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Background: The reported prevalence of non-neurologic complications following corrective surgery for adolescent idiopathic scoliosis ranges from 0% to 10%. However, most studies were retrospective evaluations of treatment techniques and did not focus solely on complications. The purpose of this study was to determine the prevalence of non-neurologic complications following surgery for adolescent idiopathic scoliosis and to identify preoperative and operative factors that can increase this risk.Methods: The demographic data, medical and surgical histories, and prevalence of non-neurologic complications were reviewed in a prospective cohort of 702 patients who had undergone corrective surgery for adolescent idiopathic scoliosis and were consecutively enrolled in a multicenter database.Results: There were 556 female and 146 male patients. The mean age at the time of surgery was 14.25 years (range, eight to eighteen years). Five hundred and twenty-three patients had only posterior spinal surgery, 105 had only anterior spinal surgery, and seventy-four had a combined anterior and posterior procedure. There was a total of 108 complications in eighty-one patients, for an overall prevalence of 15.4%. There were ten respiratory complications (1.42%), six cases of excessive bleeding (0.85%), five wound infections (0.71%), and five cases of wound hematoma, seroma, or dehiscence (0.71%). Five patients, two with an early infection and three with late failure of the implant, required a reoperation. Factors that did not correlate with an increased prevalence of complications were age, body mass index, presence of cardiac or respiratory disease, previous surgery, pulmonary function, surgical approach, number of levels fused, graft material, use of a diaphragmatic incision, Lenke curve type, or region of the major curve. Although the number of patients with renal disease was small, these patients were 7.90 times more likely to have a non-neurologic complication. Increased blood loss as well as prolonged operative and anesthesia times were associated with a higher prevalence of non-neurologic complications.Conclusions: The prevalence of non-neurologic postoperative complications following surgery for correction of adolescent idiopathic scoliosis in this study was 15.4%. The few factors noted to significantly increase the rate of complications include a history of renal disease, increased operative blood loss, prolonged posterior surgery time, and prolonged anesthesia time. [ABSTRACT FROM AUTHOR]

Background: Closed reduction and percutaneous pin fixation is the treatment of choice for completely displaced (type-III) extension supracondylar fractures of the humerus in children, although controversy persists regarding the optimal pin-fixation technique. The purpose of this study was to compare the efficacy of lateral entry pin fixation with that of medial and lateral entry pin fixation for the operative treatment of completely displaced extension supracondylar fractures of the humerus in children.Methods: This prospective, randomized clinical trial had sufficient power to detect a 10% difference in the rate of loss of reduction between the two groups. The techniques of lateral entry and medial and lateral entry pin fixation were standardized in terms of the pin location, the pin size, the incision and position of the elbow used for medial pin placement, and the postoperative course. The primary study end points were a major loss of reduction and iatrogenic ulnar nerve injury. Secondary study end points included radiographic measurements, clinical alignment, Flynn grade, elbow range of motion, function, and complications.Results: The lateral entry group (twenty-eight patients) and the medial and lateral entry group (twenty-four patients) were similar in terms of mean age, sex distribution, and preoperative displacement, comminution, and associated neurovascular status. No patient in either group had a major loss of reduction. There was no significant difference between the rates of mild loss of reduction, which occurred in six of the twenty-eight patients treated with lateral entry and one of the twenty-four treated with medial and lateral entry (p = 0.107). There were no cases of iatrogenic ulnar nerve injury in either group. There were also no significant differences (p > 0.05) between groups with respect to the Baumann angle, change in the Baumann angle, humerocapitellar angle, change in the humerocapitellar angle, Flynn grade, carrying angle, elbow flexion, elbow extension, total elbow range of motion, return to function, or complications.Conclusions: With use of the specific techniques employed in this study, both lateral entry pin fixation and medial and lateral entry pin fixation are effective in the treatment of completely displaced (type-III) extension supracondylar fractures of the humerus in children.Level Of Evidence: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

STUDY DESIGN: The medical records of 138 subjects with Early Onset Scoliosis (EOS) from 5 US institutions were reviewed to analyze their hemoglobin levels before and after surgery. Eighty-five subjects were operated with the Vertical Expandable Prosthetic Titanium Rib (VEPTR) and 53 with growing rods. OBJECTIVE: To estimate the prevalence of hypoxia and thoracic insufficiency using hemoglobin as a surrogate marker for pulmonary function, and to measure the effect of spine surgery with expandable devices. SUMMARY OF BACKGROUND DATA: An early intervention with expandable devices might improve pulmonary function. This hypothesis is difficult to test in young subjects because the standard pulmonary function tests require that the patient be at least 7-year old. Previous studies demonstrated that hemoglobin levels are correlated with chronic hypoxemia. METHODS: Blood data were collected before and 6 to 24 months after surgery. The hemoglobin and hematocrit levels were converted into Z-scores, using age-adjusted references to perform t test paired comparisons. RESULTS: The prevalence of elevated hemoglobin and hematocrit levels in EOS was 23.2% and 22.5%, respectively. The mean hemoglobin Z-score decreased from 1.26 to 0.92 (P = 0.03) after surgery and the hematocrit Z-score changed from 0.90 to 0.88 (P = 0.90). In the VEPTR group, the mean hemoglobin Z-score decreased from 0.98 to 0.69 (P = 0.20) and in the subgroup of subjects who had an expansion thoracostomy, it decreased from 0.82 to 0.24 (P = 0.04). In the subjects operated with growing rods, the hemoglobin Z-score decreased from 1.75 to 1.32 (P = 0.83). CONCLUSION: Twenty-three percent of the patients with EOS showed signs of chronic hypoxia. The hemoglobin levels decreased significantly 6 to 24 months after surgery. The greatest effect was observed in subjects with congenital scoliosis and rib fusion and who had an expansion thoracostomy with implantation of VEPTR. [ABSTRACT FROM AUTHOR]

Background: The STOP questionnaire was developed to document reasons for discontinuation of growth-friendly (GF) treatment in early onset scoliosis (EOS). This study investigated the incidence of parental request (PR) on the STOP questionnaire and compared clinical information and Early Onset Scoliosis 24-Item Questionnaire (EOSQ-24) scores of PR patients with those whose parents did not request discontinuation (non-parent request [NPR])., Materials and Methods: An international pediatric spine registry was queried for EOS patients with STOP questionnaires completed by their surgeon. Age at discontinuation, sex, and EOS etiology were recorded. GF device, number of surgical procedures, complications, STOP questionnaire reasons for discontinuation, and definitive treatment were recorded. EOSQ-24 scores and clinical information in the PR cohort were compared with the NPR cohort., Results: Data for 1326 patients were analyzed. PR was listed on the STOP questionnaires of 46 (3.5%) patients, completed at a mean age of 12 years (SD, 3.2 years). There were no statistical differences in number of procedures or complications when comparing the PR cohort with the NPR cohort. PR patients more frequently had neuromuscular EOS ( P =.002), more frequently were treated with magnetically controlled growing rods (33% vs 14%, P =.036), and more frequently were observed after GF discontinuation ( P =.628). EOSQ-24 scores for the PR cohort were significantly lower in most domains except pain/discomfort., Conclusion: For 3.5% of the EOS patients, PR was listed on the STOP questionnaire. They frequently had neuromuscular EOS and frequently were treated with magnetically controlled growing rods. Additionally, these patients had statistically lower EOSQ-24 scores across most domains. [ Orthopedics . 2024;47(6):e311-e316.].

