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STUDY DESIGN: Systematic review of the literature and analysis of pooled data. OBJECTIVES: To better understand the incidence of thromboembolic disease in postoperative spinal patients, and to establish a starting point for defining appropriate postoperative prophylaxis protocols. SUMMARY OF BACKGROUND DATA: The risk of thromboembolic disease is well studied for some orthopedic procedures. However, the incidence of postoperative thromboembolic disease is less well-defined in patients who have had spinal surgery. METHODS: The MEDLINE database was queried using the search terms deep venous thrombosis or DVT, pulmonary embolus, thromboembolic disease, and spinal or spine surgery. Abstracts of all identified articles were reviewed. Detailed information from eligible articles was extracted. Data were compiled and analyzed by simple summation methods when possible to stratify rates of DVT and/or pulmonary embolus for a given prophylaxis protocol, screening method, and type of spinal surgery. RESULTS: Twenty-five articles were eligible for full review. DVT risk ranged from 0.3% to 31%, varying between patient populations and methods of surveillance. Pooling data from the 25 studies, the overall rate of DVT was 2.1%. DVT rate was influenced by prophylaxis method: no prophylaxis, 2.7%; compression stockings (CS), 2.7%; pneumatic sequential compression device (PSCD), 4.6%; PSCD and CS, 1.3%; chemical anticoagulants, 0.6%; and inferior vena cava filters with/without another method of prophylaxis, 22%. DVT rate was also influenced by the method of diagnosis, ranging from 1% to 12.3%. CONCLUSION: As risk of DVT after routine elective spinal surgery is fairly low, it seems reasonable to use CS with PSCD as a primary method of prophylaxis. There is insufficient evidence to support or refute the use of chemical anticoagulants in routine elective spinal surgery. In addition, there is insufficient evidence to suggest that screening patients undergoing elective spinal surgery with ultrasound or venogram is routinely warranted. [ABSTRACT FROM AUTHOR]

STUDY DESIGN: Survey study. OBJECTIVE: To assess a sample of spine surgeons' current practices of thromboembolic prophylaxis after high-risk surgery for tumors and trauma. SUMMARY OF BACKGROUND DATA: Although chemoprophylaxis for thromboembolic events is not routinely used after elective spinal surgery, it is more widely recommended in high-risk patients after spine surgery for trauma or tumors. In these high-risk cases, surgeons must decide what method(s) of prophylaxis to use and when it can be safely initiated. Unfortunately, there are limited data evaluating the efficacy or safety of different prophylaxis protocols after high-risk spinal surgery; as a result there are no accepted treatment guidelines concerning this issue. To the authors' knowledge, no previous study examining practices of thromboembolic prophylaxis after high-risk spinal surgery has been published. METHODS: One hundred ninety-three orthopaedic and neurosurgical spine surgeons with established clinical interest and volume in spine trauma and/or spine tumor surgery were invited by email to complete an on-line questionnaire. Ten questions focused on varying issues that included the perceived risk of deep venous thrombosis (DVT), pulmonary embolism (PE), postoperative epidural hematoma, preferred chemoprophylactic agents, the safe time point for initiation of chemoprophylaxis, and use of inferior vena cava (IVC) filters. RESULTS: Ninety-four surgeons completed the questionnaire, which represented a 49% response rate. Regarding a safe time point to start chemoprophylaxis, the most common response was 48 hours after surgery (21 of 94, 22%). However, individual responses varied widely: 15% chose 24 hours, 13% chose 72 hours, 12% chose less than 24 hours, and 10% chose 96 hours. Some indicated they would start chemoprophylaxis before surgery, whereas others responded they would never use it. Sixty-three percent (59 of 94) stated that they based this decision on personal experience over evidence-based review of the literature. A majority of surgeons selected low-molecular-weight heparin as their agent of choice (54 of 94, 58%). Respondents most commonly (44 of 93, 47%) felt that the risk of clinically relevant postoperative epidural hematoma was between 1% and 5%; 29% (27 of 93) felt the risk was less than 1%; and 17% (16 of 93) felt it was as high as 5% to 10%. Those who felt the risk of epidural hematoma to be lower than 5% tended to initiate chemoprophylaxis earlier than those who estimated the risk to be higher than 5%. Thirty-seven percent (34 of 93) felt the perceived risk for a DVT was 1% to 5%; 25% (23 of 94) felt it was 5% to 10%; and 16% (15 of 93) felt it was less than 1%. Those who estimated the risk of DVT to be higher tended to initiate therapy earlier than groups that estimated the risk to be lower. Although the decision to use an IVC filter varied considerably, there was a clear trend towards having the filter placed before surgery (60 of 78, 77%). CONCLUSION: These data are the first to demonstrate the wide variability of surgeons' practices regarding thromboembolic prophylaxis in high-risk spine surgery patients. This variability is likely a symptom of the glaring paucity of scientific evidence concerning the risk for symptomatic epidural hematoma, DVT, and PE and the efficacy and safety of specific chemoprophylactic protocols after spine surgery. This study highlights the need for more rigorous prospective evaluation of thromboembolic risk after spinal surgery and, subsequently, the efficacy and safety of currently available thromboembolic prophylaxis protocols. [ABSTRACT FROM AUTHOR]

Background: Primary non-Hodgkin's lymphoma of bone, often more simply referred to as primary lymphoma of bone, is a rare subset of non-Hodgkin's lymphoma in children. There are only a few small series of primary lymphoma of bone in children with long-term follow-up, and none have appeared in the orthopaedic literature.Methods: A review of our institution's Pediatric Tumor Registry identified fifteen cases of primary lymphoma of bone among 306 cases of diagnosed non-Hodgkin's lymphoma between 1970 and 2003. Retrospective evaluation included collection of demographic, clinical, radiographic, treatment, and follow-up data. A univariate analysis was used to assess the prognostic significance of risk factors with respect to survival of patients from this series and in a summary analysis of data collected from similar series in the literature.Results: The patients included ten male and five female patients with a mean age of 11.6 years. Most patients had a presenting complaint of pain and had swelling and/or tenderness on physical examination. Eight children had a solitary bone lesion, and seven had multiple bone lesions. Overall, the mean number of bones involved was 3.1 per patient. The femur and the pelvis were the most frequently involved bones. The ten surviving patients were followed for a mean of 13.6 years. Five patients died: three of disease progression, one of treatment-related complications, and one of an unrelated cause. The mean time from diagnosis to death was 2.1 years. Nine patients received chemotherapy only, whereas six patients received a combination of chemotherapy and radiation therapy. In the present study, an age of nine years or less was predictive of poor survival (p < 0.05). In the summary analysis of cases collected from the literature, advanced stage, young age, non-large-cell histology, and multiple-bone involvement were predictive of poor survival (p < 0.05).Conclusions: On the basis of the present series and a comprehensive review of similar series in the literature involving patients with primary lymphoma of bone, it appears that younger age, advanced-stage disease, multiple-bone involvement, and non-large-cell histology are associated with decreased survival as compared with older age, localized disease, single-bone involvement, and large-cell histology, respectively. [ABSTRACT FROM AUTHOR]

