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The perfused, pulseless supracondylar humerus fracture (ppSCHF) remains a consistent topic of discussion in the literature. Inpatient observation of these patients postoperatively for worsening vascular exam or compartment syndrome is frequently recommended but not well studied. The purpose of this study was to evaluate the postoperative complications in a cohort of ppSCHF patients and their timeline to discharge.This study is a retrospective review of a prospectively maintained database of all operatively treated supracondylar humerus fractures from a tertiary pediatric hospital from 2013 to 2019. All patients without a palpable pulse were included. We excluded patients with4 weeks follow-up. Demographic, operative, and postoperative data were collected, including time from presentation to operating room (OR), time from OR to discharge, and incidence of postoperative complications, including return to OR, compartment syndrome, new neurovascular deficits, and Volkmann contractures. The descriptive statistics were used to summarize the data.Among 1371 operatively treated supracondylar humerus fractures, 39 (2.8%) presented with a ppSCHF. Five (15%) had a signal on doppler ultrasound, whereas 34 (85%) had no signal. Thirty-seven (95%) patients had a Gartland type III fracture and 2 (5%) had type IV fractures. Twenty-two (56%) patients had a neurological deficit, of which 14 had an anterior interosseous nerve deficit. The average time to OR was 6.9 (range 2.2 to 15) hours; 6 (15%) required open reduction. At the time of discharge, 85% of patients had a palpable pulse and 13% had a dopplerable signal. Postoperatively, no patients were returned to the OR for any secondary procedures. The average length of stay after the operation was 25 (range 8.5 to 40) hours, with 92% of patients being discharged by 36 hours postoperatively. No patients developed compartment syndrome, new neurological deficits, or Volkmann contractures at a mean follow-up of 112 (range 34 to 310) days.In our study of 39 patients presenting with ppSCHF, no patient required an unexpected return to the OR, or developed post-treatment compartment syndrome, neurological deficits, or Volkmann contractures. The average time from OR to discharge for ppSCHF was 25 hours.Level II.

A retrospective comparative study.The aim of this study was to compare the length and diameter of thoracic pedicles in patients with adolescent idiopathic scoliosis (AIS) as measured on preoperative magnetic resonance imaging (pMRI) to intraoperative computed tomography (iCT) scan.Optimally sized pedicle screw placement during instrumented posterior spinal fusion for AIS can maximize correction and minimize screw pullout. While iCT-guided navigation can quickly estimate screw position and size, this technology is not universally available. Many surgeons utilize pMRI, when obtained, to estimate screw sizes. Data comparing these measurements on pMRI and iCT is limited. We hypothesized that in patients with surgical magnitude AIS, pedicle length, and diameter measured on pMRI would have at least moderate reliability compared to those made on iCT images.The pMRI and iCT for 60 patients with structural thoracic curves who underwent posterior spinal fusion for AIS at a single center between 2009 and 2017 were analyzed. Bilateral T5-T12 vertebral levels were evaluated for pedicle chord length and pedicle isthmic diameter on both pMRI and iCT. Between-study reliability and interrater reliability was evaluated for each level of the thoracic spine.There is good reliability for pedicle length [intraclass correlation coefficient (ICC)=0.8, 95% confidence interval (CI): 0.78-0.83] and diameter (ICC=0.86, 95% CI: 0.84-0.88) between pMRI and iCT. When assessed by level, T6 has the lowest reliability for length (ICC=0.52, 95% CI: 0.33-0.67) and diameter (ICC=0.55, 95% CI: 0.35-0.69). Interrater reliability ranged from moderate-to-good reliability for all pedicle measurements for both length and diameter on pMRI and iCT.Pedicle measurements made on pMRI may be used with reasonable reliability to predict pedicle dimensions visualized on iCT, allowing surgeons to preoperatively plan pedicle screw sizes based off magnetic resonance imaging.

Vertical expandable prosthetic titanium rib (VEPTR) devices were designed to treat childhood scoliosis and thoracic insufficiency syndrome. Although they have drastically reduced patient mortality, they present a profound subcutaneous hardware burden. The authors examined the surgical and nonsurgical factors associated with salvage of VEPTR hardware exposures.Between 2014 and 2020, a prospective institutional database was queried for patients with VEPTR hardware complications who required soft-tissue reconstruction. Hardware salvage was considered successful if reconstruction allowed the hardware to be retained until the next VEPTR expansion.Fifty-eight patients required VEPTR hardware salvage. Hardware complications were successfully salvaged in 62.1 percent of patients at 60.0 percent of operative sites. Neuromuscular scoliosis (p = 0.041) and nonambulatory status (p = 0.018) were factors associated with VEPTR hardware salvage failure, whereas congenital scoliosis was associated with successful hardware salvage (p = 0.012) and preventing need for immediate hardware removal (p = 0.049). Exposed hardware, as compared to threatened exposure, was more likely to require immediate removal (p = 0.045) and result in unsuccessful hardware salvage (p = 0.015).Local and regional muscle flaps were able to prevent VEPTR hardware removal in the majority of patients, even in the setting of infection, immobility, incontinence, and multiple systemic comorbidities. Patients with neuromuscular scoliosis and nonambulatory status were at increased risk for failure, whereas those with incontinence and low body mass index trended toward increased risk of failure. Threatened exposure was associated with higher rates of salvage than exposed hardware, and thus earlier referral to plastic surgeons for soft-tissue salvage may be advised.Risk, III.