Purpose: Using patient-reported outcome measures (PROMs), this study was undertaken to determine how well patients with early onset scoliosis (EOS) fare in adulthood., Methods: Among eight healthcare centers, 272 patients (≥ 18 years) surgically managed for EOS (≥ 5 years) completed the Scoliosis Research Society (SRS)-22r, Functional Assessment of Chronic Illness Therapy-10 (FACIT-Dyspnea-10), and Short Form (SF)-12. Functional and demographic data were collected., Results: The response rate was 40% (108/272). EOS etiologies were congenital (45%), neuromuscular (20%), idiopathic (20%) syndromic (11%), and unknown (4%). All patients scored within normal limits on the FACIT-Dyspnea-10 pulmonary (no breathing aids, 78%; no oxygen, 92%). SF-12 physical health scores and most SRS-22r domains were significantly decreased (p < 0.05 and p < 0.001, respectively) compared with normative values. SF-12 and SRS-22r mental health scores (MHS) were lower than normative values (p < 0.05 and p < 0.02, respectively). Physical health PROMs varied between etiologies. Treatment varied by etiology. Patients with congenital EOS were half as likely to undergo definitive fusion. There was no difference between EOS etiologies in SF-12 MHS, with t scores being slightly lower than normative peers., Conclusion: Good long-term physical and social function and patient-reported quality of life were noted in surgically managed patients. Patients with idiopathic EOS physically outperformed those with other etiologies in objective and PROM categories but had similar MHS PROMs. Compared to normative values, EOS patients demonstrated decreased long-term physical capacity, slightly lower MHS, and preserved cardiopulmonary function., Level of Evidence: Level IV Case Series., (© 2024. The Author(s).)

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.)

Optimal orientation for magnetically controlled growing rods (MCGRs) is unclear. The objective of this study was to investigate associations of rod orientation with implant-related complications (IRCs) and spinal height gains. Using an international early-onset scoliosis (EOS) database, we retrospectively reviewed 57 patients treated with dual MCGRs from May 2013 to July 2015 with minimum 2-year follow-up. Outcomes of interest were IRCs and left/right rod length gains and thoracic (T1-T12) and spinal (T1-S1) heights. We compared patients with two rods lengthened in the cephalad ( standard; n  = 18) versus opposite ( offset; n  = 39) directions. Groups did not differ in age, sex, BMI, duration of follow-up, EOS cause, ambulatory status, primary curve magnitude, baseline thoracic height, or number of distractions/year. We compared patients whose constructs used ≥1 cross-link (CL group; n  = 22) versus no CLs (NCL group; n  = 35), analyzing thoracic height gains per distraction ( α  = 0.05). Offset and standard groups did not differ in left or right rod length gains overall or per year or in thoracic or spinal height gain. Per distraction, the CL and NCL groups did not differ significantly in left or right rod length or thoracic or spinal height gain. Complications did not differ significantly between rod orientation groups or between CL groups. MCGR orientation and presence of cross-links were not associated with differences in rod length gain, thoracic height, spinal height, or IRCs at 2-year follow-up. Surgeons should feel comfortable using either MCGR orientation. Level of evidence: 3, retrospective., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: After discontinuation of growth-friendly (GF) surgery for early onset scoliosis, patients are termed graduates: they undergo a spinal fusion, are observed after final lengthening with GF implant maintenance, or are observed after GF implant removal. The purpose of this study was to compare the rates of and reasons for revision surgery in two cohorts of GF graduates: before or after 2 years of follow-up from graduation., Methods: A pediatric spine registry was queried for patients who underwent GF spine surgery with a minimum of 2 years of follow-ups after graduation by clinical and/or radiographic evidence. Scoliosis etiology, graduation strategy, number of, and reasons for revision surgery were queried., Results: There were 834 patients with a minimum of 2-year follow-up after graduation who were analyzed. There were 241 (29%) congenital, 271 (33%) neuromuscular, 168 (20%) syndromic, and 154 (18%) idiopathic. 803 (96%) had traditional growing rod/vertical expandable titanium rib as their GF construct and 31 (4%) had magnetically controlled growing rod. Five hundred ninety-six patients (71%) underwent spinal fusion at graduation, 208 (25%) had GF implants retained, and 30 (4%) had GF implants removed.In the entire cohort, there were 108/834 (13%) patients who underwent revision surgery. Of the revisions, 71/108 (66%) occurred as acute revisions (ARs) between 0 and 2 years from graduation (mean 0.6 y), and the most common AR indication was infection (26/71, 37%). The remaining 37/108 (34%) patients underwent delayed revision (DR) surgery >2 years (mean 3.8 y) from graduation, and the most common DR indication was implant issues (17/37, 46%).Graduation strategy affected revision rates. Of the 596 patients with spinal fusion as a graduation strategy, 98/596 (16%) underwent revision, compared with only 8/208 (4%) patients who had their GF implants retained, and 2/30 (7%) that had their GF implants removed ( P ≤ 0.001).A significantly higher percentage of the ARs had a spinal fusion as the graduation strategy (68/71, 96%) compared with 30/37 DRs, (81%, P = 0.015). In addition, the 71 patients who underwent AR undergo more revision surgeries (mean: 2, range: 1 to 7) than 37 patients who underwent DR (mean: 1, range: 1 to 2) ( P = 0.001)., Conclusion: In this largest reported series of GF graduates to date, the overall risk of revision was 13%. Patients who undergo a revision at any time, as well as ARs in particular, are more likely to have a spinal fusion as their graduation strategy. Patients who underwent AR, on average, undergo more revision surgeries than patients who underwent DR., Level of Evidence: Level III, comparative., Competing Interests: C.K.H.: Medtronic—Paid consultant; Orthopediatrics—Paid consultant. J.B.E.: Biomet—Paid consultant; DePuy, A Johnson & Johnson Company—IP royalties; Johnson & Johnson—Paid consultant; Journal of Children’s Orthopedics—Editorial or governing board. G.H.T.: Executive Committee Growing Spine Founding—Board or committee member; Journal of Pediatric Orthopedics—Editorial or governing board; Orthopediatrics —IP royalties, Paid consultant, Stock or stock options; Orthopediatrics—Travel expenses and per diem financial or material support; Scoliosis Research Society—Board or committee member; Shriner’s Hospital for Children—Executive Committee and Medical Advisory Board Member; Shriner’s Hospital for Children—Salary as Interim Chief Medical Officer; Societe Internationale de Chirurgie Orthopedique et de Traumatologie—Board or committee member; Wolters Kluwer Health, Lippincott Williams & Wilkins—Publishing royalties. P.D.S.: DePuy, A Johnson & Johnson Company – IP royalties, Paid consultant, Research support, Globus Medical – IP royalties, Journal of Bone and Joint Surgery—Editorial or governing board; Journal of Bone and Joint Surgery, American—Publishing royalties; Orthopediatrics—Financial or material support; Scoliosis Research Society—Board or committee member. J.T.S.: Biomet—Paid consultant; Children’s Spine Foundation—Board of Directors; DePuy, A Johnson & Johnson Company—Paid consultant; Globus Medical—IP royalties, Paid consultant; GS Medical—Paid consultant; Missonix—Paid presenter or speaker; Nuvasive—Paid consultant; Scoliosis Research Society—Board or committee member; Wishbone Medical—Paid consultant. 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 – Research support (paid to Growing Spine Foundation); 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; ZimmerBiomet—IP royalties, Financial or material support, Paid consultant, Paid presenter or speaker; Zipline Medical, Inc.—Stock or stock options. R.F.M.: Globus Medical—Paid consultant; Pediatric Orthopaedic Society of North America—Board or committee member; Scoliosis Research Society—Board or committee member. The remaining authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

