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The concept of environmental sustainability, social responsibility, and good governance (ESG) is now well established in the corporate world and in for-profit organizations. However, it is not a concept that has reached medical and surgical association boardrooms in a meaningful way. It is important to define the concept of physician and corporate author expertise and objectives of ESG, provide a rationale for using ESG within orthopaedic organizations, and identify specific areas (primarily the "S" and the "G") where the American Academy of Orthopaedic Surgeons and other groups can align with this strategy.

It is important to be knowledgeable about the latest information on the diagnosis and the evidence-based management of developmental hip dysplasia and dislocation from birth through adolescence. The focus should be on the effect of the problem; normal growth and development of the hip joint; and the pathoanatomy, natural history, and long-term outcomes of developmental dysplasia of the hip, hip subluxation, and dysplasia. Many controversies exist in the management of this complex spectrum of disorders.

Retrospective. Utilize three-dimensional (3D) measurements to assess the relationship between thoracic scoliosis severity and thoracic kyphosis in a large, multicenter cohort, and determine impact of 3D measurements on adolescent idiopathic scoliosis (AIS) curve classification. Research has demonstrated differences in two-dimensional (2D) and 3D assessment of the sagittal plane deformity in AIS. A prior smaller, single-institution study demonstrated an association between scoliosis severity and loss of 3D thoracic kyphosis. Data included retrospective compilation of prospectively enrolled bracing candidates and prospectively enrolled surgical candidates with thoracic AIS. Analysis included two groups based on thoracic curve magnitude: moderate (20–45°) and severe (> 45°). Imaging was performed using 2D radiographs. 3D thoracic kyphosis was calculated using a 2D to 3D conversion formula. Kyphosis was categorized according to the Lenke classification sagittal plane modifier. Analysis included 3032 patients. 2D kyphosis was significantly less in the moderate group (21 ± 12 vs 23 ± 14, p = 0.028). However, estimated 3D kyphosis was significantly greater in the moderate group (13 ± 10 vs 5 ± 12, p

Surgical correction for AIS has evolved from all hooks to hybrids or all screw constructs. Limited literature exists reporting outcomes using PHDS for posterior spinal fusion (PSF). This is the largest series in evaluating results of PHDS technique. A retrospective review of consecutive AIS patients undergoing PSF by a single surgeon between 2006 and 2015 was performed. All eligible patients met a minimum 2-year follow-up. Patient demographics and radiographical parameters (radiographic shoulder height (RSH), T1 tilt, clavicle angle) at baseline, 6-week and 2-year post-operation were recorded. The primary outcome was difference in RSH from baseline measurements evaluated using repeated measures one-way analysis of variance with Bonferroni correction. A total of 219 patients (mean age at surgery: 13.68 years; 82% female) were included. The mean follow-up was 41.2 months (range 24–108 months). The RSH was significantly improved from − 14.7 ± 10.38 mm to 8.0 ± 6.9 mm (P

Background Despite widespread use of single-stage open reduction and pelvic osteotomy for treatment of developmental dysplasia of the hip (DDH) after walking age, this aggressive strategy remains controversial. We directly compared dislocated hips treated with closed reduction (CR) to those treated with open reduction and Salter innominate osteotomy (OR/IO) to estimate the relative hazard of total hip arthroplasty (THA) and the THA-free survival time. Methods In a series of patients 18 to 60 months of age, 45 patients (58 hips) underwent CR and 58 patients (78 hips) were treated with OR/IO and followed to a minimum 40 years post-reduction. Observations in the survival analysis were censored if no THA had occurred by 48 years. Multivariate Cox regression analysis was used to estimate the hazard of THA given treatment, age, and bilaterality. Complications and additional procedures were noted. Results At 48 years of follow-up, 29 (50%) of the hips survived after CR compared with 54 (69%) after OR/IO. At 45 years, the survival probability after OR/IO was 0.63 (95% confidence interval [CI] = 0.50 to 0.78) compared with 0.55 (95% CI = 0.43 to 0.72) after CR. The hazard ratio (HR) of THA was modeled as a function of treatment, age at reduction, and bilaterality. The effect of age and treatment on the outcome of hips in patients with unilateral involvement was minimal. However, age did significantly alter the relationship between treatment and outcome in bilateral cases. In the bilateral group, the predicted HR of THA was lower after CR in hips that were reduced at the age of 18 months (HR = 0.16, 95% CI = 0.04 to 0.64) but higher in those that were reduced at 36 months (HR = 4.23, 95% CI = 2.00 to 8.95). Additional procedures were indicated for 17% and 22% of hips after CR and OR/IO, respectively. Conclusions Osteoarthritis and THA was more likely after CR than OR/IO, but the data do not indicate a difference in unadjusted hip-survival time. In patients with bilateral disease, an older age at reduction was associated with an increased hazard of THA after CR than after OR/IO. Both treatments provided substantial benefit relative to the natural history of DDH, but THA is the expected outcome in middle adulthood. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