Quantitative regional assessment of thoracic function would enable clinicians to better understand the regional effects of therapy and the degree of deviation from normality in patients with thoracic insufficiency syndrome (TIS). The purpose of this study was to determine the regional functional effects of surgical treatment in TIS via quantitative dynamic magnetic resonance imaging (MRI) in comparison with healthy children.Volumetric parameters were derived via 129 dynamic MRI scans from 51 normal children (November 2017 to March 2019) and 39 patients with TIS (preoperatively and postoperatively, July 2009 to May 2018) for the left and right lungs, the left and right hemi-diaphragms, and the left and right hemi-chest walls during tidal breathing. Paired t testing was performed to compare the parameters from patients with TIS preoperatively and postoperatively. Mahalanobis distances between parameters of patients with TIS and age-matched normal children were assessed to evaluate the closeness of patient lung function to normality. Linear regression functions were utilized to estimate volume deviations of patients with TIS from normality, taking into account the growth of the subjects.The mean Mahalanobis distances for the right hemi-diaphragm tidal volume (RDtv) were -1.32 ± 1.04 preoperatively and -0.05 ± 1.11 postoperatively (p = 0.001). Similarly, the mean Mahalanobis distances for the right lung tidal volume (RLtv) were -1.12 ± 1.04 preoperatively and -0.10 ± 1.26 postoperatively (p = 0.01). The mean Mahalanobis distances for the ratio of bilateral hemi-diaphragm tidal volume to bilateral lung tidal volume (BDtv/BLtv) were -1.68 ± 1.21 preoperatively and -0.04 ± 1.10 postoperatively (p = 0.003). Mahalanobis distances decreased after treatment, suggesting reduced deviations from normality. Regression results showed that all volumes and tidal volumes significantly increased after treatment (p0.001), and the tidal volume increases were significantly greater than those expected from normal growth for RDtv, RLtv, BDtv, and BLtv (p0.05).Postoperative tidal volumes of bilateral lungs and bilateral hemi-diaphragms of patients with TIS came closer to those of normal children, indicating positive treatment effects from the surgical procedure. Quantitative dynamic MRI facilitates the assessment of regional effects of a surgical procedure to treat TIS.Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND Study groups are multicenter collaborations aimed at improving orthopaedic decision-making through higher-powered, more generalizable studies. New research is disseminated through peer-reviewed literature and academic meetings, including the Pediatric Orthopaedic Society of North America (POSNA) annual meeting, which brings together academic and medical professionals in pediatric orthopaedics. The goal of this study was to identify patterns in podium presentations (PP) at the POSNA annual meeting resulting from multicenter study groups during a 15-year period. METHODS A total of 2065 PP from the 2006 to 2020 POSNA annual meetings were identified. The abstracts of each PP were reviewed to determine if they resulted from a multicenter study group and for characteristics including subspecialty focus. PP from 2006 to 2018 were further reviewed for publication in academic journals. Pearson correlation was used to assess change in the number of PP resulting from study groups overtime. Univariate analysis was used to compare characteristics of PP based on study group involvement (significance P

With many pediatric orthopaedic surgeons spending 3 or even more days a week in clinic, a thorough understanding of the ever-changing electronic medical record is paramount to providing excellent clinical care, overall job satisfaction, and minimizing clinician burnout. Here we provide 5 tips to optimize clinic workflow for the busy pediatric orthopaedic surgeon in the electronic medical record era.

The "law of diminishing returns" is described for traditional growing rods. Magnetically controlled growing rods (MCGRs) have become a preferred implant for the surgical treatment of early-onset scoliosis (EOS). We examined a large cohort of patients with EOS to determine whether the law of diminishing returns applies to MCGRs.A prospectively collected, multicenter registry was queried for patients with EOS treated with MCGRs. Patients with only spine-based implants and a minimum of 2 years of follow-up were included; patients with congenital scoliosis, single rods,3 lengthenings, or25% missing data were excluded. Patients were analyzed in 3 cohorts: primary MCGR (pMCGR) had first-time MCGR implants, secondary MCGR (sMCGR) were converted from an MCGR to a new MCGR, and conversion MCGR (cMCGR) were converted from a non-MCGR implant to MCGR.A total of 189 patients in the pMCGR group, 44 in the cMCGR group, and 41 in the sMCGR group were analyzed. From post-MCGR placement to the most recent follow-up or pre-definitive procedure, there were no differences in the changes in major Cobb angle, T1-S1 height, or T1-T12 height over time between the pMCGR and cMCGR groups. There was a decrease in length achieved at subsequent lengthenings in all cohorts (p0.01), and the sMCGR group had a significantly poorer ability to lengthen at each subsequent lengthening versus the pMCGR and cMCGR groups (p0.02). The 1-year survival rate was 90.5% for pMCGR, 84.1% for sMCGR, and 76.4% for cMCGR; 2-year survival was 61.5%, 54.4%, and 41.4%, respectively; and 3-year survival was 37.6%, 36.7%, and 26.9%, respectively. Excluding MCGRs still expanding, 27.6% of pMCGRs, 8.8% of sMCGRs, and 17.1% of cMCGRs reached the maximum excursion. Overall, 21.7% reached the maximum excursion. Within the pMCGR cohort, idiopathic and neuromuscular etiologies had a decline in lengthening achieved over time (p0.001), while syndromic EOS demonstrated a preserved ability to lengthen over time (p = 0.51). When the etiological groups were compared with each other, the neuromuscular group had the least ability to lengthen over time (p = 0.001 versus syndromic, p = 0.02 versus idiopathic).The MCGR experiences the law of diminishing returns in patients with EOS. We found that only 21.7% of rods expanded to within 80% of the maximum excursion.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The founding of the International Congress for Early Onset Scoliosis (ICEOS) and first annual meeting in 2007 represented a significant milestone in advancing the care of patients with EOS. Due to the complexity and rarity of EOS, this annual conference is the premiere venue for physicians, researchers, and advanced practice providers to identify and understand the best treatments for children with EOS. This study examines the trend of various treatment modalities presented at ICEOS and the changes in research quality since its inception.Podium presentations from the 2007 through 2021 ICEOS annual meetings were reviewed to determine the number of study patients, use of a study group, and key features of study design. Treatment strategies being evaluated were recorded and included non-operative treatments (casting/bracing), traditional growing rods (TGR), vertical expandable prosthetic titanium rib (VEPTR), Shilla growth guidance, magnetically controlled growing rods (MCGR), and vertebral body tethering (VBT). Linear regressions were performed to analyze changes in research topic and study group utilization.A total of 532 abstracts were reviewed. An average of 97.5 ± 81.3 patients were included per study with a significant increase from 42.3 ± 89.7 in 2007 to 337.6 ± 587.4 in 2021 (rThe trends in EOS device implantation observed in registry studies align with the trends in research presented at ICEOS including the increased proportion of studies focusing on MCGR and VBT over the past decade. An attempt to increase the quality of research presented at ICEOS through multicenter study groups, increased patient recruitment, and utilization of PROMs has been seen since its inception.V.