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.)

Background: The term "Tweener" is colloquially used to refer to early-onset scoliosis (EOS) patients whose age and development make them candidates for multiple surgical options. The purpose of this study was to establish expert consensus on a definition to formally characterize the Tweener population., Methods: A 3-round survey of surgeons in an international EOS study group was conducted. Surgeons were provided with various patient characteristics and asked if each was part of their definition for Tweener patients. Responses were analyzed for consensus (≥70%), near-consensus (60% to 69%), and no consensus (<60%)., Results: Consensus was reached (89% of respondents) for including chronological age in the Tweener definition; 8 to 10 years for females and 9 to 11 years for males. Surgeons agreed for inclusion of Sanders score, particularly Sanders 2 (86.0%). Patients who have reached Sanders 4, postmenarche, or have closed triradiate cartilage should not be considered Tweeners. Bone age range of 8 years and 10 months to 10 years and 10 months for females (12 y for males) could be part of the Tweener definition., Conclusions: This study suggests that the Tweener definition could be the following: patients with open triradiate cartilage who are not postmenarche and have not reached Sanders 4, and if they have one of the following: Sanders 2 or chronological age 8 to 10 years for females (9 to 11 y for males) or bone age 8 years and 10 months to 10 years and 10 months for females (12 y for males). This definition will allow for more focused and comparative research on this population., Level of Evidence: Level V-expert opinion., Competing Interests: B.A.A. reports personal fees from DePuy Spine, NuVasive, and Stryker Spine outside the submitted work. J.B.A. reports personal fees from Johnson and Johnson outside the submitted work. J.T.B. reports grants from POSNA and personal fees from Orthopediatrics and Depuy Synthes outside the submitted work. J.B.E. reports personal fees from Zimmer/Biomet outside the submitted work. J.R.S. reports personal fees from Elsevier, Orthopediatrics, Medtronic Spine, and Depuy Synthes outside the submitted work. J.F. reports personal fees from The Research Grants Council of Hong Kong, American Society for Bone and Mineral Research, Biomet, Wolters Kluwer Health-Lippincott Williams and Wilkins, and leadership in American Board of Orthopaedic Surgery outside the submitted work. C.E.J. reports personal fees from Medtronic, Elsevier, and Shriners Hospital Montreal PQ outside the submitted work. R.F.M. reports personal fees from Globus Medical and Stryker outside the submitted work. R.M. reports personal fees from Medtronic and Orthopediatrics outside the submitted work. B.R. reports personal fees from Elsevier Publishing, grants from Pediatric Orthopaedic Society of North America and Orthopaedic Research and Education Foundation outside the submitted work. M.C.W. reports grants or contracts from Zimmer Biomet, POSNA, and Shriners Hospital for Children, personal fees from Zimmer Biomet Spine, Depuy Synthes Spine, Nuvasive Spine, Stryker/K2M Spine, CHOP FDA course, Samaritan Health Services Grand Rounds, Saint Alphonsus Grand Rounds, and Peace Health Grand Rounds, leadership in PSSG, SRS, POSNA, and Shriners Spine Surgeon Study Group outside the submitted work. H.M. reports personal fees from Pediatric Spine Foundation, grants from Scoliosis Research Society, grants from Pediatric Orthopaedic Society of North America outside the submitted work. M.G.V. reports nonfinancial support from Pediatric Spine Foundation, during the conduct of the study; grants from Setting Scoliosis Straight Foundation, grants and other from Children’s Spine Foundation, grants from Orthopaedic Scientific Research Foundation, grants and other from POSNA, other from OMeGA, personal fees from Stryker, personal fees from Biomet, personal fees from Nuvasive outside of the submitted work. B.D.R. reports grants from Pediatric Orthopaedic Society of North America, Orthopaedic Scientific Research Foundation, and Scoliosis Research Society outside the submitted work. Pediatric Spine Study Group reports support from Zimmer Biomet, DePuy Synthes Spine, Pediatric Spine Foundation, OrthoPediatrics, Nuvasive, Medtronic, Globus Medical Inc., and Stryker during the conduct of the study. The remaining authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Retrospective cohort study., Objective: To assess if initial adherence to prescribed brace wear for adolescent idiopathic scoliosis (AIS) predicts future adherence and curve improvement., Summary of Background Data: AIS bracing can be effective if patients adhere to prescribed brace wear. Previous research has associated age, sex, and brace prescription length with future adherence. We hypothesize that a patient's initial adherence to brace wear may be associated with future adherence and outcomes., Materials and Methods: Consecutive AIS patients who met the Scoliosis Research Society (SRS) criteria for bracing from 2015 to 2019 at a single center were reviewed. Patients were stratified into groups based on their adherence during the initial one-month brace wean-in period-adherent patients were defined as wearing the brace >80% of the daily prescribed amount. Brace wear was recorded by a thermosensor and assessed during the wean-in period, six-, 12-, and 24-month postbracing appointments. Statistical testing was conducted to analyze if initial adherence was associated with future adherence, curve change, and bracing success -defined as reaching Risser stage 4 with a Cobb angle <40°., Results: Sixty patients (mean age=12.5 yr) were included, of which the majority were females (83%) with thoracic curves (70%). Thirty-two patients were considered adherent, and this cohort demonstrated improved adherence relative to the nonadherent group at the six-, 12-, and 24-month appointments ( P <0.001). Adherent patients also showed a significant reduction in their scoliosis at the 12-month appointment, unlike nonadherent patients ( P <0.001). Ninety-seven percent of adherent patients achieved bracing success compared with 71% of nonadherent ( P =0.016). Females were more likely to be adherent than males., Conclusions: Initial adherence to prescribed AIS brace wear was associated with future adherence, bracing success, and curve improvement. Early recognition of nonadherence may offer an opportunity for supportive intervention to improve brace wear behavior., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Consensus and uncertainty in early onset scoliosis (EOS) treatment were evaluated in 2010. It is currently unknown how treatment preferences have evolved over the past decade. The purpose of this study was to re-evaluate consensus and uncertainty among treatment options for EOS patients to understand how they compare to 10 years ago., Methods: 11 pediatric spinal surgeons (similar participants as in 2010) were invited to complete a survey of 315 idiopathic and neuromuscular EOS cases (same cases as in 2010). Treatment options included the following: conservative management, distraction-based methods, growth guidance/modulation, and arthrodesis. Consensus was defined as ≥ 70% agreement, and uncertainty was < 70%. Associations between case characteristics and consensus for treatments were assessed via chi-squared and multiple regression analyses. Case characteristics associated with uncertainty were described., Results: Eleven surgeons [31.7 ± 7.8 years of experience] in the original 2010 cohort completed the survey. Consensus for conservative management was found in idiopathic patients aged ≤ 3, whereas in 2010, some of these cases were selected for surgery. There is currently consensus for casting idiopathic patients aged 1 or 2 with moderate curves, whereas in 2010, there was uncertainty between casting and bracing. Among neuromuscular cases with consensus for surgery, arthrodesis was chosen for patients aged 9 with larger curves., Conclusion: Presently, preferences for conservative management have increased in comparison to 2010, and casting appears to be preferred over bracing in select infantile cases. Future research efforts with higher levels-of-evidence should be devoted to elucidate the areas of uncertainty to improve care in the EOS population., Level of Evidence: Level V., (© 2022. The Author(s), under exclusive licence to Scoliosis Research Society.)