With Americans living longer, many physicians and surgeons have extended their medical and surgical practice life beyond the traditional 65-year-old retirement age. As retirement is inevitable, planning for that eventuality, which in early practice years appears unnecessary, is in fact an exercise which will pay dividends at the time of retirement. Two senior orthopaedic surgeons provide insight on the 2 main issues concerning retirement: how to prepare for retirement while in active practice, and factors to consider as to the timing of that major life event.

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

In a traditional view, the natural history of a condition or a disease tells us of the adult consequences of that entity, be it benign or otherwise. This knowledge then provides guidance as to who needs treatment, and allows us to assess whether our treatments alter an otherwise adverse natural history in a positive way without introducing iatrogenic complications. However, in the new paradigm for health care delivery of value-based care, we need to be able to express natural history in additional terms of burden of disease. This is something that lawmakers and people who pay for health care can understand and has a comparative value. It also serves as a benchmark to show the effectiveness of interventions aimed at reducing disease burden. In this paper, I will discuss why this POSNA symposium is important and make some recommendations on directions where we as individuals and as a professional society should be putting in our efforts and resources.

Introduction: Parents often access online resources to educate themselves when a child is diagnosed with developmental dysplasia of the hip (DDH). In order to be fully understood by the average adult American, online health information must be written at an elementary school reading level. It was hypothesized that current available online resources regarding DDH would score poorly on objective measures of readability (syntax reading grade-level), understandability (ability to process key messages), and actionability (providing actions the reader may take). It was additionally hypothesized that the readability, understandability, and actionability would not correlate with search rank. Methods: Patient education materials were identified utilizing two independent online searches of the term “DDH” utilizing a commonly used search ending. From the top 50 search results, websites were included if directed at educating patients/parents regarding DDH. News articles, non-text material (video), research and journal articles, industry websites, and articles not related to DDH were excluded. The readability of included resources was quantified using the Flesch-Kincaid Grade Level Index. The Patient Education Materials Assessment Tool (PEMAT) was used to assess understandability and actionability using a 0-100% scale for both measures of interest. Spearman’s rho was used to examine the association between a website’s average search rank (from first to last) and its readability, understandability, and actionability. Statistical significance was defined as p

BACKGROUND: Adolescent idiopathic scoliosis (AIS) is defined as a lateral curvature of the spine of unknown etiology with a Cobb angle of greater than 10 degrees with vertebral rotation. Bracing, specifically with a rigid thoracolumbosacral orthosis (TLSO), decreases the risk of curve progression to over 50 degrees, the threshold for surgical intervention. Some authors have suggested that 30-50% in-brace correction of the Cobb angles is required to prevent significant curve progression. The purpose of the study is to evaluate the current bracing protocol at the University of Iowa as a quality control exercise for the treatment team. METHODS: AIS patients (n = 61; 8 male, 53 female) who received a Rosenberger TLSO at the University of Iowa Department of Orthopaedics and Rehabilitation from 2016-2017 were included in the study. Inclusion criteria include presence of pre-brace and in-brace x-rays within 3 months of initiating brace treatment. Patients with other diagnoses were excluded. Radiographic indicators of brace effectiveness, such as the Cobb angle, were measured. RESULTS: The in-brace x-rays of 46 (76%) patients showed less than 30% correction. Minimal changes from the pre- to in-brace x-ray were observed in other radiographic measures. CONCLUSIONS: Results indicate that if the 30-50% correction recommended by the literature is valid, then modifications to the process of measuring, fabricating or modifying our current TLSO’s for AIS are warranted. Level of evidence: III

Adolescent idiopathic scoliosis is a common condition and often requires posterior spinal fusion for treatment. While the goals of surgery are relatively well accepted, the technique for this procedure varies among providers. To facilitate a discussion of differences in surgical planning, approach, and techniques a case-based roundtable discussion with leaders in the field of adolescent idioapthic scolisosis is presented.

