONM) signal changes during posterior spinal fusion (PSF) without vertebral column resection (VCR)., Methods: Retrospective review of severe pediatric spinal deformity patients treated with PSF without VCR or three-column osteotomy from 2008 to 2018. Exclusion criteria were prior instrumentation, lack of IONM, and incomplete radiographic data. Coronal DAR (C-DAR), sagittal DAR (S-DAR), and total DAR (T-DAR) were calculated and compared between patients with IONM signal loss and those without., Results: Two hundred and fifty-three patients met inclusion criteria. Forty-seven of two hundred and fifty-three (19%) patients had IONM signal loss. Intra-operative wake-up test was performed in seven cases; three of seven (43%) had a neurological deficit on wake-up test. All neurological deficits resolved at a mean of 41 days postop. IONM loss was associated with increased kyphosis (p = 0.003) and was not associated with Cobb angle (p = 0.16). S-DAR (p = 0.03) and T-DAR (p = 0.005) were associated with IONM signal loss but C-DAR was not (p = 0.06). Increased incidence of IONM signal loss was seen with S-DAR > 7 (p = 0.02) or T-DAR > 27 (p = 0.02). Twenty-four of ninety-two (26%) patients with S-DAR > 7 had IONM signal loss compared to twenty-three of one hundred and sixty-one (14%) with S-DAR ≤ 7 (OR, 2.1; 95% CI, 1.1-4.0). Seven of sixteen (44%) patients with T-DAR > 27 had signal loss compared to forty of two hundred and thirty-seven (17%) patients with T-DAR ≤ 27 (OR, 3.8; 95% CI, 1.3-10.9)., Conclusion: Patients with S-DAR > 7 or T-DAR > 27 have a higher risk of IONM loss during pediatric PSF even in the absence of a VCR or three-column osteotomies., (© 2023. The Author(s).)

Purpose: To assess the following hypotheses related to vertebral body tethering (VBT): 1. VBT is associated with asymmetric (concave > convex) increases in height over the instrumented vertebra. 2. The instrumented Cobb angle improves following VBT surgery with growth., Methods: This is a retrospective case series of pediatric patients from a multicenter scoliosis registry treated with VBT between 2013 to 2021., Inclusion Criteria: patients with standing radiographs at < 4 months and ≥ 2 years after surgery. Distances between the superior endplate of the UIV and the inferior endplate of the LIV were measured at the concave corner, mid-point, and convex corner of the endplates. The UIV-LIV angle was recorded. Subgroup analyses included comparing different Risser scores and tri-radiate cartilage (TRC) closed versus open using student t-tests., Results: 83 patients met inclusion criteria (92% female; age at time of surgery 12.5 ± 1.4 years) with mean follow-up time of 3.8 ± 1.4 years. Risser scores at surgery were: 0 (n = 33), 1 (n = 12), 2 (n = 10), 3 (n = 11), 4 (n = 12), and 5 (n = 5). Of the 33 Risser 0 patients, 17 had an open TRC, 16 had a closed TRC. The UIV-LIV distance at concave, middle, and convex points significantly increased from immediate post-op to final-follow-up for Risser 0 patients, but not for Risser 1-5 patients. Increases in UIV-LIV distance were not significantly different between concave, middle, and convex points for all groups. There was no significant improvement or worsening in UIV-LIV angle for any group., Conclusion: At a mean of 3.8 years following VBT, 33 Risser 0 patients demonstrated significant growth in the instrumented segment, though there was no difference between concave or convex growth, even for patients with open TRC., (© 2023. The Author(s).)

Purpose: Although the pediatric population typically has a high union rate, the cervical spine has a reputation for frequent pseduarthrosis, as high as 38% in some prior series. Our purpose was to examine the rate and risk factors for pseudarthrosis in pediatric cervical spine fusions., Methods: Retrospective review of all patients with ≥ 2 years follow-up undergoing cervical spinal fusion between January 2004 and December 2019 at a tertiary pediatric hospital. Pseudarthrosis was defined as an absence of radiographic union as assessed by the attending surgeon for which revision surgery was performed., Results: 64 patients (mean age: 8.4 ± 4.7 years) met inclusion criteria. Mean follow-up was 63.3 ± 41.4 months (range: 24-187 months). 28 fusions (44%) included the occiput. 41 patients (64%) had instrumentation, while 23 patients (36%) had uninstrumented fusions. 48 (75%) patients had a halo for a mean of 97.6 ± 49.5 days. The incidence of pseudarthrosis was as follows: overall = 8/64 (12.5%); posterior fusion = 14.8% (8/54); anterior fusions = 0% (0/4); and anteroposterior fusions = 0% (0/6). The rate of pseudarthrosis was over 8 times higher in fusions involving the occiput (occipitocervical fusion: 25.0%; 7/28 vs. cervical alone: 2.8%; 1/36; p = 0.02). Although not statistically significant, the rate of pseudarthrosis was 3 times higher in uninstrumented fusions (21.7%; 5/23) than instrumented fusions (7.3%; 3/41) (p = 0.12). In patients with uninstrumented fusion to the occiput, pseudarthrosis rate was 35.7% (5/14), which was higher compared to those who did not (6.0%; 3/50) (p = 0.01). Incidence of pseudarthrosis was similar in patients who received autograft (13.0%; 7/54) compared to allograft alone (10.0%; 1/10) (p > 0.999)., Conclusions: The pseudarthrosis rate in pediatric cervical spine fusions remained high despite frequent use of halo immobilization and autograft. Patients with uninstrumented occipitocervical fusions are at particularly high risk with more than 1 in 3 developing a pseudarthrosis., Study Design: Retrospective, Comparative., Level of Evidence: III., (© 2023. The Author(s).)