Purpose: The purpose of this study was to describe contraindications to the magnetically controlled growing rod (MCGR) in patients with early onset scoliosis (EOS) by establishing consensus amongst expert surgeons who treat these patients frequently., Methods: Nine pediatric spine surgeons from an international EOS study group participated in semi-structured interviews via email to identify factors that influence decision making in the use of MCGR. A 39-question survey was then developed to specify these factors as contraindications for MCGR-these included patient age and size, etiology, medical comorbidities, coronal and sagittal curve profiles, and skin and soft tissue characteristics. Pediatric spine surgeons from the EOS international study group were invited to complete the survey. A second 29-item survey was created to determine details and clarify results from the first survey. Responses were analyzed for consensus (> 70%), near consensus (60-69%), and no consensus/variability (< 60%) for MCGR contraindication., Results: 56 surgeons of 173 invited (32%) completed the first survey, and 64 (37%) completed the second survey. Responders had a mean of over 15 years in practice (range 1-45) with over 6 years of experience with using MCGR (range 2-12). 71.4% of respondents agreed that patient size characteristics should be considered as contraindications, including BMI (81.3%) and spinal height (84.4%), although a specific BMI range or a specific minimum spinal height were not agreed upon. Among surgeons who agreed that skin and soft tissue problems were contraindications (78.6%), insufficient soft tissue (98%) and skin (89%) to cover MCGR were specified. Among surgeons who reported curve stiffness as a contraindication (85.9%), there was agreement that this curve stiffness should be defined by clinical evaluation (78.2%) and by traction films (72.3%). Among surgeons who reported sagittal curve characteristics as contraindications, hyperkyphosis (95.3%) and sagittal curve apex above T3 (70%) were specified. Surgeons who indicated the need for repetitive MRI as a contraindication (79.7%) agreed that image quality (72.9%) and not patient safety (13.6%) was the concern. In the entire cohort, consensus was not achieved on the following factors: patient age (57.4%), medical comorbidities (46.4%), etiology (53.6%), and coronal curve characteristics (58.9%)., Conclusion: Surgeon consensus suggests that MCGR should be avoided in patients who have insufficient spinal height to accommodate the MCGR, have potential skin and soft tissue inadequacy, have too stiff a spinal curve, have too much kyphosis, and require repetitive MRI, particularly of the spine. Future data-driven studies using this framework are warranted to generate more specific criteria (e.g. specific degrees of kyphosis) to facilitate clinical decision making for EOS patients., Level of Evidence: Level V-expert opinion., (© 2022. The Author(s), under exclusive licence to Scoliosis Research Society.)

Background: Juvenile idiopathic scoliosis (JIS) outcomes with brace treatment are limited with poorly described bracing protocols. Between 49 and 100% of children with JIS will progress to surgery, however, young age, long follow-up, and varying treatment methods make studying this population difficult. The purpose of this study is to report the outcomes of bracing in JIS treated with a Boston brace™ and identify risk factors for progression and surgical intervention., Methods: This is a single-center retrospective review of 175 patients with JIS who initiated brace treatment between the age of 4 and 9 years. A cohort of 140 children reached skeletal maturity; 91 children had surgery or at least 2 year follow-up after brace completion. Standard in-brace protocol for scoliosis 3 20° was a Boston brace for 18-20 h/day after MRI (n = 82). Family history, MRI abnormalities, comorbidities, curve type, curve magnitude, bracing duration, number of braces, compliance by report, and surgical interventions were recorded., Results: Children were average 7.9 years old (range 4.1-9.8) at the initiation of bracing. The Boston brace™ was prescribed in 82 patients and nine used night bending brace. Mid-thoracic curves (53%) was the most frequent deformity. Maximum curve at presentation was on average 30 ± 9 degrees, in-brace curve angle was 16 ± 8 degrees, and in-brace correction was 58 ± 24 percent. Patients were braced an average of 4.6 ± 1.9 years. 61/91 (67%) went on to posterior spinal fusion at 13.3 ± 2.1 (range 9.3-20.9) years and curve magnitude of 61 ± 12 degrees. Of those that underwent surgery, 49/55 (86%) progressed > 10°, 6/55 (11%) stabilized within 10°, and 0/55 (0%) improved > 10° with brace wear. No children underwent growth-friendly posterior instrumentation. Of the 28 who did not have surgical correction, 3 (11%) progressed > 10°, 13/28 (46%) stabilized within 10°, and 12/28 (43%) improved > 10° with brace wear., Conclusions: This large series of JIS patients with bracing followed to skeletal maturity with long-term follow-up. Surgery was avoided in 33% of children with minimal to no progression, and no child underwent posterior growth-friendly constructs. Risk factors of needing surgery were noncompliance and larger curves at presentation., (© 2022. The Author(s).)