PURPOSE Patients with neuromuscular scoliosis undergoing posterior instrumented spinal fusion can be underweight, malnourished, and have higher complication rates. A nutrition consult is common in this population and it is unclear if weight gain occurs from the consult or surgery. The purpose of the study was to determine if nutrition consultation in the year prior to spinal fusion resulted in significant differences in weight gain or percentile on the CP growth chart. The secondary aim was to determine if there would be deformity progression during that time. METHODS Retrospective chart and radiograph review was performed for all patients with neuromuscular spinal deformity treated with posterior instrumented spinal fusion at one institution between January 1, 2009 and August 1, 2015. Inclusion criteria included

PURPOSE Although pediatric spinal deformity correction using pedicle screws has a very low rate of complications, the long-term consequences of screw malposition is unknown. CT navigation has been proposed to improve screw accuracy. The aim of this study was to determine whether intraoperative navigation during pedicle screw placement in pediatric scoliosis makes screw placement more accurate. We also examined radiation exposure, operative time blood loss and complications with and without the use of CT navigation in pediatric spinal deformity surgery. METHODS A systematic review of the literature was conducted. After screening, 13 articles were qualitatively and quantitatively analyzed to be used for the review. A random effects meta-analysis using REML methodology was employed to compare outcomes of screw accuracy, estimated blood loss, radiation exposure, and surgical duration. RESULTS Screws placed with CT navigation surgery were three times as likely to be deemed "acceptable" compared with screws placed with freehand and 2D fluoroscopy assistance, twice as likely to be "perfect", and only 1/3 as likely to be potentially unsafe (all p value

Because of the relative rarity of Early Onset Scoliosis (EOS) cases, patient registries were developed to combine clinical information from multiple institutions to maximize patient care and outcomes. This study examines the history and trends regarding the use of growth-friendly devices for index surgical procedures in EOS patients within the Pediatric Spine Study Group database.All index growth-friendly implants were queried from registry inception until October 2020. EOS etiology, device/implant type, and geographic area/institution for each procedure were recorded.From 1994 to 2020, 2786 patients underwent index surgery at a mean age of 6.2±2.9 years. There were 908 traditional growing rods (TGR) (32.3%), 922 vertical expandable prosthetic titanium rib devices (VEPTR) (33.1%), 5 hybrid VEPTR/TGR (0.18%), and 951 magnetically controlled growing rods (MCGR) (34.2%) index implants. Fifty-six different institutions reported an index implant, and 5 accounted for 823 (30%) of the cases during the study period. Institutions in the Northeast accounted for more index implants than other regions of the United States. There was a 40% increase in index implant insertions annually when comparing 1994 (3 implants/1 center) to 2018 (234 implants/56 centers), ( P0.001). Beginning in 2009, there was a 90.9% decrease in the number of TGR/VEPTR procedures (2009: 156 implants/32 centers; 2019: 22 implants/49 centers P =0.001), and a 479% increase in MCGR (2009: 1 implant/1 center; 2018: 197 implants/34 centers ( P =0.005). The overall number of growth-friendly index procedures performed in 2019 (150/49 centers) decreased 34.5% when compared to 2018 (234/48 centers).The number of growth-friendly implants reported in the Pediatric Spine Study Group registry as the initial surgical management of EOS increased markedly over the past 20 years. MCGR is currently the predominant type of device utilized for index surgical procedures by group members, surpassing the use of VEPTR and TGR in 2014. There was a significant decrease in index growth-friendly procedures in 2019 compared to 2018.Level IV.

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.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.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 .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 V.