Growing rod (GR) instrumentation and the elongation, derotation, and flexion (EDF) casting technique are 2 alternatives for the treatment of early-onset scoliosis. Our purpose was to investigate the cost of these treatment options. This was a retrospective cohort study of patients with early-onset scoliosis treated at 2 institutions from 2007 to 2014 with either GR instrumentation or EDF casting. Patients with <2 years of follow-up were excluded. Physician and hospital charges and collections, total procedures, and procedure times until final follow-up or time of fusion were compared. Nineteen patients met the inclusion criteria; 8 in the GR group and 11 in the EDF casting group. There were no significant differences between the groups in age (P = .23), public versus private insurance (P = 1.0), or major curve (P = .21) at the initiation of treatment. Excluding final fusion, the EDF casting patients had an average of 2.1 (range: 0.7-6.6) procedures/year while the GR patients had an average of 1.5 (range: 0.8-2.7) procedures/year. The average procedure time for the EDF group was 104.2 minutes; the average procedure time for the GR group, excluding the index procedure, was 62.40 minutes (P = .001). Physician charges were 85% less for the EDF group (EDF= $1892.75, GR= $12,354.53, P < .001). Physician collections were 71% less for the EDF group (EDF= $731.10, GR= $2554.88, P = .001). Hospital charges and collections were similar between the groups (P = .82, P = .42). Physician charges for casting were approximately 18% of that of GRs. Compared to GRs, physician collections were 71% less for EDF casting patients per year., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

The purpose of this study was to assess if behavior and emotional function, as measured by the Pearson Behavioral Assessment Survey for Children, Second Edition (BASC-2) in patients and parents, changes with differing treatment protocols in patients with adolescent idiopathic scoliosis (AIS). One previous study showed abnormal BASC-2 scores in a substantial number of patients diagnosed with AIS; however, no study has assessed how these scores change over the course of treatment. AIS patients aged 12 to 21 years completed the BASC-2. The 176-item questionnaire was administered to subjects at enrollment, assessing behavioral and emotional problems across 16 subscales of 5 domains: school problems, internalizing problems, inattention/hyperactivity, emotional symptoms index, and personal adjustment. Parents were given an equivalent assessment survey. Surveys were administered again after 2 years. Subject treatment groups (bracing, surgery, and observation) were established at enrollment. Patients were excluded if they did not complete the BASC-2 at both time points. Forty-six patients met the inclusion criteria, with 13 patients in the surgical, 20 in the bracing, and 13 in the observation treatment groups. At enrollment, 26% (12/46) of subjects with AIS had a clinically significant score in 1 or more subscales, and after 2 years 24% (11/46) of subjects reported a clinically significant score in at least 1 subscale (P = .8). There were no significant differences in scores between enrollment and follow-up in any treatment group. Similar to what was reported in a previous study, only 36% (4/11) of patients had clinically significant scores reported by both patient and parent, conversely 64% (7/11) of parents were unaware of their child's clinically significant behavioral and emotional problems. Common patient-reported subscales for clinically significant and at-risk scores at enrollment included anxiety (24%; 11/46), hyperactivity (24%; 11/46), attention problems (17%; 8/46), and self-esteem (17%; 8/46). At 2-year follow-up, the most commonly reported subscales were anxiety (28%; 13/46), somatization (20%; 9/46), and self-esteem (30%; 14/46). Patients with AIS, whether observed, braced or treated surgically, showed no significant change in behavior and emotional distress over the course of their treatment, or compared with each other at 2-year follow-up., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: The proximal femur is a common location for pathologic fractures in children, yet there is little published information regarding this injury. The purpose of this study was to investigate the outcomes of pediatric pathologic proximal femur fractures due to benign bone tumors., Methods: A retrospective review of patients treated for pathologic proximal femur fractures from 2004 to 2018 was conducted. Inclusion criteria were age below 18 years and pathologic proximal femur fracture secondary to a benign bone tumor. Patients were excluded if they had <1 year of follow-up. Medical charts and serial radiographs were reviewed for fracture classification, underlying pathology, treatment, complications, and time to fracture healing., Results: A total of 14 patients were included. Mean age was 6±3 (3 to 11) years, and mean follow-up was 44±21 (22 to 86) months. Index treatment was spica casting in 9/14 (68%) patients, while 5/14 (32%) were treated with internal fixation. Of the 9 patients initially treated with casting, 22% (2/9) required repeat spica casting at a mean of 0.6 months after index treatment, 67% (6/9) required internal fixation at a mean of 20.3 months after index treatment, and 11% (1/9) did not require revision treatment. Eighty-eight percent (8/9) of patients treated with casting required revision treatment compared with 40% (2/5) of those treated with internal fixation (P=0.05). Nonunion occurred after 1 refracture, malunion with coxa vara occurred in 2 fractures, and the remaining 11/14 (84%) fractures had a union at a mean of 4.9±3.0 months All cases of malunion occurred in patients initially treated nonoperatively. There were 19 distinct complications in 10/14 (71%) patients. The incidence of any revision surgery was 64% (9/14)., Conclusions: In this series, pediatric pathologic proximal femur fractures demonstrated prolonged time to union, high incidence of revision surgery (64%), and substantial complication rate (71%). In children with pathologic proximal femur fractures, treatment with internal fixation is recommended as this series showed a 78% failure rate of initial conservative management., Level of Evidence: Level IV., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