Background: Children with medical complexity are at increased risk of low bone mineral density (BMD) and complications after spinal fusion compared with idiopathic scoliosis patients. Our aim was to compare treatments and outcomes of children with medical complexity undergoing spinal fusion in those who had dual-energy x-ray absorptiometry (DXA) scans versus those who did not in an effort to standardize the workup of these patients before undergoing spinal surgery., Methods: We conducted a retrospective review of patients with low BMD who underwent spinal fusion at a tertiary care pediatric hospital between 2004 and 2016. We consulted with a pediatric endocrinologist to create standard definitions for low BMD to classify each subject. Regardless of DXA status, all patients were given a clinical diagnosis of osteoporosis [at least 2 long bone or 1 vertebral pathologic fracture(s)], osteopenia (stated on radiograph or by the physician), or clinically low bone density belonging to neither category. The last classification was used for patients whose clinicians had documented low bone density not meeting the criteria for osteoporosis or osteopenia. Fifty-nine patients met the criteria, and 314 were excluded for insufficient follow-up and/or not meeting a diagnosis definition. BMD Z -scores compare bone density ascertained by DXA to an age-matched and sex-matched average. Patients who had a DXA scan were also given a DXA diagnosis of low bone density (≤-2 SD), slightly low bone density (-1.0 to -1.9 SD), or neither (>-1.0 SD) based on the lowest BMD Z -score recorded., Results: Fifty-nine patients were analyzed. Fifty-four percent had at least 1 DXA scan preoperatively. Eighty-one percent of DXA patients received some form of treatment compared with 52% of non-DXA patients ( P =0.03)., Conclusions: Patients referred for DXA scans were more likely to be treated for low BMD, although there is no standardized system in place to determine which patients should get scans. Our research highlights the need to implement clinical protocols to optimize bone health preoperatively., Level of Evidence: Level II-retrospective prognostic study., Competing Interests: J.G.B. is on the editorial board of JAMA Pediatrics . N.S.M. is a paid consultant for and received research support from Ascendis Pharma, research support from Ultragenyx, and financial support from UpToDate. D.J.H. is a paid consultant for Medtronic. L.I.K. received financial support from K2M. J.B.E. is a paid consultant for Biomet and Johnson & Johnson, receives IP royalties from DePuy, and is on the editorial board of the Journal of Children’s Orthopedics . M.T.H. is a board/committee member of the American College of Rheumatology Arthritis Foundation and the Pediatric Orthopaedic Society of North America, has stock/stock options in EOSI, and is on the editorial board of the New England Journal of Medicine . B.D.S. is a board/committee member of AAOS, Orthopaedic Research Society, Pediatric Orthopaedic Society of North America, and Scoliosis Research Society and an unpaid consultant for OrthoPediatrics. M.P.G. is a paid presenter for Biomet, DePuy, Medtronic, and Nuvasive, received research support as a member of HSG and PSSG, and is a paid consultant for Orthobullets and received financial support and stock/stock options from them. The remaining authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Although scoliosis and kyphosis have been associated with Williams Syndrome (WS), no previous literature has reported on surgical treatment for early onset scoliosis (EOS) in WS. The aim of this case series is to report on the outcomes of spine deformity surgery in patients with EOS and WS and any perioperative anesthetic or cardiovascular complications., Methods: One multicenter database was queried for all patients with WS who underwent growth-friendly (GF) treatment before age 12 between 2000 and 2017. Demographics, surgical, and growth-friendly data were queried. Radiographs were measured for curve magnitude, T1-T12 length, and T1-S1 length., Results: Seven patients were analyzed (3 males, 4 females). Patients were at a median age of 2.8 years at initial surgery with median follow-up 3.6 years (range 2.0-12 years) after index surgery. The initial surgical treatments were as follows: 2 traditional growing rods (TGR), 2 magnetically controlled growing rods (MCGR), and 3 vertical expandable prosthetic titanium ribs (VEPTR). The median duration of growth-friendly treatment was 5.0 years (range, 2.6-10.4 years) with a median number of 9 device lengthenings. The median improvement in coronal curve magnitude from preoperative to most recent follow-up was 19° (range, 54°-9°). Three patients have completed GF treatment: one underwent definitive fusion, and two are under observation with apparent spontaneous fusion and retain the original GF implants. No peri-operative anesthetic or cardiovascular complications occurred., Conclusions: Few studies have reported on surgical outcomes in WS patients with EOS. In this case series, 6/7 patients experienced curve improvement with growth-friendly spine instrumentation. This study suggests that growth-friendly instrumentation for severe EOS in WS can be used for control of spinal deformity while allowing for further growth. Associated complications were typical of distraction-based EOS surgical treatment. There were 62 total procedures with general anesthesia, but no perioperative cardiac complications occurred., (© 2022. The Author(s), under exclusive licence to Scoliosis Research Society.)