STUDY DESIGN: Surgeon survey. OBJECTIVE: To characterize the incidence of epidural hematoma in postoperative spinal patients; to assess the effect of chemical thromboprophylaxis on the risk of epidural hematoma. SUMMARY OF BACKGROUND DATA: The precise indications and/or timing of anticoagulation for thromboembolic prophylaxis following spinal surgery are not clear. Patients who endure periods of extended recumbency and limited mobility after major operative spinal interventions may be at increased risk of thromboembolic disease. Among other factors, spine surgeons must weigh the risk of a symptomatic postoperative epidural hematoma against the benefit of DVT/PE prevention when deciding to initiate chemoprophylaxis. However, the incidence of postoperative epidural hematoma is not well-known, leading to uncertainty regarding the real versus perceived risk of this complication. METHODS: The MEDLINE database was queried using the search terms epidural hematoma and spinal or spine surgery. Abstracts of all identified articles were reviewed. Studies were deemed eligible if they specifically documented the incidence of clinically significant epidural hematoma in a series of patients who underwent spinal surgery. Detailed information from eligible articles was extracted. Data were compiled and analyzed to examine incidences of clinically relevant postoperative epidural hematoma (i.e., resulted in new, associated neurologic deficit). RESULTS: Of 493 abstracts that were identified in the search, a total of sixteen articles were eligible for full review. From this review, the range of reported incidences of epidural hematoma in the literature ranges from 0% to 0.7% in studies where patients received chemical anticoagulation and 0% and 1% in all of the included studies. In no study was the incidence of clinically relevant epidural hematoma greater than 1%. CONCLUSION: The catastrophic morbidity of a symptomatic postoperative epidural hematoma remains a substantial disincentive to start chemoprophylaxis after spinal surgery. The rarity of this complication makes study of its risk factors difficult. Although many surgeons perceive the risk to be higher, the reported incidences of clinically relevant postoperative epidural hematoma are lower, ranging from 0% to 1%. Despite this finding, there is insufficient published data available to precisely define the safety of postoperative chemoprophylaxis. Though not pertaining to prophylaxis, the available evidence does suggest that use of therapeutic doses of heparin in postoperative spinal patients who sustain a PE may have a higher incidence of bleeding complications. [ABSTRACT FROM AUTHOR]

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).)

Background: The recently described Modified Fels knee skeletal maturity system (mFels) has proven utility in prediction of ultimate lower extremity length in modern pediatric patients. mFels users evaluate chronological age, sex, and 7 anteroposterior knee radiographic parameters to produce a skeletal age estimate. We developed a free mobile application to minimize the learning curve of mFels radiographic parameter evaluation. We sought to identify the reliability of mFels for new users., Methods: Five pediatric orthopaedic surgeons, 5 orthopaedic surgery residents, 3 pediatric orthopaedic nurse practitioners, and 5 medical students completely naïve to mFels each evaluated a set of 20 pediatric anteroposterior knee radiographs with the assistance of the (What's the Skeletal Maturity?) mobile application. They were not provided any guidance beyond the instructions and examples embedded in the app. The results of their radiographic evaluations and skeletal age estimates were compared with those of the mFels app developers., Results: Averaging across participant groups, inter-rater reliability for each mFels parameter ranged from 0.73 to 0.91. Inter-rater reliability of skeletal age estimates was 0.98. Regardless of group, steady proficiency was reached by the seventh radiograph measured., Conclusions: mFels is a reliable means of skeletal maturity evaluation. No special instruction is necessary for first time users at any level to utilize the (What's the Skeletal Maturity?) mobile application, and proficiency in skeletal age estimation is obtained by the seventh radiograph., Level of Evidence: Level II., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Several skeletal maturity systems allow for accurate skeletal age assessment from a wide variety of joints. However, discrepancies in estimates have been noted when applying systems concurrently. The aims of our study were to (1) compare the agreement among 8 different skeletal maturity systems in modern pediatric patients and (2) compare these discrepancy trends qbetween modern and historic children., Methods: We performed a retrospective (January 2000 to May 2022) query of our picture archiving and communication systems and included peripubertal patients who had at least two radiographs of different anatomic regions obtained ≤3 months apart for 8 systems: (1) proximal humerus ossification system (PHOS), (2) olecranon apophysis ossification staging system (OAOSS), (3) lateral elbow system, (4) modified Fels wrist system, (5) Sanders Hand Classification, (6) optimized oxford hip system, (7) modified Fels knee system, and (8) calcaneal apophysis ossification staging system (CAOSS). Any abnormal (ie, evidence of fracture or congenital deformity) or low-quality radiographs were excluded. These were compared with a cohort from a historic longitudinal study. SEM skeletal age, representing the variance of skeletal age estimates, was calculated for each system and used to compare system precision., Results: A total of 700 radiographs from 350 modern patients and 954 radiographs from 66 historic patients were evaluated. In the modern cohort, the greatest variance was seen in PHOS (SEM: 0.28 y), Sanders Hand (0.26 y), and CAOSS (0.25 y). The modified Fels knee system demonstrated the smallest variance (0.20 y). For historic children, the PHOS, OAOSS, and CAOSS were the least precise (0.20 y for all). All other systems performed similarly in historic children with lower SEMs (range: 0.18 to 0.19 y). The lateral elbow system was more precise than the OAOSS in both cohorts., Conclusions: The precision of skeletal maturity systems varies across anatomic regions. Staged, single-parameter systems (eg, PHOS, Sanders Hand, OAOSS, and CAOSS) may correlate less with other systems than those with more parameters., Level of Evidence: Level III-retrospective study., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: The purpose is to describe how patients with a late-presenting dural leak (LPDL) after posterior spinal fusion (PSF) was diagnosed and treated at a single institution., Methods: Of the 1991 patients who underwent a PSF between 2010 and 2018, 6 patients were identified with a clinical course consistent with a potential LPDL., Results: Six patients with median age 16.9 years had onset of headache ranging 1-12 weeks postoperatively (median 6.5 weeks). All six patients presented with positional headache, and half (3/6) presented with emesis. 5/6 patients underwent contrast brain MRI, which demonstrated pachymeningeal enhancement. 4/5 patients with dural enhancement went on to have CT myelogram. Five patients had a CT myelogram, which identified a dural leak in all patients and localized the leak in four of five patients. All patients underwent an epidural blood patch, which resolved the pain in five patients. One patient without relief underwent revision surgery with removal of a medially placed screw and fibrin glue placement resolving symptoms., Conclusions: Postoperative dural leaks associated with PSF may present in a delayed fashion. The majority of leaks were not associated with screw malposition. In diagnosing patients with suspected LPDL, we suggest brain MRI with contrast as a first step. Most patients with pachymeningeal enhancement shown on contrast brain MRI had dural leaks that were identified through CT myelograms. For patients with a dural leak, if there is no disruption from screws, a blood patch appears to be an effective treatment., Level of Evidence: IV., (© 2023. The Author(s), under exclusive licence to Scoliosis Research Society.)