STUDY DESIGN Comparative effectiveness study OBJECTIVE.: To evaluate factors leading to higher percentage of brace failures in a cohort of North American patients with adolescent idiopathic scoliosis relative to their peers in Italy. SUMMARY OF BACKGROUND DATA Studies of bracing in United States have shown worse outcomes than studies from European centers, possibly due to sample characteristics or treatment approaches. METHODS Sample: Braced patients, aged 10 to 15, Risser

Retrospective.Utilize three-dimensional (3D) measurements to assess the relationship between thoracic scoliosis severity and thoracic kyphosis in a large, multicenter cohort, and determine impact of 3D measurements on adolescent idiopathic scoliosis (AIS) curve classification. Research has demonstrated differences in two-dimensional (2D) and 3D assessment of the sagittal plane deformity in AIS. A prior smaller, single-institution study demonstrated an association between scoliosis severity and loss of 3D thoracic kyphosis.Data included retrospective compilation of prospectively enrolled bracing candidates and prospectively enrolled surgical candidates with thoracic AIS. Analysis included two groups based on thoracic curve magnitude: moderate (20-45°) and severe ( 45°). Imaging was performed using 2D radiographs. 3D thoracic kyphosis was calculated using a 2D to 3D conversion formula. Kyphosis was categorized according to the Lenke classification sagittal plane modifier.Analysis included 3032 patients. 2D kyphosis was significantly less in the moderate group (21 ± 12 vs 23 ± 14, p = 0.028). However, estimated 3D kyphosis was significantly greater in the moderate group (13 ± 10 vs 5 ± 12, p 0.001). In the moderate group, the rate of normokyphosis was 78% with 2D measures and 61% with 3D measures of T5-T12 kyphosis. In the severe group, this rate changed from 72 to 32% with use of 2D and 3D measures, respectively. In the moderate group, 16% of patients were classified as hypokyphotic using 2D measures while this rate increased 38% with 3D measures (p 0.001). In the severe group, this rate changed from 18 to 68% using 2D and 3D measures, respectively (p 0.001).Increased coronal curve severity was associated with decreased thoracic kyphosis. Hypokyphosis was more pronounced in 3D. 2D radiographs increasingly underestimate kyphosis with increasing coronal severity. Assessment of sagittal alignment from 2D radiographs can be improved with a 2D-3D conversion formula. Findings indicate potential for classification system improvement with use of 3D sagittal plane measurements.IV.

Developmental dysplasia of the hip is the all-encompassing term used to describe the wide spectrum of disorders of the development of the hip that manifest in various forms and at different ages. Developmental dysplasia of the hip often evolves over time because the structures of the hip are normal during embryogenesis but gradually become abnormal. Such variability in pathology is associated with a similarly wide range in management options and recommendations aimed at preventing hip joint arthrosis. These options may be instituted at any time between birth and adulthood as techniques aimed at preserving the native hip or replacing the arthritic hip. Many of these management options are clearly indicated and considered standard practice. However, with the evolution of the understanding of hip biomechanics, better knowledge of the long-term outcomes of hip joint-preserving surgeries, and ever-improving technology influencing hip arthroplasty come new controversies, especially whether to preserve or replace the mature hip.