BACKGROUND: A database of normative quantitative measures of regional thoracic ventilatory dynamics, which is essential to understanding better thoracic growth and function in children, does not exist. RESEARCH QUESTION: How to quantify changes in the components of ventilatory pump dynamics during childhood via thoracic quantitative dynamic MRI (QdMRI)? STUDY DESIGN AND METHODS: Volumetric parameters were derived via 51 dynamic MRI scans for left and right lungs, hemidiaphragms, and hemichest walls during tidal breathing. Volume-based symmetry and functional coefficients were defined to compare left and right sides and to compare contributions of the hemidiaphragms and hemichest walls with tidal volumes (TVs). Statistical analyses were performed to compare volume components among four age-based groups. RESULTS: Right thoracic components were significantly larger than left thoracic components, with average ratios of 1.56 (95% CI, 1.41-1.70) for lung TV, 1.81 (95% CI, 1.60-2.03) for hemidiaphragm excursion TV, and 1.34 (95% CI, 1.21-1.47) for hemichest wall excursion TV. Right and left lung volumes at end-expiration showed, respectively, a 44% and 48% increase from group 2 (8 ≤ age < 10) to group 3 (10 ≤ age < 12). These numbers from group 3 to group 4 (12 ≤ age ≤ 14) were 24% and 28%, respectively. Right and left hemichest wall TVs exhibited, respectively, 48% and 45% increases from group 3 to group 4. INTERPRETATION: Normal right and left ventilatory volume components have considerable asymmetry in morphologic features and dynamics and change with age. Chest wall and diaphragm contributions vary in a likewise manner. Thoracic QdMRI can provide quantitative data to characterize the regional function and growth of the thorax as it relates to ventilation.

Retrospective cohort study. To determine if additional procedures can be safely performed under the same anesthesia as early-onset scoliosis (EOS) rib-based surgeries. EOS patients with rib-based implants often require repeated invasive surgery to treat their spinal deformity, with associated risks of cognitive development impairment from multiple anesthetic exposures. Many of these patients have comorbidities that require additional procedures, possibly increasing the risk of adverse outcomes. We performed a retrospective review of EOS patients treated with rib-based implants with at least 2 year follow up at a single institution. Patients were divided into two cohorts: Group A included patients who never had another procedure in conjunction with a rib-based implant insertion, expansion, and/or revision surgery throughout their treatment and Group B included patients who had at least one other procedure operate in conjunction with rib-based implant surgery. Univariate analysis was performed to compare demographics, surgical parameters, and incidence of complication between the two groups. A subanalysis of patients who experienced an infection requiring surgery in Group A and Group B was also performed to further analyze the impact of concomitant procedures. 147 EOS patients underwent rib-based growing instrumentation at our institution. 98 patients (Group A) did not have another procedure occur under the same anesthetic as a rib-based implant surgery and 49 patients (Group B) had another procedure performed in conjunction with a rib-based implant surgery. Gender, etiology, BMI, length of follow up and number of rib-based implant procedures were similar between both cohorts (p = 0.91, 0.24, 0.28, 0.91, 0.77, respectively). The total surgical and anesthesia time was significantly longer in the patients undergoing concomitant procedures (Group B) (p

Growth modulation is an emerging method for treatment of angular skeletal deformities such as adolescent idiopathic scoliosis (AIS). The Hueter-Volkmann law, by which growth is stimulated in tension and inhibited in compression, is widely understood, and applied in current growth-modulating interventions such as anterior vertebral body tethering (AVBT) for AIS. However, without quantification of the growth rate effects of tension or compression, the possibility of under- or over- correction exists. A definitive mechanical growth modulation relationship relating to treatment of such skeletal deformities is yet to exist, and the mechanisms by which growth rate is regulated and altered are not fully defined. Review of current literature demonstrates that longitudinal (i.e., lengthwise) growth rate in multiple animal models depend on load magnitude, anatomical location, and species. Additionally, alterations in growth plate morphology and viability vary by loading parameters such as magnitude, frequency, and whether the load was applied persistently or intermittently. The aggregate findings of the reviewed studies will assist in work towards increasingly precise and clinically successful growth modulation methods. Part 1 of this review focuses on the effects of mechanical loading, species, age, and anatomical location on the macro-scale alterations in longitudinal bone growth, as well as factors that affect growth plate material properties. Part 2 considers the effects on micro-scale alterations in growth plate morphology such as zone heights and proportions, chondrocyte viability, and related gene and protein expression.

Retrospective case–control. To identify a cohort of patients with persistent coronal imbalance (CIB) or revision surgery 5 years following fusion to an L3 lowest-instrumented-vertebra (LIV) and determine factors that make an L3 LIV high-risk. In surgical planning for AIS, L3 is chosen over L4 whenever possible to maximize motion segments below the LIV. Though fusion to an L3 LIV is common, the rate of failure and its risk factors have not been described. In this analysis of prospectively-collected multi-center data of AIS patients who underwent posterior spinal fusion (PSF) to an L3 LIV, we identified patients with CIB at 5 years and/or those who required revision surgery attributable to LIV selection. Patients who were balanced at 5 years and did not require revision surgery served as controls. Pre-operative patient and radiographic variables were compared between cases and controls to identify risk factors for CIB/revision surgery. We identified 646 patients with 2-year follow-up and 225 patients with 5-year follow-up, of which 11 were found to have CIB and/or revision surgery attributable to selecting L3 as the LIV. There were statistically significant differences between cases and controls with respect to several pre-operative factors, including BMI (24.5 in cases vs. 20.1 in controls; p = 0.01), Lenke curve type (81.8% Lenke 5/6 vs. 44.4%; p = 0.03), lumbar curve magnitude (56 vs. 45°; p