Background: Idiopathic scoliosis (IS) is a common spinal abnormality, in which orthotic management can reduce progression to surgery. However, predictors of bracing success are still not fully understood. We studied a large patient population treated with the nighttime Providence orthosis, utilizing multivariable logistic regression to assess results and predict future spine surgery., Methods: We retrospectively reviewed patients with IS meeting Scoliosis Research Society inclusion and assessment criteria presenting from April 1994 to June 2020 at a single institution and treated with a Providence orthosis. A predictive logistic regression model was developed utilizing the following candidate features: age, sex, body mass index, Risser classification, Lenke classification, curve magnitude at brace initiation, percentage correction in a brace, and total months of brace use. Model performance was assessed using the area under the receiver operating characteristic curve, accuracy, sensitivity, and specificity. The importance of individual features was assessed using the variable importance score., Results: There were 329 consecutive patients with IS with a mean age of 12.8 ± 1.4 years that met inclusion and assessment criteria. Of these, 113 patients (34%) ultimately required surgery. The model's area under the curve (AUC) was 0.72 on the testing set, demonstrating good discrimination. The initial curve magnitude (Importance score: 100.0) and duration of bracing (Importance score: 82.4) were the 2 most predictive features for curve progression leading to surgery. With respect to skeletal maturity, Risser 1 (Importance score: 53.9) had the most predictive importance for future surgery. For the curve pattern, Lenke 6 (Importance score: 52.0) had the most predictive importance for future surgery., Conclusion: Out of 329 patients with IS treated with a Providence nighttime orthosis, 34% required surgery. This is similar to the findings of the BrAist study of the Boston orthosis, in which 28% of monitored braced patients required surgery. In addition, we found that predictive logistic regression can evaluate the likelihood of future spine surgery in patients treated with the Providence orthosis. The severity of the initial curve magnitude and total months of bracing were the 2 most important variables when assessing the probability of future surgery. Surgeons can use this model to counsel families on the potential benefits of bracing and risk factors for curve progression., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The COVID-19 pandemic has led to significant disruptions in medical care, resulting in an estimated 40% of US adults avoiding care. However, the return to baseline health care utilization following COVID-19 restrictions within the pediatric orthopedic population remains unexplored. We sought to analyze the visit volume and demographics of pediatric orthopedic patients at 3 timepoints: prepandemic (2019), pandemic (2020), and pandemic post-vaccine availability (2021), to determine the impact of COVID-19 restrictions on our single-center, multisite institution., Methods: We performed a retrospective cohort study of 6318 patients seeking treatment at our institution from May through August in 2019, 2020, and 2021. Patient age, sex, address, encounter date, and ICD-10 codes were obtained. Diagnoses were classified into fractures and dislocations, non-fracture-related trauma, sports, elective, and other categories. Geospatial analysis comparing incidence and geospatial distribution of diagnoses across the time periods was performed and compared with the Centers for Disease Control (CDC) social vulnerability index (SVI)., Results: The total number of pediatric orthopedic visits decreased by 22.2% during the pandemic ( P <0.001) and remained 11.6% lower post-vaccine availability compared with prepandemic numbers ( P <0.001). There was no significant difference in age ( P =0.097) or sex ( P =0.248) of the patients across all 3 timepoints; however, patients seen during the pandemic were more often White race (67.7% vs. 59.3%, P <0.001). Post-vaccine availability, trauma visits increased by 18.2% ( P <0.001) and total fractures remained 13.4% lower than prepandemic volume ( P <0.001). Sports volume decreased during the pandemic but returned to prepandemic volume in the post-vaccine availability period ( P =0.298). Elective visits did not recover to prepandemic volume and remained 13.0% lower compared with baseline ( P <0.001). Geospatial analysis of patient distribution illustrated neighborhood trends in access to care during the COVID-19 pandemic, with fewer patients from high SVI and low socioeconomic status neighborhoods seeking fracture care during the pandemic than prepandemic. Post-vaccine availability, fracture population distribution resembled prepandemic levels, suggesting a return to baseline health care utilization., Conclusion: Pediatric orthopedic surgery visit volume broadly decreased during the COVID-19 pandemic and did not return to prepandemic levels. All categories increased in the post-vaccine availability time point except elective visits. Geospatial analysis revealed that neighborhoods with a high social vulnerability index (SVI) were associated with decreased fracture visits during the pandemic, whereas low SVI neighborhoods did not experience as much of a decline. Future research is needed to study these neighborhood trends and more completely characterize factors preventing equitable access to care in the pediatric orthopedic population., Level of Evidence: Retrospective Study, Level III., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

The selection of fusion levels in the treatment of adolescent idiopathic scoliosis remains complex. The goals of surgery are to minimize the risk of future progression and optimize spinal balance while fusing the least number of levels necessary. Several classifications, rules, and algorithms exist to guide decision making, although these have previously not been easily referenced in a study. This review aims to provide an evidence-based approach of selecting fusion levels that balances the expert opinion of the authors with the current literature., (Copyright © 2023 by the American Academy of Orthopaedic Surgeons.)

Background: There is no uniform classification system for traumatic upper cervical spine injuries in children. This study assesses the reliability and reproducibility of the AO Upper Cervical Spine Classification System (UCCS), which was developed and validated in adults, to children., Methods: Twenty-six patients under 18 years old with operative and nonoperative upper cervical injuries, defined as from the occipital condyle to the C2-C3 joint, were identified from 2000 to 2018. Inclusion criteria included the availability of computed tomography and magnetic resonance imaging at the time of injury. Patients with significant comorbidities were excluded. Each case was reviewed by a single senior surgeon to determine eligibility. Educational videos, schematics describing the UCCS, and imaging from 26 cases were sent to 9 pediatric orthopaedic surgeons. The surgeons classified each case into 3 categories: A, B, and C. Inter-rater reliability was assessed for the initial reading across all 9 raters by Fleiss's kappa coefficient (kF) along with 95% confidence intervals. One month later, the surgeons repeated the classification, and intra-rater reliability was calculated. All images were de-identified and randomized for each read independently. Intra-rater reproducibility across both reads was assessed using Fleiss's kappa. Interpretations for reliability estimates were based on Landis and Koch (1977): 0 to 0.2, slight; 0.2 to 0.4, fair; 0.4 to 0.6, moderate; 0.6 to 0.8, substantial; and >0.8, almost perfect agreement., Results: Twenty-six cases were read by 9 raters twice. Sub-classification agreement was moderate to substantial with α κ estimates from 0.55 for the first read and 0.70 for the second read. Inter-rater agreement was moderate (kF 0.56 to 0.58) with respect to fracture location and fair (kF 0.24 to 0.3) with respect to primary classification (A, B, and C). Krippendorff's alpha for intra-rater reliability overall sub-classifications ranged from 0.41 to 0.88, with 0.75 overall raters., Conclusion: Traumatic upper cervical injuries are rare in the pediatric population. A uniform classification system can be vital to guide diagnosis and treatment. This study is the first to evaluate the use of the UCCS in the pediatric population. While moderate to substantial agreement was found, limitations to applying the UCCS to the pediatric population exist, and thus the UCCS can be considered a starting point for developing a pediatric classification., Level of Evidence: Level III., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Prior research has shown that patients with adolescent idiopathic scoliosis (AIS) have a higher prevalence of vitamin D deficiency compared with healthy peers. In adult orthopaedic populations, vitamin D deficiency has been shown to be a risk factor for higher reported pain and lower function. We investigated whether there was an association between vitamin D levels and AIS patient-reported outcomes, as measured by the Scoliosis Research Society (SRS-30) questionnaire., Methods: This was a single-center, cross-sectional study. Postoperative AIS patients were prospectively recruited during routine follow-up visits, 2 to 10 years after spine fusion. Vitamin D levels were measured by serum 25-hydroxyvitamin D (ng/mL). Patients were categorized based on vitamin D level: deficient (<20 ng/mL), insufficient (20 to 29 ng/mL), or sufficient (≥30 ng/mL). The correlation between vitamin D levels and SRS-30 scores was analyzed using multivariable analysis and pair-wise comparisons using Tukey method., Results: Eighty-seven AIS patients (83% female) were enrolled who presented at median 3 years (interquartile range: 2 to 5 y; range: 2 to 10 y) after spine fusion. Age at time of surgery was mean 15 (SD±2) years. Major coronal curves were a mean of 57 (SD±8) degrees preoperatively and 18 (SD±7) degrees postoperatively. It was found that 30 (34%) of patients were vitamin D sufficient, 33 (38%) were insufficient, and 24 (28%) were deficient. Although there was no correlation between vitamin D level and Pain, Mental Health, or Satisfaction domains ( P >0.05), vitamin D-deficient patients were found to be younger ( P <0.001) and had lower SRS-30 function ( P =0.002), Self-image ( P <0.001), and total scores ( P =0.003)., Conclusions: AIS patients with vitamin D deficiency (<20 ng/mL) are more likely to be younger age at time of surgery, and report lower Function, Self-image, and Total SRS-30 scores postoperatively. Further work is needed to determine whether vitamin D supplementation alters curve progression and patient outcomes., Level of Evidence: Level II-prognostic study., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: This study compared the outcomes of juvenile patients with cerebral palsy (CP) and scoliosis who underwent spinal fusion (SF) versus growing rod (GR) surgery., Methods: Two prospective multicenter registries were queried for patients 8-10 years old with minimum 2-year follow-up who underwent SF or GR surgery (no MCGR). Demographics, radiographs, complications, and outcome scores were recorded., Results: There were 35 patients in the SF and 15 in the GR group. The mean age at surgery was 10 and 9.3 years in the SF and GR groups, respectively (p = 0.004). In the SF group preoperatively, the major curve measured 86° and 80° in the GR group (p = 0.40). "Definitive" surgery in the GR group consisted of SF in 10, implant retention in three, and implant removal in two. The SF group had 60.8% and the GR group had 45.0% correction following "definitive" surgery (p = 0.03). In the SF group, 8 patients and in the GR group, 9 patients (SF = 22.9%, GR = 60.0%) had a complication (p = 0.01). In the SF group, two patients (5.7%) had reoperations for infection; eight patients (53.3%) in the GR group had reoperations for infection and implant complications (p < 0.001). In the SF group, 23/30 parents (76.6%) noted that the child's life "improved a lot." In the GR group, 3/6 parents (50.0%) noted they were "neutral" about their child's ability to do things, 2/6 (33.3%) were "very dissatisfied.", Conclusions: SF treatment for juvenile patients with CP and scoliosis resulted in fewer complications and unplanned reoperations and better radiographic outcomes compared with GR. Quality of life improvements were also better in the SF group., Level of Evidence: Level III., (© 2022. The Author(s), under exclusive licence to Scoliosis Research Society.)