In this article, we outline several key concepts to help develop your operating room team. This is an evolutionary process with numerous benefits to the team members, surgeon, and most importantly the patients. We outline strategies for engaging and preparing your team members so that the operating room runs more efficiently. We also outline the do's and don'ts of building trust amongst team members which is critical to transforming into a high functioning team., Competing Interests: L.M.A. is on the speakers bureau for Zimmer Biomet and Nuvasive. She is a reviewer for Journal of Pediatric Orthopaedics and for Journal of Bone and Joint Surgery. She is a consultant for Orthobullets. She has stock in EliLily Pharmaceuticals. She is a committee member for the International Pediatric Orthopaedic Symposium, POSNA and the Scoliosis Research Society. M.J.H. declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Severe early-onset scoliosis (EOS) is managed surgically but represents a challenge due to limited implant fixation points, large curve size, and fragile patients with comorbidities. Magnetically controlled growing rods (MCGRs) have the advantage of avoiding surgical intervention for routine lengthening, but their ability to address severe EOS has not been studied, to our knowledge., Methods: A retrospective review of a prospectively collected international database identified 44 children with severe (≥90°) EOS treated with MCGRs who met our study criteria. Etiology, age, and sex-matched patients treated with traditional growing rods (TGRs) were identified from the same database. Patients were evaluated at a 2-year follow-up. No patients with vertically expandable prosthetic titanium ribs (VEPTRs) were included. The health-related quality of life was evaluated with the 24-Item Early Onset Scoliosis Questionnaire (EOSQ-24)., Results: The mean preoperative major coronal curve was 104° in the MCGR group and 104° in the TGR group. At the 2-year follow-up, the mean major coronal curves were 52° and 66° (p = 0.001), respectively. The mean T1-T12 heights were 155 mm and 152 mm preoperatively and 202 mm and 192 mm at the 2-year follow-up (p = 0.088). According to Kaplan-Meier analysis, the 2-year unplanned-revision-free survival was 91% in the MCGR group and 71% in the TGR group (p < 0.005). The 2-year score in the EOSQ-24 pulmonary function domain was better in the MCGR group. There were no other significant differences in the EOSQ-24 scores between the groups., Conclusions: MCGRs for severe EOS provided significantly better major curve correction with significantly fewer unplanned revisions than TGRs at a 2-year follow-up., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/G741)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Facet fractures have been reported in a total of 6 young athletes in 4 previous publications. These injuries were not diagnosed on magnetic resonance imaging (MRI) or radiographs, and were identified on computed tomography (CT). Our purpose was to report a series of athletes with operatively managed facet fractures. This may be an under-recognized diagnosis., Methods: Retrospective review of pediatric patients with operatively managed isolated lumbar or sacral facet fractures from 3 tertiary pediatric hospitals from 2014 to 2019. Clinical records and imaging studies were reviewed., Results: Ten patients with symptomatic lumbar or sacral facet fractures met inclusion criteria (mean age at presentation; 13.3±2.1 years, 70% Female). All patients reported competitive participation in sports. On physical examination, 10/10 (100%) of patients had lower back pain that was exacerbated with lumbar spine extension. Limited CT scans demonstrated facet fractures in 10/10 (100%) patients not detected on plain film or MRI. All patients experienced significant relief of pain following excision of the facet fracture fragment. At time of first postoperative visit, 9/10 (90%) patients were pain free while one had generalized back pain thought to be related to fibromyalgia and not facet pathology. At time of last follow-up, 2/10 (20%) of patients reported nonspecific back pain that was not localized in the area of the facet fracture, while 80% (8/10) remained pain free. All patients 100% (10/10) returned to full participation to sports. There were no complications noted in this series. Average follow-up was 27 months (range: 1 to 68 mo)., Conclusions: Athletes with localized back pain exacerbated by spine extension may have a facet fracture. As facet fractures are usually not identified with radiographs or MRI, a limited CT scan should be considered in the evaluation of pediatric athletes with localized back pain exacerbated by extension. In this series, surgical excision of facet fracture fragments was safe and provided predictable pain relief., Competing Interests: L.M.A.: Eli Lilly: Stock or stock Options. Journal of Pediatric Orthopedics: Editorial or governing board. Nuvasive: Paid consultant; Paid presenter or speaker. Orthobullets: Publishing royalties, financial or material support. Pediatric Orthopaedic Society of North America: Board or committee member. D.J.M.: Pediatric Orthopaedic Society of North America: Board or committee member. P.J.C.: Journal of Bone and Joint Surgery—American: Editorial or governing board. Nuvasive: Paid consultant. Pediatric Orthopaedic Society of North America: Board or committee member. Scoliosis Research Society: Board or committee member. Spine Deformity: Editorial or governing board. D.L.S.: CHLA Foundation: Board or committee member. Grand Rounds: Paid consultant. Green Sun Medical: Stock or stock Options. Growing Spine Foundation: Board or committee member. Growing Spine Study Group: Board or committee member. Journal of Children’s Orthopaedics: Editorial or governing board. Nuvasive (Co-PI, Paid to Growing Spine Foundation): Research support. Orthobullets: Editorial or governing board; Paid consultant; Stock or stock Options. Orthopedics Today: Editorial or governing board. Spine Deformity: Editorial or governing board. Wolters Kluwer Health: Publishing royalties, financial or material support. ZimmerBiomet: IP royalties; Other financial or material support; Paid consultant; Paid presenter or speaker. Zipline Medical Inc.: Stock or stock Options. Scoliosis Research Society: Board or committee member. Zimmer Biomet: Paid consultant. The remaining authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Abstract: Pre-operative nutritional assessments have been used as a "cornerstone" to help optimize nutritional status and weight in children with cerebral palsy (CP) to lower the risk of postoperative complications. However, the potential value of nutritional assessments on surgical outcomes in patients with CP undergoing major orthopedic surgery remains unproven.Do pre-operative nutritional assessments reduce complication rates of varus derotational osteotomy surgery in children with CP? Are complication rates higher in patients with a gastrostomy tube (G-tube) and can they be decreased by pre-operative nutritional assessment?One-hundred fifty-five patients with CP who underwent varus derotational osteotomy from January 1, 2012 through December 31, 2017 at a tertiary pediatric hospital with minimum 6 months follow-up were retrospectively identified. One-hundred-ten (71%) were categorized as "non-ambulatory" (Gross Motor Function Classification System [GMFCS] IV-V), and 45 (29%) as "ambulatory" (GMFCS I-III). Variables assessed included age, GMFCS level, G-tube, body mass index (BMI) percentile, complications, and if patients underwent pre-operative nutritional assessment.One-hundred-eleven patients (71.6%) underwent pre-operative nutritional assessment. Sixty-two of 155 patients (40.0%) had G-tubes. In non-ambulatory patients with G-tubes, BMI percentile changes were not significantly different between patients with a pre-operative nutritional assessment compared to those without at 1 (P = .58), 3 (P = .61), 6 (P = .28), and 12 months (P = .21) postoperatively. In non-ambulatory patients who underwent pre-operative nutritional assessment, BMI percentile changes were not significantly different between those with and without G-tubes at 1 (P = .61), 3 (P = .71), 6 (P = .19), and 12 months (P = .10). Pulmonary complication rates were significantly higher in non-ambulatory patients with G-tubes than in non-ambulatory patients without G-tubes (20% vs 4%, P = .03). Pre-operative nutritional assessments did not influence postoperative complication rates for non-ambulatory patients with or without a G-tube (P = .12 and P = .16, respectively). No differences were found in postoperative complications between ambulatory patients with and without G-tubes (P = .45) or between ambulatory patients with or without nutritional assessments (P = .99).Nutritional assessments, which may improve long term patient nutrition, should not delay hip surgery in patients with CP and progressive lower extremity deformity. Patients and their families are unlikely to derive any short-term nutritional improvement using routine pre-operative evaluation and surgical outcomes are unlikely to be improved.Level of Evidence: III, retrospective comparative., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Improving pain control and decreasing opioid prescription and usage continue to be emphasized across both pediatric and adult populations. The purpose of this review is to provide a comprehensive assessment of recent literature and highlight new advancements pertaining to pain control in pediatric orthopaedic surgery., Methods: An electronic search of the PubMed database was performed for keywords relating to perioperative pain management of pediatric orthopaedic surgery. Search results were filtered by publication date for articles published between January 1, 2015 and December 1, 2020 and yielded 404 papers., Results: A total of 32 papers were selected for review based upon new findings and significant contributions in the following categories: risk factors for increased opioid usage, opioid overprescribing and disposal, nonpharmacologic interventions, nonsteroidal anti-inflammatory drugs, peripheral nerve blocks, spine surgery specific considerations, surgical pathway modifications, and future directions., Conclusions: There have been many advances in pain management for pediatric patients following orthopaedic surgery. Rapid recovery surgical care pathways are associated with shorter length of stay and improved pain control in pediatric spine surgery. Opioid overprescribing continues to be common and information regarding safe opioid disposal practices should be routinely provided for pediatric patients undergoing surgery., Level of Evidence: Level IV-literature review., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Retrospective cohort, multicenter. A single surgeon study demonstrated that pedicle tract preparation with power tools was associated with lower fluoroscopy times and revision rates compared to manual tools, while maintaining patient safety., Objective: Our purpose was to determine the safety of power-assisted pedicle tract preparation by early adopters of this technology., Methods: Retrospective review comparing patients that underwent posterior spinal fusion by seven pediatric spine surgeons at six institutions between January 1, 2008 and August 31, 2019. The manual pedicle tract preparation used a pedicle awl. Power tract preparation used a flexible 2.0-2.4 mm drill bit, followed by a larger drill bit or a reamer. All screws were inserted with power technique., Results: In the manual tract preparation group, 9424 screws were placed in 585 cases. In the power tract preparation group, 22,209 screws were placed in 1367 cases. Seven patients (7/1952; 0.36%; 95% CI: 0.14-0.74%) had 11 mal-positioned screws (11/31,633; 0.03%; 95% CI: 0.017-0.062%). Seven screws (7/9424; 0.07%; 95% CI: 0.030-0.15%) were in the manual cohort and four (4/22,209; 0.02%; 95% CI: 0.0049-0.046%) were in the power cohort. There were significantly more revisions per screw in the manual cohort (p = 0.02). However, there were not significantly more revisions per patient in the manual cohort (manual: 0.5%, 3/585 vs. power: 0.3%, 4/1,367; p = 0.43). Of these seven, three patients (3/585; 0.5%; 95% CI: 0.1-1.5%) experienced neurologic injury or neuro-monitoring changes requiring screw removal in the manual cohort, and 1 patient (1/1,367, 0.07%; 95% CI: 0.002-0.4%) in the power cohort (p = 0.08). Three additional patients underwent revision in the power cohort: 1 for an asymptomatic lateral breech, 1 for a spinal headache/medial breech that developed after an MVA, and 1 for an iliac vein injury during pedicle tract preparation., Conclusion: This is the first multi-center study examining power pedicle preparation. Overall, 99.9% of pedicle screws placed with power pedicle preparation did not have complications or revision. Equivalent patient safety was demonstrated compared to manual technique., Level of Evidence: III., (© 2021. Scoliosis Research Society.)