Survey. Bracing is the mainstay of conservative treatment in Adolescent Idiopathic Scoliosis (AIS). The purpose of this study was to establish best practice guidelines (BPG) among a multidisciplinary group of international bracing experts including surgeons, physiatrists, physical therapists, and orthotists utilizing formal consensus building techniques. Currently, there is significant variability in the practice of brace treatment for AIS and, therefore, there is a strong need to develop BPG for bracing in AIS. We utilized the Delphi process and the nominal group technique to establish consensus among a multidisciplinary group of bracing experts. Our previous work identified areas of variability in brace treatment that we targeted for consensus. Following a review of the literature, three iterative surveys were administered. Topics included bracing goals, indications for starting and discontinuing bracing, brace types, brace prescription, radiographs, physical activities, and physiotherapeutic scoliosis-specific exercises. A face-to-face meeting was then conducted that allowed participants to vote for or against inclusion of each item. Agreement of 80% throughout the surveys and face-to-face meeting was considered consensus. Items that did not reach consensus were discussed and revised and repeat voting for consensus was performed. Of the 38 experts invited to participate, we received responses from 32, 35, and 34 for each survey, respectively. 11 surgeons, 4 physiatrists, 8 physical therapists, 3 orthotists, and 1 research scientist participated in the final face-to-face meeting. Experts reached consensus on 67 items across 10 domains of bracing which were consolidated into the final best practice recommendations. We believe that adherence to these BPG will lead to fewer sub-optimal outcomes in patients with AIS by reducing the variability in AIS bracing practices, and provide a framework future research. Level IV.

Background Proximal femoral growth disturbance (PFGD) can be the most devastating complication of the treatment of development dysplasia of the hip. The reported incidence ranges from 0% to 73%. The condition involves varying degrees of growth disturbances of the femoral capital epiphysis, the physeal plate or both. Purpose This manuscript will discuss normal growth and development of the hip, the blood supply to the upper end of the femur, pathological and radiographic changes, classifications used to describe PFGD and, most importantly, the potential causes of these growth disturbances and the authors’ strategies for avoiding PFGD.

This review summarizes evidence developed at the University of Iowa concerning the management and outcomes of developmental dysplasia of the hip beginning with the observations and analyses of Dr Arthur Steindler in the early 1900s. The strong evidence-based practice tradition established by Steindler 100 years ago continues as we critically evaluate our procedures and patient outcomes, only altering approaches when warranted by strong personal and research evidence. Our practice continues to be conservative in that we strive to produce the best environment possible for the hip to develop on its own and operate only when less invasive methods have failed.

Background: Spinal muscular atrophy (SMA) is a progressive neuromuscular disease commonly including progressive scoliosis resulting in severe deformity and negatively affecting pulmonary function. Surgical correction and stabilization of this progressive deformity is generally recommended; however, the timing and method of surgical fixation remains controversial. Methods: Retrospective review of clinical, radiographic, and pulmonary function data from 16 children with SMA and surgically treated scoliosis between 1985 and 2013. Radiographic data included direct measures of major curve, coronal balance, pelvic obliquity, T1-T12 height, T1-S1 height, and T1-rod length. Estimations of rib collapse, thoracic cavity shape, and space-available-for-lung (T6:T12, width ratio; T6:T10, rib-vertebral-angle difference ratios; and lung height) were determined. Eleven patients were able to complete pulmonary function testing. Results were compared with published outcomes for growing rod constructs. Results: Posterior spinal fusion was performed at an average age of 9.8±3.6 years. The mean age at most recent follow-up was 19.4 years (range, 10 to 37 y), with a mean follow-up of 10.1 years (range, 3.1 to 26 y). Radiographic measurements improved from preoperative to latest follow-up as follows: major curve, 78±20 degrees to 27±24 degrees; coronal balance, 4.1±4.0 cm to 1.9±2.2 cm; pelvic obliquity (median), 23 to 5 degrees; T1-T12 height, 19±3 cm to 22±3 cm; T1-S1 height, 31±7 cm to 36±6 cm; T1-rod length, 0.8±1.1 cm (postop) to 2.8±1.6 cm (final); and space-available-for-lung ratio, 0.88±0.26 to 0.95±0.25. Rib collapse continued throughout the follow-up period in all but 1 patient. Pulmonary function testing demonstrated a decrease in rate of decline in forced vital capacity and forced expiratory volume when comparing preoperative with postoperative rates. Mean length of stay was 7.8±4.4 days. Complications included reintubation for low tidal volumes (n=1), pneumonia (n=1), superficial wound breakdown (n=1), and superficial infection (n=1). Conclusions: Definitive posterior spinal fusion for treatment of scoliosis associated with SMA is effective at controlling curve progression and pelvic obliquity without negatively impacting the space-available-for-lung ratio, trunk height, or pulmonary function at 10 years follow-up. Level of Evidence: Therapeutic Level IV.