Background: Identifying beneficial preventive strategies for surgical-site infection (SSI) in individual patients with different clinical and surgical characteristics is challenging. The purpose of this study was to investigate the association between preventive strategies and patient risk of SSI taking into consideration baseline risks and estimating the reduction of SSI probability in individual patients attributed to these strategies., Methods: Pediatric patients who underwent primary, revision, or final fusion for their spinal deformity at 7 institutions between 2004 and 2018 were included. Preventive strategies included the use of topical vancomycin, bone graft, povidone-iodine (PI) irrigations, multilayered closure, impermeable dressing, enrollment in quality improvement (QI) programs, and adherence to antibiotic prophylaxis. The CDC definition of SSI as occurring within 90 days postoperatively was used. Multiple regression modeling was performed following multiple imputation and multicollinearity testing to investigate the effect of preventive strategies on SSI in individual patients adjusted for patient and surgical characteristics., Results: Univariable regressions demonstrated that enrollment in QI programs and PI irrigation were significantly associated, and topical vancomycin, multilayered closure, and correct intraoperative dosing of antibiotics trended toward association with reduction of SSI. In the final prediction model using multiple regression, enrollment in QI programs remained significant and PI irrigation had an effect in decreasing risks of SSI by average of 49% and 18%, respectively, at the individual patient level., Conclusion: Considering baseline patient characteristics and predetermined surgical and hospital factors, enrollment in QI programs and PI irrigation reduce the risk of SSI in individual patients. Multidisciplinary efforts should be made to implement these practices to increase patient safety., Level of Evidence: Prognostic level III study., (© 2022. The Author(s), under exclusive licence to Scoliosis Research Society.)

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

Background: In a recent retrospective study, in cast correction of the major curve correlated with final curve size in patients with early-onset scoliosis treated with casting. We therefore sought to perform a prospective study with controlled methodology to determine if there are parameters associated with reduction of coronal deformity., Methods: A prospective, observational study was conducted between 2014 and 2019 at selected sites willing to comply with a standard radiographic and follow-up protocol. Radiographic data was collected at time points of precast, in traction, initial in-cast, and at minimum 1 year follow-up. Multivariate linear regression models were utilized to control for potential confounders using a stepwise procedure. Twenty-nine patients met inclusion criteria., Results: On multivariate analysis, traction major curve (P=0.043) and initial in-cast (P=0.011) major curve Cobb angles were independently associated with final out of cast major curve Cobb angle. The only factor that was independently associated with failure to cure (<15-degree major curve) was traction major curve Cobb angle (P=0.046). A threshold traction major curve Cobb angle of 20 degrees was found to have good accuracy with 81% sensitivity and 73% specificity (receiver operator curve area: 0.869, P<0.001). A traction major curve Cobb angle over 20 degrees would accurately predict failure of casting treatment to cure scoliosis in 79% of cases. A threshold in-cast major curve Cobb angle of 21 degrees was found to have slightly less accuracy than traction with 69% sensitivity, 82% specificity, and 74% accuracy (receiver operator curve area: 0.830, P=0.004)., Conclusions: Radiographic measurements in traction and initially in the cast are predictive of curve size at follow-up for children with early-onset scoliosis treated with casting. The standardization and utility of traction films should be further explored., Level of Evidence: Level II., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

The coronavirus disease-2019 (COVID-19) pandemic had unique and profound personal and professional challenges for everyone. However, this is not the first or last health care crisis we will face. There are clear lessons learned from historical examples and the current pandemic that can be utilized to tackle future challenges. In this article a combination of personal experience, interviews with respected leaders, and literature were used to reflect on lessons learned as a leader navigating the COVID-19 pandemic. Key components to leadership through a crisis include communication, flexibility, patience, teamwork, resiliency, and understanding individuals' struggles. What was clear is that the ability of the health care system and the people that drive it to adapt and evolve so rapidly to the COVID-19 pandemic was truly remarkable., Competing Interests: The author declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Surgical site infection (SSI) rates in pediatric spinal deformity surgery for cerebral palsy (CP) patients are higher than that in idiopathic scoliosis. The use of vancomycin powder is associated with decreased risk of SSI in neuromuscular patients. Prior studies in adult and pediatric early-onset scoliosis patients have shown that vancomycin powder alters microbacterial profile in patients that develop SSI. However, the effects of topical vancomycin powder on microbiology in spinal deformity surgery for CP patients has not been studied., Methods: An international multicenter database of CP neuromuscular scoliosis patients was used in this retrospective cohort study. All patients that underwent posterior spinal instrumented fusion for CP neuromuscular scoliosis from 2008 to 2019 were queried, and 50 cases complicated by postoperative SSI were identified. Intraoperative antibiotic details were documented in 49 cases (98.0%). Microbiology details were documented in 45 cases (91.8%). Microbiology for patients that received topical vancomycin powder were compared with patients that did not. A multivariate regression model was used to control for potential confounders., Results: There were 45 patients included in this study. There were 27 males (60.0%) and 18 females (40.0%). Mean age at surgery was 14.8±2.4 years. There were 24 patients that received topical vancomycin powder (53.3%). The mean time from index surgery to SSI was 4.3±11.3 months.On univariate analysis of microbiology cultures by vancomycin powder cohort, there were no significant differences in culture types. Proteus spp. trended on significance with association with vancomycin powder use (P=0.078). When controlling for potential confounders on multivariate analysis, intraoperative topical vancomycin powder was associated with increased risk for proteus infection (adjusted odds ratio: 262.900, 95% confidence interval: 1.806-38,267.121, P=0.028)., Discussion: In CP patients undergoing pediatric spinal deformity surgery, the use of vancomycin powder was independently associated with increased risk for proteus infections. Further study into antibiotic regimens for spinal deformity surgery in the CP population should be performed., Level of Evidence: Level III-retrospective cohort study., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