Study Design: Retrospective, multicenter comparative., Objectives: Our purpose was to compare early onset scoliosis (EOS) patients treated with ultra-low, low, and high implant density constructs when undergoing conversion to definitive fusion. Larson et al. demonstrated that implant density (ID) at fusion does not correlate with outcomes in the treatment of adolescent idiopathic scoliosis, but did not address growth-friendly graduates., Methods: EOS patients treated with growth-friendly constructs converted to fusion between 2000 and 2017 were reviewed from a multicenter database. ID was defined as number of pedicle screws, hooks, and sublaminar/bands per level fused. Patients were divided into ultra-low ID (< 1.3), low (≥ 1.3 and < 1.6), and high ID (≥ 1.6)., Exclusion Criteria: < 2 years follow-up from fusion or inadequate radiographs., Results: A total of 152 patients met inclusion criteria with 39 (26%) patients in the high ID group, 33 (22%) patients in the low ID group, and 80 (52%) in the ultra-low ID group. Groups were similar in operative time (p = 0.61), pre-fusion major curve (p = 0.71), mean number of levels fused (p = 0.58), clinical follow-up (p = 0.30), and radiographic follow-up (p = 0.90). Patients in the low ID group (11.6 ± 1.5 years) were slightly younger at the time of definitive fusion than patients in the ultra-low ID group (12.9 ± 2.2 years) and high ID group (12.5 ± 1.7 years) (p = 0.009). There was significantly more blood loss in the high ID group than the other two groups (high ID: 946.8 ± 606.0 mL vs. low ID: 733.9 ± 434.5 mL and ultra-low ID: 617.4 ± 517.2 mL; p = 0.01), but there was no significant difference with regard to percent of total blood volume lost (high ID: 59.3 ± 48.7% vs. low ID: 54.5 ± 37.5% vs. ultra-low ID: 51.7 ± 54.9%; p = 0.78). There was a difference in initial improvement in major curve between the groups (high ID: 21.6° vs. low ID: 18.0° vs. ultra-low ID: 12.6°; p = 0.01). However, during post-fusion follow-up, correction decreased 7.1° in the high ID group, 2.6 in the low ID group, and 2.8 in the ultra-low ID group (p = 0.19). At final follow-up, major curve correction from pre-fusion was similar between groups (high ID: 14.5° vs. low ID: 15.5° vs. ultra-low ID: 9.7°, p = 0.14). At final follow-up, there was no difference in T1-T12 length gain (p = 0.85), T1-S1 length gain (p = 0.68), coronal balance (p = 0.56), or sagittal balance (p = 0.71). The revision rate was significantly higher in the ultra-low ID group (13.8%; 11/80) versus the high ID group (2/39; 5.1%) and low ID group (0/33; 0%) (p = 0.04)., Conclusions: Although an ID < 1.3 in growth-friendly graduates produces similar outcomes with regard to curve correction and spinal length gain as low and high ID, this study suggests that an ID < 1.3 is associated with an increased revision rate., Level of Evidence: III., (© 2021. Scoliosis Research Society.)