Introduction: Early-onset scoliosis (EOS) is a spinal deformity that occurs in patients 9 years of age or younger. Severe deformity may result in thoracic insufficiency, respiratory failure, and premature death. The purpose of this study is to describe the modern-day natural history of mortality in patients with EOS., Methods: The multicenter Pediatric Spine Study Group database was queried for all patients with EOS who are deceased, without exclusion. Demographics, underlying diagnoses, EOS etiology, operative and nonoperative treatments or observation, complications, and date of death were retrieved. Descriptive statistics and survival analysis with Kaplan-Meier curves were performed., Results: There were 130/8009 patients identified as deceased for a registry mortality rate of 16 per 1000 patients. The mean age at death was 10.6 years (range: 1.0 to 30.2 y) and the most common EOS etiology was neuromuscular (73/130, 56.2%; P<0.001). Deceased patients were more likely be treated operatively than nonoperatively or observed (P<0.001). The mean age of death for patients treated operatively (12.3 y) was older than those treated nonoperatively (7.0 y) or observed (6.3 y) (P<0.001) despite a larger deformity and similar index visit body mass index and ventilation requirements. Kaplan-Meier analysis confirmed an increased survival time in patients with a history of any spine operation compared with patients without a history of spine operation (P<0.0001). Operatively treated patients experienced a median of 3.0 complications from diagnosis to death. Overall, cardiopulmonary related complications were the most common (129/271, 47.6%; P<0.001), followed by implant-related (57/271, 21.0%) and wound-related (26/271, 9.6%). The primary cause of death was identified for 78/130 (60.0%) patients, of which 57/78 (73.1%) were cardiopulmonary related., Conclusions: This study represents the largest collection of EOS mortality to date, providing surgeons with a modern-day examination of the effects of surgical intervention to better council patients and families. Both fatal and nonfatal complications in children with EOS are most likely to involve the cardiopulmonary system., Level of Evidence: Level IV-therapeutic., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The purpose of this study was to utilize a multicenter, multisurgeon cohort to assess the effect of surgeon experience on outcomes of growth friendly instrumentation (GFI) in early onset scoliosis (EOS). We hypothesized that unplanned return to the operating room (UPROR), estimated blood loss (EBL), and surgical time would be greater amongst early career surgeons (ECSs) when compared with advanced career surgeons (ACSs)., Methods: An international pediatric spine database was queried for patients ages 2 to 10 years treated by posterior distraction-based GFI with at least of 2-year follow up. Two groups were created for analysis based on surgeon experience: ECSs (with ≤10 y of experience) and ACSs (with >10 y of experience). The primary outcome was UPROR. Additional outcomes included: operating room time, EBL, neurological deficits, infection rate, hardware failure, and the Early Onset Scoliosis Questionnaire (EOSQ-24). Subgroup analysis was performed for further assessment based on procedure type, superior anchor type, etiology, and curve severity., Results: A total of 960 patients met inclusion criteria including 243 (25.3%) treated by ECS. Etiology, sex, superior anchor, and EOSQ-24 scores were similar between groups (P>0.05). There were no clinically significant differences in patient age or preoperative major coronal curve. UPROR (35.8% vs. 32.7%, P=0.532), infection (17.0% vs. 15.6%, P=0.698), operating room time (235 vs. 231 min, P=0.755), and EBL (151 vs. 155 mL, P=0.833) were comparable between ECS and ACS groups. The frequency of having at least 1 complication was relatively high but comparable among groups (60.7% vs. 62.6%, P=0.709). EOSQ-24 subdomain scores were similar between groups at 2-year follow-up (P>0.05). Subgroup analysis revealed that ECS had increased surgical time compared with ACS in severe curves >90 degrees (270 vs. 229 min, P=0.05)., Conclusions: This study represents the first multicenter assessment of surgeon experience on outcomes in EOS. Overall, surgeon experience did not significantly influence UPROR, complication rates, EBL, or surgical time associated with GFI in this cohort of EOS patients., Level of Evidence: Level III., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 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: Limiting complications, especially unplanned return to the operating room (UPROR), is a major focus in the surgical management of early-onset scoliosis (EOS). Although UPROR remains common in this population, its effect on long-term health-related quality of life (HRQoL) remains unclear. The purpose of this study was to investigate the association between UPROR and end-of-treatment HRQoL in EOS patients treated with growth-friendly instrumentation., Methods: Patients with EOS who underwent growth-friendly instrumentation at age less than 10 years from 1993 to 2018, and completed treatment, were identified in a multicenter EOS registry. UPROR events were recorded, and end-of-treatment (defined as skeletal maturity and/or definitive spinal fusion) HRQoL was assessed via the 24-item Early-Onset Scoliosis Questionnaire (EOSQ-24)., Results: A total of 825 patients were identified, and 325 patients (age at surgery: 6.4 y, follow-up: 8.1 y) had end-of-treatment HRQoL data necessary for our investigation. Overall, 129/325 (39.7%) patients experienced 264 UPROR events; the majority (54.2%) were implant-related. Aside from age and etiology, no other variables were determined to be confounders or effect modifiers. Congenital patients with UPROR had worse pain/discomfort by 10.4 points (P=0.057) and worse pulmonary function by 7.8 points (P=0.102) compared with non-UPROR patients adjusting for age. Neuromuscular patients with UPROR had worse pulmonary function by 10.1 points compared with non-UPROR patients adjusting for age (P=0.037). Idiopathic and syndromic patients with UPROR reported consistently worse domain scores than their non-UPROR counterparts, but smaller (<5-point) differences were seen., Conclusions: UPROR during growth-friendly surgical treatment for EOS is associated with worse HRQoL in all patients, but particularly in those with neuromuscular or congenital etiologies. Ongoing efforts to avoid UPROR are critical., Level of Evidence: Level II. This is a multicenter retrospective cohort study investigating the effect of UPROR on HRQoL (prognostic study)., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: It is unclear whether traditional growing rod (TGR) treatment outcomes vary by early-onset scoliosis (EOS) subtype. The goal of this study was to compare radiographic outcomes and complications of TGR treatment by EOS subtype., Methods: We queried an international database of EOS patients from 20 centers to identify "graduates" who had (1) undergone primary TGR treatment from 1993 to 2014; (2) completed TGR treatment; and (3) had an uneventful clinical examination within 6 months after completion of TGR treatment with no anticipated further intervention. We included 202 patients in 4 etiologic subgroups: neuromuscular (n=65), syndromic (n=57), idiopathic (n=52), and congenital (n=28). Mean age at surgery was 7.1 years (range, 1.6 to 14.9 y); mean duration of follow-up was 8 years (range, 2 to 18.6 y). The groups did not differ by mean age, body mass index, sex, number of lengthenings, or duration of follow-up. The following preoperative differences were significant: (1) greater mean major curve in the neuromuscular versus idiopathic subgroup; (2) shorter spinal height (T1-S1) in the congenital versus idiopathic subgroup; and (3) smaller proportion of ambulatory patients in the neuromuscular subgroup versus all other subgroups., Results: We found no significant differences among subgroups in mean major curve correction or changes in thoracic height (T1-T12), spinal height, or global kyphosis at any point. Rates of deep surgical site infection, implant-related complications, and neurological complications were not different among subgroups. The medical complication rate was significantly lower in the idiopathic group compared with the other groups., Conclusions: Major curve correction and spinal and thoracic height increases did not differ significantly at any point by EOS subtype. Rates of deep surgical site infection, implant-related complications, and neurological complications did not differ by subtype. Except for the lower rate of medical complications in the idiopathic group, our findings suggest that, after TGR treatment, patients can expect similar outcomes regardless of their EOS subtype., Level of Evidence: Level III, therapeutic., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Case series., Objective: In this study we focus on this group, and describe the largest cohort to date of single ventricle patients undergoing surgical correction of scoliosis at a single institution., Summary of Background Data: Outcomes of spinal surgery for patients with congenital heart disease (CHD) have evolved and most affected patients have uncomplicated procedures. The risk of perioperative complications remains highest in patients with single ventricle ("Fontan") physiology., Methods: We reviewed patients with single ventricle CHD and operative scoliosis repair over a 25-year span. Patients who had undergone a Fontan, bidirectional Glenn, and/or Kawashima procedure before operative scoliosis repair were included. Patients were excluded if they lacked preoperative cardiac care and/or sufficient medical history at our institution., Results: Twenty-three patients were included. The average age at surgery was 13.6 years (range, 5-23). Seventy percent of the cohort was female (16/23). The majority of patients underwent a Fontan before scoliosis surgery (20/23, 87%). Patients without intraoperative tranexamic acid (TXA) had a 67% complication rate (8/12) versus 36% (4/11) in those with intraoperative TXA (P = 0.29). There was a significant difference in estimated blood loss by weight (cc/kg) between non-TXA and TXA patients (P = 0.016). Twelve patients experienced complications (52%), all of which occurred postoperatively. There were no deaths, cerebrovascular events, adverse perioperative cardiac or hemodynamic complications, or wound infections. Using the Clavien-Dindo-Sink classification for postoperative complications, four patients had serious adverse events, including one permanent neurologic deficit., Conclusion: Spinal surgery for scoliosis has been performed in selected patients with single ventricle physiology at a single institution without mortality for 25 years. Operative blood loss may be reduced by routine use of TXA. Complications occur most commonly in the postoperative period, and can include pleural effusion.Level of Evidence: 4., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Prior research has indicated adolescent idiopathic scoliosis (AIS) patients have lower bone mineral density and lower vitamin D levels than healthy peers. Vitamin D deficiency has been associated with higher levels of pain. This study investigated whether vitamin D-deficient AIS patients had higher pain before or immediately after posterior spine fusion (PSF) surgery., Methods: 25-Hydroxy vitamin D levels were tested in all AIS patients at their pre-operative appointment. Patients were grouped by serum 25-hydroxy vitamin D level: deficient, < 20 ng/mL; insufficient, 20-29 ng/mL; sufficient, ≥ 30 ng/mL. Primary outcomes included pre-operative Scoliosis Research Society Health-Related Quality of Life (SRS-30) and numeric rating scale (NRS) scores (0-10) up to 72 h post-operatively, and analyzed using ANOVA and linear mixed modeling, respectively. 176 patients undergoing PSF were included. Intra-operative characteristics by vitamin D status were also assessed. The cohort was 82% female and an average of 15.2 years (range 10.6-25.3 years) at fusion. Average major curve was 60 (range 40-104) degrees pre-operatively., Results: Forty-five (26%) patients were deficient in vitamin D, 75 (43%) were insufficient, and 56 (32%) were sufficient. Patients with vitamin D deficiency had lower average household income by zip code (p < 0.01) and higher secondhand smoke exposure (p < 0.001). There were no differences in pre-operative SRS-30 score, pre- and post-operative major curve angles, or estimated blood loss across vitamin D groups. Trajectories of NRS indicated no differences in pain during the first 72 h after surgery., Conclusion: Vitamin D deficiency in this population is associated with potential markers of lower socioeconomic status; however, it does not influence AIS PSF patients' experience of pain before or immediately after spine fusion surgery., Level of Evidence: II., (© 2021. Scoliosis Research Society.)