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: Despite tremendous efforts, the incidence of surgical site infection (SSI) following the surgical treatment of pediatric spinal deformity remains a concern. Although previous studies have reported some risk factors for SSI, these studies have been limited by not being able to investigate multiple risk factors at the same time. The aim of the present study was to evaluate a wide range of preoperative and intraoperative factors in predicting SSI and to develop and validate a prediction model that quantifies the risk of SSI for individual pediatric spinal deformity patients., Methods: Pediatric patients with spinal deformity who underwent primary, revision, or definitive spinal fusion at 1 of 7 institutions were included. Candidate predictors were known preoperatively and were not modifiable in most cases; these included 31 patient, 12 surgical, and 4 hospital factors. The Centers for Disease Control and Prevention definition of SSI within 90 days of surgery was utilized. Following multiple imputation and multicollinearity testing, predictor selection was conducted with use of logistic regression to develop multiple models. The data set was randomly split into training and testing sets, and fivefold cross-validation was performed to compare discrimination, calibration, and overfitting of each model and to determine the final model. A risk probability calculator and a mobile device application were developed from the model in order to calculate the probability of SSI in individual patients., Results: A total of 3,092 spinal deformity surgeries were included, in which there were 132 cases of SSI (4.3%). The final model achieved adequate discrimination (area under the receiver operating characteristic curve: 0.76), as well as calibration and no overfitting. Predictors included in the model were nonambulatory status, neuromuscular etiology, pelvic instrumentation, procedure time ≥7 hours, American Society of Anesthesiologists grade >2, revision procedure, hospital spine surgical cases <100/year, abnormal hemoglobin level, and overweight or obese body mass index., Conclusions: The risk probability calculator encompassing patient, surgical, and hospital factors developed in the present study predicts the probability of 90-day SSI in pediatric spinal deformity surgery. This validated calculator can be utilized to improve informed consent and shared decision-making and may allow the deployment of additional resources and strategies selectively in high-risk patients., Level of Evidence: Prognostic 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/G814)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Study Design: Retrospective review of prospective data from multicenter registry., Objective: Compare outcomes of posterior spinal fusion (PSF) versus magnetically controlled growing rods (MCGR) versus vertebral body tethers (VBT) in 8- to 11-year-old idiopathic early onset scoliosis (EOS) patients., Summary of Background Data: In EOS, it is unclear at what age the benefit of growth-sparing strategies outweighs increased risks of surgical complications, compared with PSF., Methods: One hundred thirty idiopathic EOS patients, 81% female, aged 8-11 at index surgery (mean 10.5 yrs), underwent PSF, MCGR, or VBT. Scoliosis curve, kyphosis, thoracic and spinal height, complications, and Quality of Life (QoL) were assessed preoperatively and at most recent follow-up (prior to final fusion for VBT/MCGR)., Results: Of 130 patients, 28.5% received VBT, 39.2% MCGR, and 32.3% PSF. The VBT cohort included more females (P < 0.0005), was older (P < 0.0005), more skeletally mature (P < 0.0005), and had smaller major curves (P < 0.0005). At follow-up, scoliosis curve corrected 41.1 ± 22.4% in VBT, 52.2 ± 19.9% in PSF, and 27.4 ± 23.9% in MCGR (P < 0.0005), however, not all VBT/MCGR patients finished treatment. Fifteen complications occurred in 10 VBTs, 6 requiring unplanned surgeries; 45 complications occurred in 31 MCGRs, 11 requiring unplanned surgeries, and 9 complications occurred in 6 PSFs, 3 requiring unplanned revisions. Cox proportional hazards regression adjusted for age, gender, and preoperative scoliosis curve revealed that MCGR (hazard ratio [HR] = 21.0, 95% C.I. 4.8-92.5; P < 0.001) and VBT (HR = 7.1, 95% C.I. 1.4-36.4; P = 0.019) patients were at increased hazard of requiring revision, but only MCGR patients (HR = 5.6, 95% C.I. 1.1-28.4; P = 0.038) were at an increased hazard for unplanned revisions compared with PSF. Thoracic and spinal height increased in all groups. QoL improved in VBT and PSF patients, but not in MCGR patients., Conclusion: In older idiopathic EOS patients, MCGR, PSF, and VBT controlled curves effectively and increased spinal height. However, VBT and PSF have a lower hazard for an unplanned revision and improved QoL.Level of Evidence: 3., (Copyright © 2021 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.)

Competing Interests: The authors declare no conflicts of interest.

Purpose: The Clavien-Dindosink (CDS) classification system provides more treatment-focused granularity than subjective methods of describing surgical complications; however, it has not been validated in posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). The purpose of this study was to modify the CDS system for application in patients with AIS undergoing PSF to assess its inter- and intra-rater reliability for describing complications faced by this population., Methods: A review of all complications specific to patients with AIS captured in a large multicenter international database was performed. All complications were classified according to CDS, modified by addition of "prolonged initial hospital stay" as a criterion for Grade II. A survey of this complication list and an additional 20 clinical vignettes (sent out on two occasions) was sent to nine spinal deformity surgeons. Weighted kappa values were used to determine inter- and intra-rater reliability., Results: The Fleiss κ value for interrater reliability among 5 respondents grading all AIS complications was 0.8 (very good). For each grade, interrater reliability was very good, with an overall range of 0.8-1. The overall kappa value for intrarater reliability among eight respondents grading 20 vignettes was between 0.6 (good) and 0.9 (very good)., Conclusion: The modified CDS classification system has very good interrater and intrarater reliability in describing complications following PSF in patients with AIS. This system may be of greater utility for reporting outcomes than a "major" versus "minor" complication system and can serve as a valuable tool for improving surgical practices and patient outcomes in this population., Level of Evidence: IV case series., (© 2021. Scoliosis Research Society.)

Study Design: Case report., Introduction: Juvenile rheumatoid arthritis (JRA) typically presents with fever, rash, anterior uveitis, and/or joint pain. We present three cases with initial torticollis due to rotatory subluxation of C1-C2 as an initial sign of JRA., Case Reports: Three girls, ages 5-9, presented with C1-2 rotatory subluxation. Traction was able to reduce the atlanto-axial joint in all cases. Based on imaging, history, exam, and laboratory results, they were diagnosed with JRA. After reduction of the atlantoaxial joint, they were transitioned to a halo vest and disease-modifying antirheumatic drugs (DMARDs). The older 2 children underwent C1-2 fusion. The younger child has minimal symptoms and has not undergone surgical intervention 4 years from initial presentation., Conclusion: Rotatory subluxation can be the first presenting sign of JRA. Younger children may be able to be treated conservatively with traction and medication, while older children may require occiput to C2 fusion due to bony destruction and basilar invagination., Level of Evidence: IV., (© 2021. Scoliosis Research Society.)