Study Design: Retrospective cohort study., Objective: The purpose of this study is to investigate the incidence of surgical site infection in neuromuscular scoliosis (NMS) patients at a tertiary children's hospital before and after the implementation of strategies mentioned in the 2013 Best Practice Guideline., Summary of Background Data: Patients with NMS are at high risk for surgical site infection following spine surgery. In 2013, a Best Practice Guideline for surgical site infection prevention in high-risk pediatric spine surgery patients reported strategies to decrease incidence. To date, no studies have looked at the efficacy of these strategies., Methods: A retrospective review of surgical site infection in NMS patients was performed. NMS patients undergoing primary posterior spinal fusion from January 2008 to December 2012 (Group 1) and January 2014 to December 2018 (Group 2) were included, with 2013 excluded as a transition year. The primary outcome was incidence of surgical site infection within 1 year of surgery, as defined by the Centers for Disease Control and National Healthcare Safety Network. All patients had at least 1 year of documented follow-up., Results: One hundred ninety eight patients were included, 62 in Group 1 and 136 in Group 2. Age, BMI, sex, fusion to pelvis, preoperative Cobb angle, incontinence, drain use, blood loss, surgical time, and other perioperative values were similar (P > 0.05). Deep surgical site infection occurred in 10 (16.1%) patients in Group 1 and six (4.4%) patients in Group 2 (P = 0.005). Thirteen (59.1%) identified organisms were gram-negative, with 11 (84.6%) isolated from Group 1 (P = 0.047). Polymicrobial infections accounted for six (37.5%) infections overall., Conclusion: The incidence of surgical site infection in NMS patients decreased significantly (16.1% vs. 4.4%) after the implementation of the strategies mentioned in the 2013 Best Practice Guideline. Further studies are required to continue to decrease the incidence in this high-risk population.Level of Evidence: 3., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Methylnaltrexone, a peripheral opioid antagonist, is used to decrease opioid-induced constipation; however, there is limited evidence for its use in children. The primary objective of the study is to assess the efficacy of per os (PO) methylnaltrexone in inducing bowel movements (BMs) in patients with adolescent idiopathic scoliosis who underwent a posterior spinal fusion and instrumentation (PSFI). Secondary outcomes include hospital length of stay, postoperative pain scores, and postoperative opioid usage., Methods: Retrospective chart review identified all adolescent idiopathic scoliosis patients above 10 years of age who underwent PSFI with a minimum of 24 hours of postoperative opioid analgesia after the initiation of the new bowel regimen protocol. The bowel regimen included daily administration of PO methylnaltrexone starting on postoperative day 1 until BM is achieved. A case-matched cohort was obtained with patients who did not receive PO methylnaltrexone and otherwise had the same bowel function regimen. Case-matched controls were also matched for age, sex, body mass index, and curve severity. t Tests and Pearson χ2 tests were used for statistical analysis., Results: Fifty-two patients received oral methylnaltrexone (14±2.6 y) and 52 patients were included in the case-matched control group (14±2.1 y). The methylnaltrexone group had a significantly shorter hospital length of stay (3.09±0.66) compared with controls (3.69±0.80) (P<0.01). 59% (31 of 52) of the methylnaltrexone group had a BM by postoperative day postoperative day 2, compared with 30% (16 of 52) of the control group (P<0.01). In the methylnaltrexone group, 44% (23 of 52) of the patients required a Dulcolax (bisacodyl) suppository and 11% (6 of 52) required an enema, compared with 50% (26 of 52) and 33% (12 of 52) of the control group respectively (P=0.43 and 0.12). In addition, significantly less patients had abdominal distension during their postoperative stay in the methylnaltrexone group (17%, 9 of 52) compared with the control group (40%, 21 of 52) (P<0.01). There was no significant difference in self-reported average FACES pain score (P=0.39) or in opioid morphine equivalents required per hour (P=0.18)., Conclusions: Patients who received PO methylnaltrexone after PSFI had decreased length of stay and improved bowel function. Administration of methylnaltrexone did not increase maximum self-reported FACES pain values or opioid consumption compared with controls. The use of oral methylnaltrexone after PSFI reduces postoperative constipation, which has implications for reducing hospital length of stay and overall morbidity., Level of Evidence: Level III-retrospective comparative study., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Tension band plating for temporary hemiepiphysiodesis has been reported by several authors as simple and effective for treating angular deformities of the lower limb. Anecdotally, patients have reported higher pain levels than expected given the small size of incision and relatively minimal amount of dissection, and we sought to investigate this further., Methods: Patients 16 years old or less with lower extremity angular deformities or limb length inequality were prospectively enrolled before tension band plating from 2 pediatric institutions from July 2016 to December 2018. Participants completed postoperative questionnaires regarding their pain and activity level. Pain was assessed using the FACES Pain Scale. Patients were included if they completed the 1 month survey., Results: Of the 48 patients that met inclusion criteria (mean age at surgery: 13.1 y; range: 7 to 16 y), 39 patients completed the survey at 3 months postoperatively. There was a significant change in pain level between 1 week and 1 month postoperatively (P<0.001). Eighty-three percent (34/41) of patients were still taking pain medication at 1 week, which decreased to 38% (18/48) at 1 month. At 3 months, 21% (8/39) patients reported they were still using pain medication. At 1 month, 65% of patients (31/48) had not returned to their prior activity level. Of the 39 patients who played sports, 59% (23/39) still had not fully returned to sports at 1 month., Conclusion: At 1 month following tension band plating, 65% of patients had not returned to their preoperative activity level, and 38% were taking pain medications. Although the tension band plate and surgical incision is small in size, patients and parents should be counseled that there are significant activity limitations and pain levels for a month or longer in many patients., Level of Evidence: Level II., Competing Interests: D.L.S. reports he is a board or committee member for the CHLA Foundation, Growing Spine Foundation, and Growing Spine Study Group; a paid consultant for Grand Rounds; has stock or stock options in Green Sun Medical; is on the editorial or governing board for the Journal of Children’s Orthopaedics, Orthopedics Today, Spine Deformity; receives research support from Nuvasive (Co-PI, Paid to Growing Spine Foundation), is a paid consultant, is on the editorial or governing board, and has stock or stock options in Orthobullets; receives publishing royalties, financial, or material support from Wolters Kluwer Health; receives IP royalties, other financial or material support, is a paid consultant, paid presenter, or speaker at Zimmer Biomet; has stock or stock options in Zipline Medical Inc. P.M.S. receives IP royalties from Orthofix Inc. and orthopediatrics. L.M.A. is a paid consultant, paid presenter, or speaker at Biomet and Nuvasive; has stock or stock options in Eli Lilly; is on the editorial or governing board for the Journal of Pediatric Orthopedics; receives publishing royalties, financial or material support from Orthobullets; is a board or committee member for the Pediatric Orthopaedic Society of North America, Scoliosis Research Society; is a paid consultant at Zimmer. The remaining authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: There is no evidence-based consensus on the risk factors for concomitant osteomyelitis and septic arthritis. The purpose of this study was to investigate clinical parameters predictive of concomitant osteomyelitis in children with septic arthritis., Methods: A retrospective review was conducted on patients with septic arthritis with magnetic resonance imaging (MRI) between January 2004 and October 2016 at a tertiary care pediatric hospital. Medical charts were reviewed for information including symptoms, diagnosis of osteomyelitis, serum laboratory studies, joint fluid analyses, imaging results, and treatment. Positive diagnosis of osteomyelitis was defined as a hyperintense signal of osseous structures on T2-weighted MRI consistent with infection per attending pediatric radiologist final read., Results: A total of 71 patients with 73 septic joints were included. The mean age was 6±4 (0.1 to 17) years and the mean follow-up was 14.9±24.1 (1.0 to 133.1) months. Septic arthritis with concomitant osteomyelitis occurred in 43 of 71 (61%) patients, whereas 28 of 71 (39%) patients had septic arthritis alone. Inflammatory markers such as white blood cell count, erythrocyte sedimentation rate, and C-reactive protein on admission were not associated with concomitant osteomyelitis. Multivariate logistic regression revealed that positive joint fluid bacterial culture (P=0.021) and pain for >4 days before admission (P=0.004) are independent risk factors for concomitant osteomyelitis in children with septic arthritis. Among the 24 septic arthritis patients with pain for >4 days before presentation, 96% (23/24) had concomitant osteomyelitis, whereas 43% (20/47) of patients with pain for ≤4 days had concomitant osteomyelitis., Conclusion: Pain for >4 days before presentation is an independent predictor of osteomyelitis in children with septic arthritis. In pediatric septic arthritis, MRI should be considered, particularly in patients presenting with pain for >4 days as 96% of these patients had concomitant osteomyelitis., Level of Evidence: Level III-retrospective comparative study., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Case: There is a paucity of literature regarding pediatric upper cervical spine traumatic instability, atlanto-occipital dislocations, and fractures, with no clear treatment algorithm. We present a 12-year-old girl with significant posterior C1-C2 distraction and resultant ligamentous injury after a motor vehicle collision who was treated with a halo vest for 3 months. At 8-month follow-up, follow-up magnetic resonance imaging demonstrated complete ligamentous healing without instability on dynamic radiographs, and at 18-month follow-up, the patient made a full recovery., Conclusion: In some pediatric patients with isolated posterior ligamentous injury, as long as anatomic alignment can be achieved with halo-vest application, a fusion may be avoided., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B390)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Competing Interests: Disclosure: The author indicated that no external funding was received for any aspect of this work. On the Disclosure of Potential Conflicts of Interest form, which is provided with the online version of the article, the author checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work (http://links.lww.com/JBJS/G187).