AIS patients consider shoulder balance an important cosmetic outcome after surgery. We examined the impact of preoperative left shoulder elevation (LSE) and choice of upper instrumented vertebra (UIV) on postoperative shoulder imbalance (PostSI). This was a retrospective cohort study utilizing a prospective AIS database. Patients had Lenke type 1–4 curves and preoperative shoulder height ≥ 1.0 cm. Patients with preoperative LSE and right shoulder elevation (RSE) were compared. Shoulder height difference 34.5° was predictive of PostSI ≥ 2.0 cm for patients with preoperative LSE. AIS patients with preoperative LSE are less likely to achieve level shoulders postoperatively. Choice of higher UIV did not affect postoperative shoulder imbalance in this cohort. A PTC > 34.5° was predictive of severe PostSI in patients with preoperative LSE. II.

Patients with spinal muscular atrophy (SMA) are often treated with growth friendly devices such as vertical expandable prosthetic titanium rib(VEPTR) and magnetically controlled growing rods(MCGR) to correct spinal deformity and improve pulmonary function. There is limited data on this topic, and the purpose of this study was to assess the effect of these constructs and the addition of chest wall support (CWS) on spinal deformity, thorax morphology and pulmonary outcomes. This is a retrospective analysis of prospectively collected data. We included patients with chest wall deformity and scoliosis secondary to SMA who were treated with growth friendly interventions and had two-year follow-up. Descriptive statistics and univariate analyses were performed. This study included 66 patients (25% MCGR, 73% VEPTR, 2% unknown). Approximately 23% of constructs included CWS. The average Cobb angle improved from 67° (SD: 27°) to 50° (SD: 26°) at 2 years in patients with CWS (p = 0.02), and from 59° (SD: 20°) to 46° (SD: 15°) at 2 years in patients without CWS (p

Background Severe early-onset scoliosis (EOS) has been associated with a multitude of comorbidities, chief among them being deficient thoracic spine growth and pulmonary complications. EOS management with rib-based instrumentation involves repeated lengthening. Despite expansion practice patterns, there is limited literature and no evidence-based guidelines for optimal expansion intervals. Our study evaluates clinical outcomes in relation to lengthening intervals with the aim of optimizing the timing of surgical expansion in EOS patients. Methods A single-institution retrospective review of 60 EOS patients treated with rib-based growth instrumentation with a minimum of 3-year follow-up and 3 expansion/revision surgeries. Patients were separated into 2 expansion cohorts: (1) more frequent lengthening [MFL group (≤7 mo)] and (2) less frequent lengthening [LFL group (>7 mo)]. Demographic information and clinical factors were recorded. Univariate and bivariate analyses were performed. Results Both the MFL group (35 patients) and LFL group (25 patients) were similar in sex distribution, diagnosis, preoperative parameters of interest, and treatment duration. The mean follow-up was 6.0 years. There was an increase in postoperative T1-S1 spine height gained in the MFL group (P=0.006) as well as a higher percent expected spine growth based on normative values (P=0.03) when compared with the LFL group. The MFL group had more expansion/revision surgeries (P=0.003) but no increase in the number of complications (P=0.86). Conclusions More frequent lengthenings were associated with statistically significant overall spinal height gain and percent expected growth without a significant increase in complication rates. It was shown that change in major curve and space available for the lungs was not associated with the lengthening intervals. Level of evidence Level III-a comparative retrospective study.

Retrospective case–control study. The aim of this study was to identify the risk factors and health-related quality of life (HRQoL) impact of severe (> 4 cm) post-operative coronal imbalance at 2 years following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). Coronal imbalance is an unfavorable outcome following PSF for AIS, though the degree of imbalance in such patients is typically mild. We hypothesize that a small number of patients become and remain severely imbalanced post-operatively, though this phenomenon has not been well studied. Prospectively collected data from a large multicenter registry were reviewed. Patients with severe coronal imbalance (SCIB; > 4 cm) 2 years after PSF were included. Matched controls without SCIB at 2 years were included at a 3:1 ratio. Comparisons were made between demographics, pre-operative radiographic measures, surgical factors, residual post-operative radiographic measures, and 2-year SRS-22 scores. Nine of 954 (0.9%) patients (88.9% females; mean age 14.8 ± 2.3 years) were found to be severely imbalanced at 2 years. These patients had significantly greater pre-operative bending thoracic curve magnitude (45° vs. 33°; p = 0.013), curve flexibility (22.9% vs. 63.3%; p = 0.004), and kyphosis (41° vs. 26.5°; p = 0.034) compared to matched controls. Pre-operative curve flexibility of

It is a retrospective cohort study. 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. 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. 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