Background: Little data exists on surgical outcomes of sports-related cervical spine injuries (CSI) sustained in children and adolescent athletes. This study reviewed demographics, injury characteristics, management, and operative outcomes of severe CSI encountered in youth sports., Methods: Children below 18 years with operative sports-related CSI at a Level 1 pediatric trauma center were reviewed (2004 to 2019). All patients underwent morden cervical spine instrumentation and fusion. Clinical, radiographic, and surgical characteristics were analyzed., Results: A total of 3231 patients (mean, 11.3±4.6 y) with neck pain were evaluated for CSI. Sports/recreational activities were the most common etiology in 1358 cases (42.0%). Twenty-nine patients (2.1%) with sports-related CSI (mean age, 14.5 y; range, 6.4 to 17.8 y) required surgical intervention. Twenty-five were males (86%). Operative CSI occurred in football (n=8), wrestling (n=7), gymnastics (n=5), diving (n=4), trampoline (n=2), hockey (n=1), snowboarding (n=1), and biking (n=1). Mechanisms were 27 hyperflexion/axial loading (93%) and 2 hyperextension injuries (7%). Most were cervical fractures (79%) and subaxial injuries (79%). Seven patients (24%) sustained spinal cord injury (SCI) and 3 patients (10%) cord contusion or myelomalacia without neurological deficits. The risk of SCI increased with age (P=0.03). Postoperatively, 2 SCI patients (29%) improved 1 American Spinal Injury Association Impairment Scale Grade and 1 (14%) improved 2 American Spinal Injury Association Impairment Scale Grades. Increased complications developed in SCI than non-SCI cases (mean, 2.0 vs. 0.1 complications; P=0.02). Bony fusion occurred in 26/28 patients (93%) after a median of 7.2 months (interquartile range, 6 to 15 mo). Ten patients (34%) returned to their baseline sport and 9 (31%) to lower-level activities., Conclusions: The incidence of sports-related CSI requiring surgery is low with differences in age/sex, sport, and injury patterns. Older males with hyperflexion/axial loading injuries in contact sports were at greatest risk of SCI, complications, and permanent disability. Prevention campaigns, education on proper tackling techniques, and neck strength training are required in sports at high risk of hyperflexion/axial loading injury., Level of Evidence: Level III-retrospective cohort study., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Despite the relative frequency of posterior spinal fusion (PSF) and instrumentation for adolescent idiopathic scoliosis (AIS), there are limited guidelines for postoperative return to sports. Few studies explore factors influencing treating surgeons' recommendations., Methods: A survey presenting several clinical vignettes of patients who had undergone PSF for AIS was distributed to 1496 Pediatric Orthopaedic Society of North America (POSNA) members. Of the 257 returned surveys, 170 met the inclusion criteria. Mixed-effects models were created to assess the effects of the surgeon and hypothetical patient characteristics on return to jogging, noncontact, contact, and collision sports., Results: Estimated marginal mean time to return to sporting activities increased for more physically demanding sports [jogging: 4.1 mo, 95% confidence interval (CI): 3.8-4.3; noncontact: 4.6 mo, 95% CI: 4.3-4.9; contact: 6.8 mo, 95% CI: 6.4-7.1; collision: 9.8 mo, 95% CI: 9.2-10.4]. Hypothetical patient characteristics (sex, age, obesity, skeletal maturity, levels fused, and fusions ending in thoracic versus lumbar spine) were not associated with changes in return to sport recommendations for jogging, noncontact, contact, or collision activities. Surgeon volume, experience, fellowship type, and practice setting all affected return to all activities (P<0.05). Surgeons with prior complications from return to sport delayed return to collision activities (9.4 mo, 95% CI: 8.4-10.3) versus surgeons without complications (7.2 mo, 95% CI: 5.7-8.7, P<0.001)., Conclusions: Surgeons currently allow earlier return to high-intensity sports after PSF for AIS compared with previous studies. Protocol trends vary based on physician-related factors such as years in practice, case volume, fellowship training, practice type, and prior experience with complications. Patient-related factors were not found to impact return to sport protocols. This survey provides a portrait of current practice trends and serves as a foundation for future investigation., Level of Evidence: Level V-survey study., Competing Interests: R.J.M. consults for OrthoPediatrics and Philips Healthcare. M.P.G. consults for Nuvasive and Orthobullets; is on the speaker bureau for Nuvasive, Medtronic, Depuy Synthes, and Zimmer Biomet; owns stock in Orthobullets, and is a member of the Pediatric Spine Study Group and Harms Study Group. The remaining authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The use of vancomycin powder has been shown to decrease risk of surgical site infection (SSI) in early onset scoliosis (EOS). While there is potential benefit in SSI reduction, there is also theoretical risk in creating increased bacterial resistance to standard treatment regimens. However, the effects of topical vancomycin powder on microbiology in these patients has not been studied., Methods: A multicenter database for EOS patients was retrospectively analyzed. All patients that underwent surgical treatment with traditional growing rods, magnetically controlled growing rods, vertical expandable prosthetic titanium rib, and Shilla for EOS performed after 2010 were identified (n=1115). Patients that sustained at least 1 SSI after guided growth surgery were assessed (n=104, 9.3%). Patients with culture and antibiotic details were included (n=55). Patients that received vancomycin powder at index surgery were compared with patients that did not. A multivariate regression model was used to control for potential confounders., Results: There were 55 patients included in this study, including 26 males (47%) and 29 females (53%). Mean age at index surgery was 7.2±6.9 years. Vancomycin powder was utilized in 18 cases (33%). Mean time from index surgery to SSI was 2.0±1.3 years. There were 2 cases of wound dehiscence (4%), 7 cases of superficial infection (13%), and 46 cases of deep infection (84%).There were significant differences in overall microbiology results between vancomycin and no vancomycin cohorts (P=0.047). On univariate analysis, the vancomycin powder cohort had a significantly high incidence of cultures without growth (n=7, 39% vs. n=4, 11%, relative risk: 2.063, 95% confidence interval: 0.927-4.591, P=0.028). This association remained significant on multivariate analysis (adjusted odds ratio: 9.656, 95% confidence interval: 1.743-53.494, P=0.009)., Conclusions: In EOS patients undergoing procedures complicated by SSI, the use of vancomycin powder was independently associated with increased risk of no culture growth. Surgeons and infectious disease physicians should be aware and adjust diagnostic and treatment strategies appropriately., Level of Evidence: Level III-retrospective cohort study., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Spinal fusion surgery is associated with high levels of stress and anxiety for patients and their caregivers. Medical simulation has demonstrated efficacy in improving preparedness, knowledge, and overall experience prior to other medical procedures. The current study examines the utility of a multi-faceted preparation program (SIMDiscovery) using simulation techniques to reduce anxiety and increase preparedness among patients undergoing spinal fusion surgery and their caregivers., Methods: Participants attended SIMDiscovery where they received hands-on preparation about what to expect before, during, and after their surgery. Anxiety, preparedness, and knowledge about the procedure were assessed pre- and post-participation using self-report measures. Participants also completed a questionnaire at their first post-operative medical appointment. Differences from pre to post and between patients and caregivers were calculated with paired and independent sample t-tests., Results: Participants included 22 patients and 29 caregivers. Post-SIMDiscovery, both groups demonstrated increased knowledge for the surgical process and lower state anxiety. Patients reported increased feelings of preparedness in all areas while caregivers reported increased feelings of preparedness in most areas. Families continued to report positive impact of the program 30 days after surgery; however, they also identified areas where they desired increased preparation., Conclusions: SIMDiscovery increased patients' and caregivers' knowledge regarding spinal fusion surgery and helped them feel less anxious and more prepared regarding most aspects of the surgical process. These changes were generally maintained throughout the post-operative period. Participants identified areas for increased preparation, highlighting the importance of continuing to adapt programs based on patient and family feedback., Level of Evidence: Level III., (© 2021. Scoliosis Research Society.)

Research has demonstrated similar efficacy of drill epiphysiodesis and percutaneous epiphysiodesis using transphyseal screws for the management of adolescent leg length discrepancy. A cost analysis was performed to determine which procedure is more cost-effective. Patients seen for epiphysiodesis of the distal femur and/or proximal tibia and fibula between 2004 and 2017 were reviewed. A decision analysis model was used to compare costs. Two hundred thirty-five patients who underwent either drill (155/235, 66%) or screw (80/235, 34%) epiphysiodesis were analyzed with an average age at initial procedure of 13 years (range, 8.4 to 16.7 years). There was no significant difference in average initial procedure cost or total cost of all procedures across treatment groups (n = 184). The cost difference between drill and screw epiphysiodesis is minimal. In order for screw epiphysiodesis to be cost-favored, there would need to be a significant decrease in its cost or complication rate. (Journal of Surgical Orthopaedic Advances 30(3):181-184, 2021).