Background: Recent focus on surgical site infections (SSIs) after posterior spine fusion (PSF) has lowered infection rates by standardizing perioperative antibiotic prophylaxis. However, efforts have neglected to detail antibiotic treatment of SSIs. Our aim was to document variability in antibiotic regimens prescribed for acute and latent SSIs following PSF in children with idiopathic, neuromuscular, and syndromic scoliosis., Methods: This study included patients who developed a SSI after PSF for scoliosis at a pediatric tertiary care hospital between 2004 and 2019. Patients had to be 21 years or younger at surgery. Exclusion criteria included growing rods, staged surgery, and revision or removal before SSI diagnosis. Infection was classified as acute (within 90 d) or latent. Clinical resolution of SSI was measured by return to normal lab values. Each antibiotic was categorized as empiric or tailored., Results: Eighty subjects were identified. The average age at fusion was 14.7 years and 40% of the cohort was male. Most diagnoses were neuromuscular (53%) or idiopathic (41%).Sixty-three percent of patients had an acute infection and 88% had a deep infection. The majority (54%) of subjects began on tailored antibiotic therapy versus empiric (46%). Patients with a neuromuscular diagnosis had 4.0 times the odds of receiving initial empiric treatment compared with patients with an idiopathic diagnosis, controlling for infection type and time (P=0.01). Ninety-two percent of patients with acute SSI retained implants at the time of infection and 76% retained them as of August 2020. In the latent cohort, 27% retained implants at infection and 17% retained them as of August 2020., Conclusions: Patients with acute infections were on antibiotics longer than patients with latent infections. Those with retained implants were on antibiotics longer than those who underwent removal. By providing averages of antibiotic duration and lab normalization, we hope to standardize regimens moving forward and develop SSI-reducing pathways encompassing low-risk patients., Level of Evidence: Level III., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Many patients with presumed idiopathic scoliosis are found to have Chiari I malformation (CM-I) on MRI. The objective of this study is to report on scoliosis progression in CM-I with no syringomyelia., Methods: A retrospective review of patients with scoliosis and CM-I was conducted from 1997 to 2015. Patients with syringomyelia and/or non-idiopathic scoliosis were excluded. Clinical and radiographic characteristics were recorded at presentation and latest follow-up. CM-I was defined as the cerebellar tonsil extending 5 mm or more below the foramen magnum on MRI., Results: Thirty-two patients (72% female) with a mean age of 11 years (range 1-16) at scoliosis diagnosis were included. The average initial curve was 30.3° ± SD 16.3. The mean initial Chiari size was 9.6 mm SD ± 4.0. Fifteen (46.9%) experienced Chiari-related symptoms, and three (9%) patients underwent Posterior Fossa Decompression (PFD) to treat these symptoms. 10 (31%) patients went on to fusion, progressing on average 13.6° (95% CI 1.6-25.6°). No association was detected between decompression and either curve progression or fusion (p = 0.46, 0.60). For those who did not undergo fusion, curve magnitude progressed on average 1.0° (95% CI - 4.0 to 5.9°). There was no association between age, Chiari size, presence of symptoms, initial curve shape, or bracing treatment and fusion., Conclusion: Patients with CM-I and scoliosis may not require surgical treatment, including PFD and fusion. Scoliosis curvature stabilized in the non-surgical population at an average progression of 1.0°. These results suggest that CM-I with no syringomyelia has minimal effect on scoliosis progression., (© 2021. Scoliosis Research Society.)