Background The primary goal in managing early-onset scoliosis (EOS) is delaying/preventing surgical intervention while allowing improved spinal growth and chest wall and lung development to improve life expectancy. The effectiveness of serial casting for patients with neuromuscular and syndromic EOS is unclear. Methods Patients from 2 multicenter registries who underwent serial casting for nonidiopathic scoliosis (NIS) were reviewed retrospectively. Comparisons were made between precasting and postcasting major and compensatory curves and spine height. The need for surgical intervention and any treatment complications were documented. Risk factors for major curve progression from baseline to casting cessation were evaluated via univariate analysis. Results Forty-four patients (23 females; 21 males) with NIS (26 syndromic, 18 neuromuscular) and a mean age of 3.2 years at baseline were included. Mean follow-up and casting duration was 3.9 and 2.0 years, respectively. There were no statistically significant differences between mean precasting and postcasting major curve (55 vs. 60 degrees; P=0.348), minor curve (31 vs. 33 degrees; P=0.510), or rib-vertebra angle difference (18 vs. 29 degrees; P=0.840). However, thoracic height (15.5 vs. 16.8 cm; P=0.031) and lumbar height (8.9 vs. 9.8 cm; P=0.013) were significantly greater upon casting cessation. Currently, 13 patients (30%) have had successful casting (improvement of major curve ≥10 degrees) while 24 patients (55%) experienced major curve progression (worsening), and 19 patients (43%) required surgical intervention. Mean time from first casting to surgery was 34.5±15.1 months. There were no statistically significant predictors for major curve progression on univariate analysis. Conclusions Spinal deformity progression despite casting and the subsequent need for surgical intervention for NIS were significantly higher compared with those reported for idiopathic EOS. However, serial casting did afford a substantial delay in surgical intervention. Ultimately, serial casting for neuromuscular or syndromic EOS is an effective strategy for delaying surgical intervention, despite suboptimal radiographic outcomes. Level of evidence Level III.

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.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.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%; P0.001). Deceased patients were more likely be treated operatively than nonoperatively or observed (P0.001). 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) (P0.001) 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 (P0.0001). 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%; P0.001), 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.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 IV-therapeutic.

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

Supracondylar humerus fractures are the most commonly operated upper extremity fracture in pediatric orthopaedics, yet there does not currently exist a standardized recommendation for a postoperative protocol. As advanced practice providers take on larger roles in the care of fracture patients, it may alleviate confusion to standardize postoperative protocols. The aim of this study was to compare outcomes between three different postoperative management protocols following operative fixation of supracondylar humerus fractures.This is a retrospective study of all patients who underwent operative fixation of a supracondylar humerus fracture during the 2014 to 2015 academic year. Postoperative protocols were classified as either "liberal," "intermediate," or "conservative," based on how quickly the surgeon allowed unrestricted motion of the elbow postoperatively. Patients were evaluated for range of motion, functional elbow motion, and elbow clinical function, as well for postoperative complications. Univariate analysis was conducted to detect the differences in outcomes between protocol groups with P0.01 considered significant.One hundred patients were included in the final analysis, with 17 patients in the liberal group, 50 in the intermediate group, and 33 in the conservative group. There were no differences in patient population (age, sex, fracture type, concomitant nerve palsy, ipsilateral injuries, or physical therapy referrals) between the groups (P0.01). There were no differences in range of motion, functional motion, or elbow clinical function (P0.01) between the postoperative protocol groups. There were no postoperative complications (unplanned return to operating room, refracture, need for fixation revision, or infection) in any patient.There were no differences in postoperative complications or outcomes between the patients in the liberal, intermediate, or conservative protocol groups. In an efficiency-focused era, we conclude that a standardized liberal protocol be considered at a busy orthopaedic center.This study is a level III therapeutic study. It is a retrospective study that compares the outcomes after following 1 of 3 different postoperative protocols.

Retrospective analysis of a prospectively collected multicenter database. Our goal was to study unplanned return to the OR (UPROR, a postoperative complication that could not be treated without an additional anesthetic) as a function of C-EOS diagnosis and implant type. Growing concerns over the impact of multiple anesthetic events on the young brain have focused attention on limiting UPROR in early onset scoliosis (EOS). We studied all patients with a diagnosis of EOS who had surgical implantation of growing instrumentation from October 4, 2010, to September 27, 2015, with a minimum 2-year follow-up. Among the complications requiring surgical treatment (revision for implant or anchor failure, infection, or implant removal), we analyzed all UPROR events—those that required a separate anesthetic (could not be treated as part of a planned surgical lengthening) within the first 2 years after initial implantation. UPROR was analyzed by diagnosis, deformity type, and implant strategy using the C-EOS classification. A total of 369 patients met inclusion criteria. Eighty-five of the 369 (23%) required unplanned trips to the operating room for various reasons. The C-EOS group at highest risk of an unplanned trip to the operating room is the hyperkyphotic neuromuscular (M3+, 14/85) cohort, followed closely by the congenital (C3N, 9/85) and neuromuscular (M3N, 8/85) groups with normal sagittal profiles and Cobb angles between 50° and 90°. Implant strategy was significantly related to risk of UPROR (p = .009; Table 1), with traditional implants (vertically expandable prosthetic titanium rib/traditional growing rod) being less likely to have an UPROR event. Growing instrumentation to treat EOS, when considered comprehensively, results in a true unplanned reoperation rate within 2 years of implantation of 23% (85/369). UPROR events are more common with certain C-EOS groups (hyperkyphotic neuromuscular deformities) and implant strategies. Families should be counseled that unplanned anesthetics are common with any implant strategy available today. Level III, therapeutic.