BACKGROUND Understanding national trends in the treatment of pediatric supracondylar humeral fractures will provide important insight into variations in regional treatment and identify areas for improving value and quality in care delivery in the U.S. METHODS U.S. national trends in the treatment of supracondylar humeral fractures were evaluated through query of the Humana (2007 to 2014) and ING (2007 to 2011) administrative claims databases. Geographic variation and changes in surgical and transfer rates over time were further explored through the Nationwide Emergency Department Sample (NEDS) database (2006 to 2011). Hospital characteristics impacting treatment decisions were identified. RESULTS A total of 29,642 pediatric patients with supracondylar humeral fractures were identified in the administrative claims databases and a projected 63,348 encounters for supracondylar humeral fracture were identified in the NEDS database. The majority of the patients (76.1%; 22,563 of 29,642) were treated definitively with cast immobilization. Operative treatment was performed in 23.9% of the patients (7,079 of 29,642), with no change observed in the operative rate over time (p = 0.055). Of patients undergoing operative treatment, closed reduction and percutaneous pinning (CRPP) was performed in 87.3%, with a significant increase noted in the rate of CRPP over time (p = 0.0001); open reduction was performed in 12.7%, with a significant decrease noted in the rate of open reduction over time (p < 0.0001). Regional surgical rates generally showed significant variation from 2006 to 2010, followed by a convergence in the surgical rate among all geographic regions in 2011. These trends occurred simultaneous to a significant increase in transfer rates nationwide, from 5.6% in 2006 to 9.1% in 2011 (p = 0.0011). Transfer rates were significantly higher (p < 0.0001) for nontrauma, nonteaching, and nonmetropolitan centers while surgical rates were significantly higher (p < 0.0001) for trauma, teaching, and metropolitan centers when rates were analyzed by hospital designation. CONCLUSIONS Operative treatment was performed in 24% of pediatric patients with supracondylar humeral fractures from 2007 to 2014. There was a convergence of surgical rates across geographic regions, suggesting that a "standard of care" in the treatment of supracondylar humeral fractures is being established nationally. CLINICAL RELEVANCE Cases of pediatric supracondylar humeral fracture are increasingly being transferred to and, when managed surgically, receiving care at metropolitan facilities designated as trauma centers or teaching hospitals, with a corresponding decrease observed in the rate of open reduction. The optimization of nationwide referral and treatment patterns may improve value in care delivery.

More than 100 MRIs per 1000 inhabitants are performed in the United States annually, more than almost every other country. Little is known regarding the cost of obtaining an MRI and factors associated with differences in cost. By surveying all hospital-owned and independent imaging centers in Iowa, we wished to determine (1) the cost to the consumer of obtaining a noncontrast shoulder MRI, (2) the frequency and magnitude of discounts provided, and (3) factors associated with differences in cost including location (hospital-owned or independent) and Centers for Medicare & Medicaid Services designation (rural, urban, and critical access). There were 71 hospitals and 26 independent imaging centers that offered MRI services in Iowa. Each site was contacted via telephone and posed a scripted request for the cost of the technical component of a noncontrast shoulder MRI. Radiologists’ reading fees were not considered. Statistical analysis was performed using standard methods and significance was defined as a probability less than 0.05. The mean technical component cost to consumers for an MRI was USD 1874 ± USD 694 (range, USD 500-USD 4000). Discounts were offered by 49% of imaging centers, with a mean savings of 21%. Factors associated with increased cost include hospital-owned imaging centers (USD 2062 ± USD 664 versus USD 1400 ± USD 441 at independent imaging centers; p