Study Design: Retrospective comparative study OBJECTIVES: The goal of this study was to investigate fluoroscopy time and radiation exposure during pediatric spine surgery using a dedicated radiology technologist with extensive experience in spine operating rooms. Repetitive use of intraoperative fluoroscopy during posterior spinal fusion (PSF) exposes the patient, surgeon, and staff to radiation., Methods: Retrospective review was conducted on patients with posterior spinal fusion (PSF) of ≥ 7 levels for adolescent idiopathic scoliosis (AIS) at a pediatric hospital from 2015 to 2019. Cases covered by the dedicated radiology technologist (dedicated group) were compared to all other cases (non-dedicated group). Surgical and radiologic variables were compared between groups., Results: 230 patients were included. 112/230 (49%) were in the dedicated group and 118/230 (51%) were in the non-dedicated group. Total fluoroscopy time was significantly reduced in cases with the dedicated technologist (46 s) compared to those without (69 s) (p = 0.001). Radiation dose area product (DAP) and air kerma (AK) were reduced by 43% (p < 0.001) and 42% (p < 0.001) in the dedicated group, respectively. The dedicated group also had reduced total surgical time (4.1 vs. 3.5 h; p < 0.001) and estimated blood loss (447 vs. 378 cc (; p = 0.02). Multivariate regression revealed that using a dedicated radiology technologist was independently associated with decreased fluoroscopy time (p = 0.001), DAP (p < 0.001), AK (p < 0.001), surgical time (p < 0.001), and EBL (p = 0.02)., Conclusions: In AIS patients undergoing PSF, using a dedicated radiology technologist was independently associated with significant reductions in fluoroscopy time, radiation exposure, surgical time, and EBL. This adds to the growing body of research demonstrating that the experience level of the team-not just that of the surgeon-is necessary for optimal outcomes., Level of Evidence: III.