BACKGROUND Severe early-onset scoliosis leads to deficient spine height, thoracic growth inhibition, and ultimately pulmonary compromise. Rib-based growing instrumentation seeks to correct thoracic deformities, in part by correcting the spinal deformity, adding height, increasing thoracic volume, and allowing for continual spinal growth until maturity. However, the amount of growth in these patients relative to their peers is unknown. METHODS Sixty patients who had undergone surgical intervention for the treatment of early-onset scoliosis were assessed via radiographic measurements of coronal T1-S1 height and major curve angle before implantation and again at most recent follow-up (minimum 2 years). T1-S1 measurements were then compared with age-matched peers to assess growth differences. Clinical information was examined for relevant parameters. RESULTS The average age of our cohort at initial surgery and most recent follow-up was 4.4±3.8 and 10.0±4.4 years old, respectively. In this patient set, there was an average increase in T1-S1 height of 13.1±11.1 mm per year, with the majority of growth occurring in the first 2 years following implantation, and improvement in a major curve from 68±8 to 53±7 degrees. Overall, 77% of patients saw improvement in the major curve at most recent follow-up. Furthermore, a statistically significant greater percent of expected growth was seen in congenital compared with neuromuscular scoliosis (P

BACKGROUND Implantable rib-based distraction devices have revolutionized the treatment of children with early onset scoliosis and thoracic insufficiency syndrome. Unfortunately, the need for multiple skin incisions and repeated surgeries in a fragile patient population creates considerable infection risk. In order to assess rates of infection for different incision locations and potential risk factors, we generated a prospectively collected database of patients treated with rib-based distraction devices. METHODS We analyzed a cohort of patients with thoracic insufficiency syndrome from various etiologies that our institution treated with rib-based distraction devices from 2013 to 2016. Surgery type (implantation, expansion, revision/removal), and surgeon adjudicated surgical site infection (SSI) were collected. For this study, we developed a novel, rib-based distraction device surgical site labeling system in which incisions could be labeled as either proximal or distal surgical exposure areas. Treating surgeons documented the operative site, procedure, and SSI site in real-time. RESULTS A total of 166 unique patients underwent 670 procedures during the study period, producing 1537 evaluable surgical sites; 1299 proximal and 238 distal. Patients were 6.81±4.0 years of age on average. Forty-seven procedures documented SSIs (7.0%), while 40 (24.1%) patients experienced an infection. Analysis showed significant variation in the rate of infection between implantation, and expansion, and revision procedures, with implantation procedures having the highest infection rate at 13.1% (P

Pediatric distal humerus fractures are common, and numerous variations can occur depending on patient's age, position of the extremity at the time of injury, and energy of impact. Classic injury patterns include the flexion/extension supracondylar humerus, medial epicondyle, lateral condyle, and the transphyseal distal humerus. We describe our treatment philosophy for pediatric elbow fractures and how these principles were applied to some unusual fractures that presented to our institution.

Hand radiographs for skeletal maturity staging are now frequently used to evaluate remaining growth potential for patients with adolescent idiopathic scoliosis (AIS). Our objective was to create a model predicting a patient's risk of curve progression based on modern treatment standards.We retrospectively reviewed all AIS patients presenting with a major curve50 degrees, available hand radiographs, and complete follow up through skeletal maturity at our institution over a 3-year period. Patients with growth remaining underwent rigid bracing of curves25 degrees, whereas patients between 10 and 25 degrees were observed. Treatment success was defined as reaching skeletal maturity with a major curve50 degrees. Four risk categories were identified based on likelihood of curve progression.Of 609 AIS patients (75.4% female) presenting with curves over 10 degrees and reaching skeletal maturity at most recent follow up, 503 (82.6%) had major thoracic curves. 16.3% (82/503) of thoracic curves progressed into surgical treatment range. The highest risk group (Sanders 1 to 6 and curve 40 to 49 degrees, Sanders 1 to 2 and curve 30 to 39) demonstrate a 30% success rate with nonoperative treatment. This constitutes an 111.1 times (95% confidence interval: 47.6 to 250.0, P0.001) higher risk of progression to surgical range than patients in the lowest risk categories (Sanders 1 to 8 and curve 10 to 19 degrees, Sanders 3 to 8 and curve 20 to 29 degrees, Sanders 5 to 8 and curve 30 to 39 degrees).Skeletal maturity and curve magnitude have strong predictive value for future curve progression. The results presented here represent a valuable resource for orthopaedic providers regarding a patient's risk of progression and ultimate surgical risk.Level III-retrospective cohort study.

Congenital myopathies (CMs) are complex conditions often associated with early-onset scoliosis (EOS). The purpose of this study was to investigate radiographic outcomes in CM patients undergoing EOS instrumentation as well as complications. Secondarily, we sought to compare these patients to a population with higher prevalence, cerebral palsy (CP) EOS patients.This is a retrospective study of a prospectively collected multicenter registry. The registry was queried for EOS patients with growth-sparing instrumentation (vertical expandable prosthetic titanium ribs, magnetically controlled growing rods, traditional growing rod, or Shilla) and a CM or CP diagnosis with minimum 2 years follow-up. Outcomes included major curve magnitude, T1-S1 height, kyphosis, and complications.Sixteen patients with CM were included. Six (37.5%) children with CM experienced 11 complications by 2 years. Mean major curve magnitude for CM patients was improved postoperatively and maintained at 2 years (P0.01), with no significant increase in T1-S1 height or maximum kyphosis(P0.05). Ninety-seven patients with CP EOS were included as a comparative cohort. Fewer CP patients required baseline respiratory support compared with CM patients (20.0% vs. 92.9%, P0.01). Fifty-four (55.7%) CP patients experienced a total of 105 complications at 2 years. There was no evidence that the risk of complication or radiographic outcomes differs between cohorts at 2 years, though CP EOS patients experienced significant improvement in all measurements at 2 years.EOS CM children face a high risk of complication after growing instrumentation, with similar curve correction and risk of complication to CP patients.Level III.