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: Pediatric orthopaedic fellowship directors (FDs) have a valuable impact on the education of trainees and future leaders in the field. There is currently no research on the characteristics of pediatric orthopaedic FDs., Methods: Programs were identified using the Pediatric Orthopaedic Society of North America fellowship directory. Operative, nonoperative, and specialty programs were included. Data was collected through Qualtrics survey, e-mail, telephone, and online searches. Variables included demographics (age, sex, race/ethnicity), Hirsch index (h-index) as a measure of research productivity, graduate education, residency and fellowship training, years of hire at current institution and as FD, and leadership roles., Results: Fifty-five FDs were identified. The majority (49/55, 89%) were male and 77% (27/35) were Caucasian. The mean age at survey was 51.1±8.2 years. The mean h-index was 17.2. Older age correlated with higher h-index (r=0.48, P=0.0002). The average duration from fellowship graduation to FD appointment was 9.6±6.7 and 6.9±6.1 years from institutional hire. Sixteen FDs (29%) had additional graduate level degrees. Almost all (52/55, 95%) FDs completed orthopaedic surgery residencies and all graduated fellowship training. Twenty-nine percent (16/55) completed more than 1 fellowship. Most FDs (51/55, 93%) completed a fellowship in pediatric orthopaedic surgery. Ten FDs (18%) completed pediatric orthopaedic surgery fellowships that included spine-specific training. One-third of all current FDs were fellowship-trained at either Boston Children's Hospital (9/55, 16%) or Texas Scottish Rite Hospital for Children (9/55, 16%)., Conclusions: Pediatric orthopaedic FDs are typically early-career to mid-career when appointed, with a strong research background. Nearly a third completed additional graduate degrees or multiple fellowships. Although male dominated, there are more female FDs leading pediatric orthopaedic programs compared with adult reconstruction, trauma, and spine fellowships. As fellowships continue to grow and diversify, this research will provide a baseline to determine changes in FD leadership., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Increasingly, patients with early onset scoliosis (EOS) are completing a growth friendly surgical program followed by observation, removal of implants or a definitive spinal fusion. These patients are colloquially referred to as "graduates". A standardized definition of a graduate is needed for research and comparing the outcomes, family counseling, and a better understanding of the population., Methods: A 15-question electronic survey was completed by 39 experienced pediatric spine surgeons to identify factors salient to the definition of a graduate of EOS surgical programs. A Delphi/Nominal group technique session with nine questions was then performed face-to-face with 21 members of the Pediatric Spine Study Group to discuss and refine the definition. A follow-up electronic survey was then distributed to these same 21 members to gain consensus on the final definition., Results: From the initial survey, it was identified that a graduate did not require definitive spinal fusion after a growing program. From the Delphi session, it was determined that skeletal maturity was the most important factor in defining a graduate. A strictly defined minimum length of follow-up was not felt to be a prerequisite for qualification of graduation. After the final electronic version was distributed, > 80% of respondents agreed upon the final definition, thereby achieving consensus., Conclusion: The Pediatric Spine Study Group recommends adoption of the following definition: a "graduate" is a patient who has undergone any surgical program to treat early onset scoliosis, and has reached skeletal maturity and does not have a planned surgical intervention for EOS in the future., Level of Evidence: V.

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.)

A 2012 publication regarding the surgical management of pediatric lateral humeral condyle fractures (PLHCF) found that leaving pins exposed produced an average savings of $3442 per patient compared to burying pins, with fewer complications. The primary objective of this present study was to determine the impact of this cost analysis on surgeons' treatment preferences at the same hospital. The secondary aim was to verify that leaving pins exposed continued to be a cost-effective and safe treatment strategy. We reviewed all PLHCF treated with open reduction and internal fixation at our institution between 2004 and 2017. The Clavien-Dindo Classification was used to grade complications. Variations in treatment course were evaluated using a chi-squared test to compare the proportions of buried and exposed pins, pre- and postcost analysis report publication. Two hundred forty-eight patients were included. The mean age was 5.9 years (range 1-12 years). In 174 (70%) cases, the pins were buried and in the remaining 30% the pins were exposed. Between 2004 and 2012, the majority of pins were buried (90%) compared to between 2013 and 2017, when the majority of pins were exposed (62%) (P < 0.001). There was no difference detected in complication rate (P = 0.75) or complication severity (P = 0.61) across groups. The demonstrated cost-effectiveness of exposing the pins in the treatment of PLHCF has had a statistically significant impact on surgeon behavior at our institution. Publishing cost analysis research can change physician practice to improve quality, safety and value of care delivery., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

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.

Design: Prospective cerebral palsy (CP) registry review., Objectives: (1) Evaluate the incidence/risk factors of gastrointestinal (GI) complications in CP patients after spinal fusion (SF); and (2) investigate the validity of the modified Clavien-Dindo-Sink classification., Background: Perioperative GI complications result in increased length of stay (LOS) and patient morbidity/mortality. However, none have analyzed the outcomes of GI complications using an objective classification system., Methods: A prospective/multicenter CP database identified 425 children (mean, 14.4 ± 2.9 years; range, 7.9-21 years) who underwent SF. GI complications were categorized using the modified Clavien-Dindo-Sink classification. Grades I-II were minor complications and grades III-V major. Patients with and without GI complications were compared., Results: 87 GI complications developed in 69 patients (16.2%): 39 minor (57%) and 30 major (43%). Most common were pancreatitis (n = 45) and ileus (n = 22). Patients with preoperative G-tubes had 2.2 × odds of developing a GI complication compared to oral-only feeders (OR 2.2; 95% CI 0.98-4.78; p = 0.006). Similarly, combined G-tube/oral feeders had 6.7 × odds compared to oral-only (OR 6.7; 95% CI 3.10-14.66; p < 0.001). The likelihood of developing a GI complication was 3.4 × with normalized estimated blood loss (nEBL) ≥ 3 ml/kg/level fused (OR 3.41; 95% CI 1.95-5.95; p < 0.001). Patients with GI complications had more fundoplications (29% vs. 17%; p = 0.03) and longer G-tube fasting periods (3 days vs. 2 days; p < 0.001), oral fasting periods (5 days vs. 2 days; p < 0.001), ICU admissions (6 days vs. 3 days; p = 0.002), and LOS (15 days vs. 8 days; p < 0.001). LOS correlated with the Clavien-Dino-Sink classification., Conclusion: Gastrointestinal complications such as pancreatitis and ileus are not uncommon after SF in children with CP. This is the first study to investigate the validity of the modified Clavien-Dindo-Sink classification in GI complications after SF. Our results suggest a correlation between complication severity grade and LOS. The complexity of perioperative enteral nutritional supplementation requires prospective studies dedicated to enteral feeding protocols., Level of Evidence: Therapeutic-level III.

Background: The risk of surgical site infection in pediatric posterior spine fusion (PSF) is up to 4.3% in idiopathic populations and 24% in patients with neuromuscular disease. Twenty-three percent of pediatric PSF tissue cultures are positive before closure, with a higher rate in neuromuscular patients. Our primary aim was to evaluate the feasibility of a complete randomized controlled trial to study the efficacy of surgical site irrigation with povidone-iodine (PVP-I) compared with sterile saline (SS) to reduce the bacterial contamination rate before closure in children undergoing PSF., Methods: One hundred seventy-five subjects undergoing PSF were enrolled in a multicenter, single-blind, pilot randomized controlled trial. We recruited patients at low-risk (LR) and high-risk (HR) for infection 3:1, respectively. Before closure, a wound culture was collected. Nonviable tissues were debrided and the wound was soaked with 0.35% PVP-I or SS for 3 minutes. The wound was then irrigated with 2 L of saline and a second sample was collected., Results: One hundred fifty-three subjects completed the protocol. Seventy-seven subjects were allocated to PVP-I (18 HR, 59 LR) and 76 to SS (19 HR, 57 LR). Cultures were positive in 18% (14/77) of PVP-I samples (2 HR, 12 LR) and in 17% (13/76) of SS samples (3 HR, 10 LR) preirrigation and in 16% (12/77) of PVP-I samples (5 HR, 7 LR) and in 18% (14/76) of SS samples (4 HR, 10 LR) postirrigation. Eight percent (3/37) HR subjects (1 PVP-I, 2 SS) experienced infection at 30 days postoperative. No LR subjects experienced infection., Conclusions: Positive cultures were similar across treatment and risk groups. The bacterial contamination of wounds before closure remains high regardless of irrigation type. A complete randomized controlled trial would be challenging to adequately power given the similarity of tissue positivity across groups., Level of Evidence: Level II-pilot randomized controlled trial.