Study Design: Retrospective., Objective: The aim of this study is to evaluate if standing in a Schroth trained position influences the radiographic assessment of Cobb angle and other radiographic parameters compared to a normal standing position. Schroth method has been associated with improved Cobb angle. This study aims to evaluate if standing in the Schroth trained position influences radiographic assessment of Cobb angle compared to a normal standing position., Methods: This is a retrospective review of patients with adolescent idiopathic scoliosis (AIS) who were participating in Schroth therapy at the time of radiographs. Ten pairs of radiographs were included in this study. Each pair consisted of two micro-dose biplanar PA thoracolumbar spine radiographs obtained on the same day, one with the patient standing in the Schroth trained position and one in their normal standing position. Each pair of radiographs was independently evaluated by three attending pediatric spine surgeons for Cobb angle, coronal balance, shoulder balance, and leg length discrepancy, for a total of 30 paired readings (3 readings for each of the 10 pairs of radiographs)., Results: Major Cobb angle was a mean of 6° less (p = 0.02) and the compensatory curve was 5° less (p = 0.03) in the Schroth trained position compared to their normal standing position. Neither coronal balance (p = 0.40) nor shoulder balance (p = 0.16) was significantly different. Mean leg length discrepancy was 6.8 mm greater in the Schroth trained versus normal position (p < 0.001)., Conclusion: Standing in a Schroth trained position for a PA spine radiograph was associated with a mean change in major Cobb angle of 6° compared to a normal standing position. If bracing was recommended for curves > 25° and surgery for curves > 45°, different treatment recommendations would have been made in 33% (10/30) of attendings' readings for the Schroth versus normally paired radiographs taken on the same day on the same patient. Studies evaluating the effect of Schroth therapy on Cobb angle must report if patients are standing in a normal or Schroth trained position during radiographs for conclusions to be valid, or differences may be due to a temporary, voluntary change in posture., Level of Evidence: III.

Study Design: Multicenter retrospective., Objective: To determine the long-term complication rate associated with surgical treatment of spondylolisthesis in adolescents. There is limited information on the complication rate associated with posterior spinal fusion (PSF) of spondylolisthesis in the pediatric and adolescent population., Methods: Patients who underwent PSF for spondylolisthesis between 2004 and 2015 at four spine centers, < 21 years of age, were included. Exclusion criteria were < 2 years of follow-up or anterior approach. Charts and radiographs were reviewed., Results: 50 patients had PSF for spondylolisthesis, 26 had PSF alone, while 24 had PSF with trans-foraminal lumbar interbody fusion (TLIF). Mean age was 13.9 years (range 9.6-18.4). Mean follow-up was 5.5 years (range 2-15). Mean preoperative slip was 61.2%. 20/50 patients (40%) experienced 23 complications requiring reoperation at a mean of 2.1 years (range 0-9.3) for the following: implant failure (12), persistent radiculopathy (3), infection (3), persistent back pain (2), extension of fusion (2), and hematoma (1). In addition, there were 22 cases of radiculopathy (44%) that were transient. Rate of implant failure was related to preoperative slip angle (p = 0.02). Reoperation rate and rates of implant failure were not associated with preoperative % slip (reoperation: p = 0.42, implant failure: p = 0.15), postoperative % slip (reoperation: p = 0.42, implant failure: p = 0.99), postoperative kyphosis of the lumbosacral angle (reoperation: p = 0.81, implant failure: p = 0.48), change in % slip (reoperation: p = 0.30, implant failure: p = 0.12), change in slip angle (reoperation: p = 0.42, implant failure: p = 0.40), graft used (reoperation: p = 0.22, implant failure: p = 0.81), or addition of a TLIF (reoperation: p = 0.55, implant failure: p = 0.76)., Conclusion: PSF of spondylolisthesis in the adolescent population was associated with a 40% reoperation rate and high rate of post-operative radiculopathy. Addition of a TLIF did not impact reoperation rate or rate of radiculopathy.

Background: Parental mental status and behavior may influence postoperative recovery and the use of pain medication. The purpose of this study is to identify if parents with high anxiety are associated with prolonged narcotic use in adolescent patients following posterior spinal fusion surgery. Prolonged narcotic use in this study was defined as opioid use at their first postoperative visit., Methods: AIS patients age 11 to 20 years undergoing posterior spinal fusion and a parent were prospectively enrolled. At the preoperative appointment, patients completed the Spence Children's Anxiety Scale and parents completed the State-Trait Anxiety Inventory. High parental anxiety was defined as 1 SD above the normative mean. At the first postoperative visit, patients were asked about medication use., Results: A total of 58 patients (49 females and 9 males) were enrolled. Overall, 29% (17/58) of parents had a high general anxiety trait on the State-Trait Anxiety Inventory and 71% (41/58) had normal general anxiety. Of the patients whose parents had high general anxiety, 47% (8/17) were still taking narcotics at their first postoperative visit compared with 20% (8/41) of patients with normal anxiety parents (P=0.03)., Conclusions: Patients with high general anxiety parents were more than twice as likely to still be on narcotics at their first postoperative visit. This information can be used to counsel families on the impact of anxiety on narcotic usage., Level of Evidence: Level II-prognostic studies-investigating the effect of a patient characteristic on the outcome of the disease.

Background: To prospectively evaluate a displacement-based classification system and an outcome-derived algorithm in the treatment of children with lateral condyle fractures., Methods: All children with a lateral condyle fracture were prospectively enrolled at our institution between 2013 and 2016. Fractures were classified and treated on the basis of the following classification system: type 1: <2 mm; treated with long arm casting, type II: 2 to 4 mm; treated with closed reduction and percutaneous pinning (CRPP), and type III: >4 mm; open reduction and percutaneous pinning (ORPP). Functional outcomes were assessed at 6 to 12 weeks and at 1-year follow-ups using the Pediatric Outcomes Data Collection Instrument (PODCI)., Results: A total of 55 patients (mean age, 6 y; range 2 to 12 y) were prospectively enrolled. There were 17 (31%) type I fractures treated with a long arm cast, 8 (15%) type II treated with CRPP, and 30 (54%) type III treated with ORPP. Postoperative complications included delayed union (N=5) and pin site infection (N=3). Delayed unions on the basis of fracture type was type I (1/17, 6%), type II (1/8, 13%), and type III (3/30, 10%) (P=0.85). The rate of delayed unions in type II and III fractures fixed with k-wires was 11% (4/38). Four patients required a second operation with screw fixation. No significant differences were found across PODCI domains at 1-year follow-up when comparing our study population with normative data., Conclusions: This is the first prospective study of a treatment protocol for pediatric lateral condyle fractures and validates the use of displacement as a guide for best evidence-based treatment. Children with a lateral condyle fracture can achieve excellent functional outcomes in all classification types with comparable complication rates when radiographic fracture displacement is used to guide surgical and clinical decision making., Level of Evidence: Level II.