BACKGROUND Congenital myopathies (CMs) are complex conditions often associated with early-onset scoliosis (EOS). The purpose of this study was to investigate radiographic outcomes in CM patients undergoing EOS instrumentation as well as complications. Secondarily, we sought to compare these patients to a population with higher prevalence, cerebral palsy (CP) EOS patients. METHODS This is a retrospective study of a prospectively collected multicenter registry. The registry was queried for EOS patients with growth-sparing instrumentation (vertical expandable prosthetic titanium ribs, magnetically controlled growing rods, traditional growing rod, or Shilla) and a CM or CP diagnosis with minimum 2 years follow-up. Outcomes included major curve magnitude, T1-S1 height, kyphosis, and complications. RESULTS Sixteen patients with CM were included. Six (37.5%) children with CM experienced 11 complications by 2 years. Mean major curve magnitude for CM patients was improved postoperatively and maintained at 2 years (P 0.05). Ninety-seven patients with CP EOS were included as a comparative cohort. Fewer CP patients required baseline respiratory support compared with CM patients (20.0% vs. 92.9%, P

Bracing treatment for adolescent idiopathic scoliosis (AIS) is typically initiated in skeletally immature patients with primary curves greater than 25°. The goal of this study was to develop a model predicting a patient's likelihood of progressing to bracing treatment.All patients with AIS presenting to a large pediatric spine center with a primary curve below 25° and skeletally immature (Sanders stage 1-6) were included. A patient was considered to have progressed into the bracing range if their primary curve reached a 25° threshold prior to skeletal maturity. Binary logistic regression analysis was performed to predict the likelihood of curve progression into bracing range.A total of 180 patients (71% female) were included in this study with an average presenting age of 13.2 ± 1.4 years. At presentation, 31 (17%) were pre-peak height velocity, 62 (34%) were at their peak height velocity, and 87 (48%) were in the late adolescent growth stage. The high-risk patient group was defined as Sanders 1-2 and curve size 10 and 25° or Sanders 3-6 and curve size 20 but 25°. Those in the high-risk group demonstrated an over 5 times higher risk of progression to bracing range when accounting for age, sex, and curve location (OR: 5.168, 95% CI: 2.212-12.071, p 0.001).Patient's curve magnitude and skeletal maturity can be used to predict their likelihood of curve progression to greater than 25° and thus require bracing treatment. Orthopaedic providers can consider earlier treatment interventions or stricter follow-up adherence for patients at high risk for progression.3-retrospective cohort study.

BACKGROUND Women are underrepresented across most surgical specialties and especially in the field of orthopaedic surgery. Despite pediatric orthopaedic surgery being one of the most gender diverse subspecialties in orthopaedics, women may still face barriers to academic advancement. Research presentations at national meetings and publication record are important drivers of advancement in the field of academic orthopaedic surgery. The aim of this study is to assess whether research abstracts authored by women are less likely to be published than abstracts authored by men. METHODS Abstracts from research podium presentations given at the Pediatric Orthopaedic Society of North America annual meetings from 2006 to 2020 were reviewed to assess research quality and determine basic study characteristics. For each abstract, author gender was determined through a search of institutional websites and professional networking websites for gender-specific pronouns. Resulting publications corresponding to the 2006 to 2018 were identified using a systematic search of PubMed and Google Scholar databases. Kaplan-Meier inverse survival analysis with log rank test were used to determine differences in publication rates based on whether the last (senior) author was female versus male. Multivariate, binary logistic regression was performed to assess factors predictive of eventual publication. RESULTS One thousand five hundred and eighty-one of 1626 (97.2%) of abstracts from 2006 to 2020 had an identifiable last author gender, with 17.8% (281/1581) female. No differences in study quality were identified across genders including sample size, level of evidence, or impact factor of journal if leading to publication. Women were more likely to author abstracts in foot, ankle, or lower extremity surgery [17.8% (50/281) vs. 12.9% (168/1300), P=0.032] and less likely to author abstracts focusing on the hip [11.0% (31/281) vs. 17.1% (222/1300), P=0.012]. Abstracts with women as the last author were significantly less likely to be published compared with abstracts with men as the last author [59.6% (143/240) vs. 67.9% (783/1154), P=0.013]. Multivariate analysis demonstrated that last author female gender was predictive of a lower likelihood of publication (odds ratio: 0.684, 95% confidence interval: 0.513-0.912, P=0.010). Women were less likely to be the last author of abstracts presented by study groups [2.1% (6/281) vs. 5.5% (71/1300), P=0.019]. CONCLUSION In pediatric orthopaedic surgery, abstracts authored by women are less likely to reach publication, despite no identifiable differences in study quality. Reasons for this discrepancy must be explored including insufficient mentorship, exclusion from study group participation, or potential bias against female researchers in the field of orthopaedic surgery. LEVEL OF EVIDENCE Level IV.