Study Design: Retrospective case series., Objectives: To describe how pediatric patients with spinal and pelvic osteomyelitis are diagnosed and treated and assess the diagnostic value of magnetic resonance imaging (MRI), needle aspiration biopsy (NAB), and blood cultures in this population. Spinal and pelvic osteomyelitis de novo are uncommon in children and minimal literature exists on the subject. Research has shown that NAB and blood cultures have variable diagnostic yield in adult native osteomyelitis. At our institution, there is no standard protocol for diagnosing and treating pediatric spinal and pelvic osteomyelitis de novo., Methods: All diagnoses of spinal and pelvic osteomyelitis at a pediatric tertiary care center from 2003 to 2017 were reviewed. Patients aged 0-21 at diagnosis were included. Patients with osteomyelitis resulting from prior spinal operations, wounds, or infections and those with chronic recurrent multifocal osteomyelitis were eliminated. All eligible patients' diagnoses were confirmed by MRI., Results: 29 patients (18 men, 11 women) met the inclusion criteria. The median age at diagnosis was 11 years old (range 1-18). More than half of all cases (17/29, 59%) affected the lumbar spine. The most common symptoms were back pain (20/29, 69%), fever (18/29, 62%), hip pain (11/29, 38%), and leg pain (8/29, 28%). The majority of NABs and blood cultures performed were negative, but of the positive tests Staphylococcus aureus was the most prevalent bacteria. 86% (25/29) had an MRI before a diagnosis was made and 72% (13/18) had an NAB performed post-diagnosis., Conclusions: MRI is a popular and helpful tool in diagnosing spinal osteomyelitis de novo. NAB cultures are often negative but can be useful in determining antibiotic treatment., Level of Evidence: Level IV.

Background: Sotos syndrome (SS), or cerebral gigantism, describes children with macrocephaly, craniofacial abnormalities, general overgrowth, ligamentous laxity, developmental delay, and neurological disabilities. Fewer than 500 cases have been reported since Sotos and colleagues described the condition in 1964 and no literature exists on the management of spinal deformity in children under 10 years old.The aims of this study were: (1) to characterize the presentation of spinal deformities in patients with SS; and (2) to provide preliminary results of growth-friendly instrumentation (GFI) in these children., Methods: Thirteen children (9 boys) with SS and minimum of 2-year follow-up were identified from 2 multicenter early-onset scoliosis (EOS) databases (1997-2017). Mean age at index surgery and follow-up duration were 5.0 years (range, 1.8 to 10 y) and 7.2 years (range, 2.1 to 14.9 y), respectively. Patients underwent GFI for a mean of 5.7 years (range, 2 to 10.2 y), with an average of 9 lengthenings (range, 2 to 18). Definitive spinal fusion was performed in 4 patients (31%). Major curve magnitude, T1-T12 and T1-S1 lengths, thoracic kyphosis, and lumbar lordosis were evaluated preindex, postindex, latest GFI, and postfusion, when possible., Results: Five thoracolumbar (38%), 4 double major (31%), 2 main thoracic (15%), and 2 double thoracic curves (15%) were seen that spanned a mean of 6.8 levels (5 to 9). Major curves improved 36% (range, 5% to 71%), from a mean of 71 degrees (range, 48 to 90 degrees) to 46 degrees (range, 20 to 73 degrees) postindex surgery (P<0.001). Major curves remained stable at a mean of 52 degrees (range, 20 to 87 degrees) at latest GFI (P=0.36). True T1-T12 and T1-S1 growth velocities during GFI were 0.5 mm/mo (range, 0.4 to 0.8 mm/mo) and 0.8 mm/mo (range, 0.1 to 2.1 mm/mo), respectively. Twenty-six complications occurred in 9 patients (69%) averaging 2 complications per patient (range, 0 to 7)., Conclusions: This is the first study to evaluate the outcomes of GFI in children with SS and EOS. Compared with published data for outcomes of GFI in EOS, children with SS may have less major curve correction. Growth-friendly surgery remains an effective treatment method for EOS in patients with SS., Levels of Evidence: Level IV-retrospective case-series.

Study Design: Retrospective case-series., Objectives: To evaluate the outcomes of bracing in skeletally immature patients with moderate-severe idiopathic scoliosis (IS) curves ≥ 40°., Background: In contrast to prior beliefs, the recent studies have reported successful outcomes with brace treatment may occur in some patients with moderate-severe scoliosis ≥ 40°. Despite other encouraging case-series, non-operative treatment is rarely attempted and the efficacy of bracing large curves remains uncertain., Methods: 100 skeletally immature children (mean 11.8 ± 2.36 years; range 6.1-16.5) with IS ≥ 40° were identified. 80 were adolescent IS (80%) and 20 juvenile IS (20%). The Risser plus score was used to evaluate skeletal maturity. 66 children were Risser 0 (66%). SRS-SOSORT outcome guidelines were used: > 5° progression, stabilization between - 5° and 5° and, > 5° improvement., Results: Mean initial Cobb was 45° ± 3.9° (range 40°-59°), with in-brace and  % correction of 30° ± 8.7° (range 7°-48°) and 34 ± 17.5% (range 2-84%), respectively. 57 progressed (57%), 32 stabilized (32%), and 11 improved (11%) after a median of 1.8 years (IQR 1.2-2.9). Open triradiate cartilage at presentation (p = 0.005) and less in-brace correction (p = 0.009) were associated with progression. 58 children (58%) underwent surgery after a mean of 3.0 years (range 0.7-7.3). Surgical patients were younger (11.2 vs. 12.7 years; p = 0.003), more often Risser 0 (79% vs. 48%; p < 0.001); however, presented with similar curves (45° vs. 44°; p = 0.31). Open triradiate cartilage at presentation (OR 15.3; 95% CI 4.3-54.6; p < 0.001) and less in-brace correction (p = 0.03) increased the likelihood of surgery. All 20 JIS patients avoided temporary growth rods, with 18 (90%) eventually requiring surgery., Conclusion: Non-operative treatment was successful in 42% of children. Risk factors for surgery were younger age, open triradiates, and less in-brace correction. Bracing can be effective in delaying surgery until skeletal maturity in patients with curves ≥ 40°. Patients should be counseled on the risks and benefits of bracing and surgery., Level of Evidence: Level IV.

Study Design: It is a retrospective cohort study., Objectives: To compare the radiographic and clinical outcomes of serial body casting for infantile idiopathic scoliosis (IIS) with versus without the use of general anesthesia (GA). Serial body casting for IIS has traditionally been performed under GA. However, reports of neurotoxic effects of anesthetics in young children have prompted physicians to consider instead performing these procedures while patients are awake and distracted by electronic devices., Methods: Patients from a multicenter registry who underwent serial casting for IIS were included. The patients were divided into asleep (GA) and awake (no GA) cohorts. Comparisons were made between pre-casting, first in-cast, and post-casting radiographic measures in each cohort. The rates of successful casting (≥ 10° major CA improvement), curve progression, and incidence of casting abandonment for surgical intervention were also compared., Results: One-hundred and twenty-one patients who underwent serial casting for IIS were included. Ninety-two (76%) patients were asleep during casting procedures, while 29 (24%) were awake. Patients in the awake cohort were older (p < 0.01), had a lower BMI (p = 0.03), and more severe curve magnitudes (p < 0.01) at baseline. Patients in the awake cohort experienced greater first-in-cast correction of the major curve (p = 0.01) and improvement in thoracic spine height (p < 0.01). The rate of casting success was higher in the awake cohort (72%) as compared to the asleep cohort (48%) (p = 0.02), although the rate of curve progression (worsening) was similar (p = 0.880). Lastly, there was a lower rate of conversion to surgery at 2 years post-initiation of casting, although this was not statistically significant (0% vs. 8%; p = 0.126)., Conclusions: Patients who underwent awake serial casting had similar radiographic outcomes as compared to those who were under general anesthesia during the procedures. Thus, awake casting may provide a safe and effective alternative to the use of general anesthesia in patients with idiopathic infantile scoliosis., Level of Evidence: III.