Study Design: Retrospective multi-center enrollment., Objective: To examine the impact of patient and surgical factors on proximal complication and revision rates of early onset scoliosis patients using a multicenter database. Proximal anchor pullout and junctional kyphosis are common causes necessitating revision surgery during growth friendly treatment of early onset scoliosis (EOS). Many options exist for proximal fixation and may impact the rate of these complications., Methods: Retrospective review of multicenter database of patients with growth friendly constructs for EOS. Inclusion criteria were patients with index instrumentation < 10 years of age and minimum of 2 year follow-up., Results: 353 patients met the inclusion criteria and had the following constructs: growing rods with spine anchors = 303; growing rods with rib anchors = 15 and VEPTR = 35. Mean age at index instrumentation was 6.0 years. Mean preoperative Cobb angle was 76° and mean kyphosis was 54°. Mean follow-up was 6.0 years. 21.8% of patients (77/353) experienced anchor pullout. Lower anchor pullout rates were associated with a higher numbers of proximal anchors (p = 0.003, r = - 0.157), and 5 or more anchors were associated with lower rates of anchor pullout (p = 0.014). Anchor type (rib hooks vs spine anchors vs rib cradle) did not impact rate of anchor pullout (p = 0.853). Kyphosis data was available for 198 patients. 23.2% (46/198) of these patients required proximal extension of their construct after index surgery. Initial instrumentation below the upper end vertebrae (UEV) of kyphosis was associated with higher rates of subsequent proximal revision; 28.9% (20/69) compared to 20.1% (26/129) for those instrumented at or above the UEV (p = 0.035). Preoperative kyphosis and change in thoracic kyphosis were not associated with anchor pullout (p = 0.436, p = 0.115) or proximal revision rates (p = 0.486, p = 0.401)., Conclusion: Five or more anchors are associated with lower rates of anchor pullout. Proximal anchor placement at or above the UEV resulted in a significant decrease in rates of proximal extension of the construct.

Literature regarding the value of pre-operative nasal methicillin resistant Staphylococcus aureus (MRSA) swabs to predict surgical site infections (SSIs) in children undergoing lower extremity surgery is limited. The purpose of our study was to determine if pre-operative nasal MRSA swab results were predictive of SSI development in children undergoing a femoral varus derotational osteotomy (VDRO).Patients who underwent VDRO between 2004-2016 were reviewed to determine pre-operative MRSA colonization rates and SSI devolvement rates. Patients with less than 1 year of follow-up, previous history of infections, or absent pre-operative MRSA swab were excluded. SSI rates of patients with negative MRSA and positive MRSA swab result were compared using the Fisher exact test. Aside from contact isolation precautions, no other changes in treatment were made during inpatient hospital course based on positive pre-operative nasal MRSA swab results.247 patients met the inclusion criteria (mean age: 9.3 ± 3.6 years, 62% male). There were 242 (98%) patients with a negative MRSA swab and 5 (2%) patients with a positive MRSA swab. Out of the 242 patients with a negative MRSA swab, 4 developed an SSI. Of the patients with positive MRSA swab results, 0% (0/5) developed an SSI compared to 1.7% (4/242) of negative MRSA swab results who developed an SSI. Results indicated no significant difference in SSI development rates between the groups (P = 1.00).In this series of children undergoing VDRO surgery, the results of a pre-operative MRSA nasal swab had no relationship to SSI incidence and no impact on clinical patient care. Pre-operative MRSA nasal swabs appear to be of limited benefit for routine pre-operative screening in this patient population.Level III, retrospective comparative.

Study Design: Retrospective, multicenter., Objective: To investigate clinical outcomes in particular T1-S1 growth in patients with SHILLA instrumentation independent of inventor's reports. Guided growth with apical fusion and sliding pedicle screws (GGC/SHILLA) is an alternative to distraction-based growing rods for the treatment of EOS. A recent report of patients treated with GGC primarily at the center where the procedure was invented reported surprisingly good spinal growth similar to normal growth., Methods: Retrospective review of EOS patients treated with GGC between 2007 and 2013 was performed from a multicenter database prior to final fusion. Inclusion criteria were < 10 years at index surgery and minimum 2-year follow-up. Patients with GGC performed at the inventor's institution or prior spinal instrumentation were excluded. Predicted normal T1-S1 change during the growth period was calculated for each patient based on Dimeglio's growth rates., Results: 20 patients (mean age at surgery: 5.7 years) with the following diagnoses met inclusion criteria: syndromic (N = 9), neuromuscular (N = 5), idiopathic (N = 3) and congenital (N = 3). Preoperative mean Cobb was 77° (range 33°-111°). Mean increase in T1-S1 length from preoperative to postoperative was 51.5 mm, and change from postoperative to final follow-up was 21.8 mm (4.2 mm/year) which was 36% of predicted growth. 15/20 (75%) patients underwent 21 revision surgeries most commonly for implant complications (N = 26) and 8/20 (40%) underwent definitive fusion at a mean of 5.1 ± 1.2 years after guided growth surgery., Conclusion: This study constitutes the largest case series of patients with EOS treated with GGC outside of the inventor's institution. The change in T1-S1 observed through the follow-up period in EOS patients treated with GGC was approximately 1/3rd of predicted normal growth, and less than 1/3rd of growth reported in previous reports. Similar curve correction and complication rates but less T1-S1 growth during the growth period were found compared to prior GGC (SHILLA) series.

The purpose of this study is to define the rate of implant failure and risk factors for failure in patients treated operatively for displaced medial epicondyle fractures.Patients <18 years of age with medial epicondyle humerus fractures that were treated with screw or k-wire fixation between 2005 and 2015 were eligible. Inclusion criteria included follow-up until radiographic union and no known medical conditions that could impair healing.Thirty four patients with 35 fractures were identified with an average age of 12 years old. 11.4% (n = 4/35) of fractures were treated using K-wires, 25.7% (n = 9/35) were treated using a screw and washer construction, and 62.9% (n = 22/35) were treated using screw alone. There were 16 reported complications (46%) including implant prominence requiring reoperation (6), implant failure (1), and fracture displacement (1). Other complications included non-union/delayed union (4), new ulnar nerve palsy (2), and decreased range of motion (2). Rates of complications were not different between the types of fixation (P = 1.0). Those who developed complications were younger than those who did not (P = 0.05). 91.4% of patients returned to full activity including weight bearing and throwing sports.Although 25% of patients experienced implant complications and the overall complication rate approached 50%, nearly all reported return to full activity.