Background: Arthrogryposis multiplex congenita (AMC) is a condition that describes neonates born with ≥2 distinct congenital contractures. Despite spinal deformity in 3% to 69% of patients, inadequate data exist on growth-friendly instrumentation (GFI) in AMC. Our study objectives were to describe current GFI trends in children with AMC and early-onset scoliosis (EOS) and to compare long-term outcomes with a matched idiopathic EOS (IEOS) cohort to determine whether spinal rigidity or extremity contractures influenced outcomes., Methods: Children with AMC and spinal deformity of ≥30° who were treated with GFI for ≥24 months were identified from a multicenter EOS database (1993 to 2017). Propensity scoring matched 35 patients with AMC to 112 patients with IEOS with regard to age, sex, construct, and curve. Multivariable linear mixed modeling compared changes in spinal deformity and the 24-item Early Onset Scoliosis Questionnaire (EOSQ-24) across cohorts. Cohort complications and reoperations were analyzed using multivariable Poisson regression., Results: Preoperatively, groups did not differ with regard to age (p = 0.87), sex (p = 0.96), construct (p = 0.62), rate of nonoperative treatment (p = 0.54), and major coronal curve magnitude (p = 0.96). After the index GFI, patients with AMC had reduced percentage of coronal correction (35% compared with 44%; p = 0.01), larger residual coronal curves (49° compared with 42°; p = 0.03), and comparable percentage of kyphosis correction (17% compared with 21%; p = 0.52). In GFI graduates (n = 81), final coronal curve magnitude (55° compared with 43°; p = 0.22) and final sagittal curve magnitude (47° compared with 47°; p = 0.45) were not significantly different at the latest follow-up after definitive surgery. The patients with AMC had reduced T1-S1 length (p < 0.001), comparable T1-S1 growth velocity (0.66 compared with 0.85 mm/month; p = 0.05), and poorer EOSQ-24 scores at the time of the latest follow-up (64 compared with 83 points; p < 0.001). After adjusting for ambulatory status and GFI duration, patients with AMC developed 51% more complications (incidence rate ratio, 1.51 [95% confidence interval (CI), 1.11 to 2.04]; p = 0.009) and 0.2 more complications/year (95% CI, 0.02 to 0.33 more; p = 0.03) compared with patients with IEOS., Conclusions: Patients with AMC and EOS experienced less initial deformity correction after the index surgical procedure, but final GFI curve magnitudes and total T1-S1 growth during active treatment were statistically and clinically comparable with IEOS. Nonambulatory patients with AMC with longer GFI treatment durations developed the most complications. Multidisciplinary perioperative management is necessary to optimize GFI and to improve quality of life in this complex population., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The authors indicated that no external funding was received for any aspect of this work. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work and “yes” to indicate that the author had other relationships or activities that could be perceived to influence, or have the potential to influence, what was written in this work (http://links.lww.com/JBJS/G318)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Purpose: Previous reports have demonstrated the effectiveness of casting for EOS. Brace treatment for EOS has not been studied. The purpose of this multicenter retrospective study was to compare radiographic outcomes, complications, and rates of conversion to surgery in children with EOS treated with casting or bracing., Methods: Children aged 2-6 years with idiopathic or neuromuscular EOS treated with casting or bracing with minimum follow-up of 2 years were identified., Results: 68 patients (36 cast, 32 brace) were analyzed. Diagnosis, age at start of treatment, and duration of follow-up were similar. Although the cast patients had a larger pre-treatment major curve magnitude (50° vs 31°, p < 0.001), both groups had a similar major curve magnitude at most recent follow-up (36° vs 32°, p = 0.456). T1-T12 and T1-S1 length increased in both groups. The cast and brace patients had similar complications and conversions to surgery. Sub-analysis showed that while casting resulted in curve improvement regardless of etiology, bracing was able to prevent curve progression in patients with idiopathic EOS but not in patients with non-idiopathic EOS (Δ- 15° vs 27°, p = 0.006). Regression analysis (significance p = 0.10) controlling for baseline age, major curve magnitude, and T1-T12 and T1-S1 length showed that treatment method was associated with difference in major curve magnitude (p = 0.090) and T1-T12 length (p = 0.024)., Conclusion: In our study, serial casting led to curve improvement in children with idiopathic and neuromuscular EOS, whereas brace treatment appeared to prevent curve progression in patients with idiopathic EOS but did not appear to control the curve in neuromuscular EOS.

Introduction: After discontinuation of growth friendly (GF) surgery for early onset scoliosis, patients undergo spinal fusion or continued observation. This last planned treatment is colloquially called "definitive" treatment, conferring these patients as "graduates" of a growing program. The 5-year radiographic and clinical outcomes of this cohort are unknown., Methods: An international pediatric spine database was queried for patients from a GF program (spine or rib-based) with minimum 5-year follow-up from last planned surgery (GF or spinal fusion). Radiographs and charts were reviewed for main coronal curve angle and maximum kyphosis as well as occurrence of secondary surgery., Results: Of 580 graduates, 170 (29%) had minimum 5-year follow-up (37% male). Scoliosis etiology was congenital in 41 (24%), idiopathic 36 (21%), neuromuscular 51 (30%), and syndromic 42 (25%). Index surgery consisted of spine-based growing rods in 122 (71%) and rib-based distraction in 48 (29%). Mean age at index surgery was 6.8 years, and patients underwent an average of 5.4 lengthenings over an average of 4.9 years (range, 6 mo to 11 y). Last planned treatment was at an average age of 11.8 years (range, 7 to 17 years). Last planned treatment consisted of spinal fusion in 114 patients, 47 had growing implants maintained, 9 had implants removed. Average follow-up was 7.3 years (range, 5 to 13 y).When compared from postdefinitive treatment to 2-year follow-up, there was noted progression of the coronal curve angle (46±19 to 51±21 degrees, P=0.046) and kyphosis (48±20 to 57±25 degrees, P=0.03). However, between 2 and 5 years, no further progression occurred in the coronal (51±21 to 53±21 degrees, P=0.26) or sagittal (57±25 to 54±28 degrees, P=0.93) planes. When stratified based on etiology, there was no significant coronal curve progression between 2- and 5-year follow-up. When comparing spinal fusion patients to those who had maintenance of their growing construct, there was also no significant curve progression.Thirty-seven (21%) underwent at least 1 (average, 1.7; range, 1 to 7) revision surgery following graduation, and 15 of 37 (41%) underwent 2 or more revision surgeries. Reason for revision was implant revision (either GF or spinal fusion) in 34 patients, and implant removal in 3. On an average, the first revision was 2.5 years after the definitive treatment plan (range, 0.02 to 7.4 y). In total, 15 of 37 (41%) revisions occurred over 2 years following the final decision for treatment plan, and 7 of 37 (19%) occurred 5 or more years after the definitive treatment.Patients who underwent spinal fusion as a definitive treatment strategy were more likely to undergo revision surgery (27%) than patients who had their GF implants maintained (11%) (P=0.04)., Conclusions: Five years following "graduation" from growing surgery for early onset scoliosis, there is progression of curve magnitude in both the coronal and sagittal planes up to 2 years, with no further progression at 5 years. A total of 21% of patients undergo at least 1 revision surgery, and average time to revision surgery is over 2 years from last planned surgery. Risk of revision surgery was higher in patients who underwent a spinal fusion as their definitive treatment strategy., Level Evidence: Level III-retrospective comparative., Type of Evidence: Therapeutic.