BACKGROUND: Vertebral fracture after posterior arthrodesis and instrumentation for idiopathic scoliosis is a rare occurrence with limited reported cases in the literature. CASE PRESENTATION: A 16-year-old female patient surgically treated for adolescent idiopathic scoliosis with T2-L1 posterior spinal fusion was in a low-energy fall resulting in fracture of L1 and new kyphosis and scoliosis of the thoracolumbar spine at the distal aspect of the fusion. The fracture was initially managed conservatively, however pain persisted and thus she was indicated for extension of the fusion and correction of the post-traumatic kyphosis. CONCLUSIONS: Fractures after posterior spinal fusion for idiopathic scoliosis are rare and evidence for the appropriate management remains limited in the literature. Level of Evidence: V

BACKGROUND: Adolescent idiopathic scoliosis (AIS) has been associated with unnecessary referrals, but the provider and patient costs associated with these referrals remain unknown. The purpose of this study was to determine the prevalence and associated costs of unnecessary referrals for AIS in a university hospital-based orthopaedic clinic. These data are required to estimate the cost-efficacy of scoliosis screening programs. METHODS: We accessed the electronic medical records of all patients referred during 2013-2014 with suspected AIS. Spine radiographs were reviewed to determine whether the referral was “unnecessary,” defined as a Cobb angle

Introduction Adolescent idiopathic Scoliosis (AIS) affects 2% to 3% of the population of which only 0.3% to 0.5% of affected patients will have a curvature of >20 degrees, the curve magnitude at which treatment is generally recommended. For AIS the current natural history data is limited and most of the information comes from a small body of literature from the University of Iowa. Methods The Iowa natural history studies began as retrospective reviews but beginning in 1976, the cohort was followed prospectively. Outcomes assessed in this group of patients included; mortality, pulmonary function, pregnancy-(effect of pregnancy on scoliosis and the effect of scoliosis on pregnancy), radiographic, curve progression, and osteoarthritis. In addition, validated questionnaires were used to evaluate back pain, pulmonary symptoms, general function, depression, and body image. Results Patients with untreated AIS can function well as adults, become employed, get married, have children, and grow to become active older adults. Unfortunately, untreated scoliosis may lead to increased back pain and pulmonary symptoms for patients with large thoracic curves. Patients with untreated AIS can also develop substantial deformity, and the cosmetic aspect of this condition cannot be disregarded. Conclusions The summary findings of this unique lifetime natural history of AIS patients provides patients and parents a solid evidence base upon which to make informed decisions.

The recently developed magnetically controlled growing rod (MCGR) system has gained popularity because it limits additional surgical lengthening procedures and promises reduction of the complication rate previously reported for the traditional growing rods. A retrospective single-center study was performed. Demographic and complications data were recorded. A statistical analysis was conducted to quantify the effect of MCGR placement and of subsequent lengthening on the Cobb angle, T1-T12 kyphosis, and the distances from T1-T12 and T1-S1. Twenty-four patients met the inclusion criteria. Six had idiopathic scoliosis and 18 patients had nonidiopathic scoliosis (neuromuscular and syndromic scoliosis). Nine patients underwent primary MCGR placement, and 15 had the traditional growing rods removed and replaced with MCGRs. The mean age at surgery and at last follow-up was 6.3 years and 8.8 years, respectively. The mean follow-up was 29.2 months. The MCGR placement significantly reduced the Cobb angle and kyphosis by an average of 21.33° and 10.79°, respectively. The T1-T12 and the T1-S1 distances increased an average of 1.19 and 1.89 cm/year, respectively, during the follow-up period. The average percentage of achieved-to-intended distraction was 65% on the concave side and 68% on the convex side at last follow-up. There were 9 postoperative complications in 8 (33%) patients, 6 of whom had nonidiopathic scoliosis. The MCGR system is reliable and effective in the treatment of patients affected by early-onset scoliosis. [ Orthopedics . 2020;43(6):e601–e608.]

This study describes a new procedure for a safer and easier access for the intrathecal injection of the recently approved nusinersen therapy in spinal muscular atrophy. This therapy changed the natural history of the disease, but, to date, scoliosis surgery was an excluding criteria for nusinersen therapy. The bone mass, due to the posterior spinal fusion of the scoliosis surgery, prevents the needle for the nusinersen administration from intervertebral access. This is a single-center, single-surgeon case series descriptive study. A laminotomy at the L3-L4 level was performed to provide safer access for the intrathecal injection. The procedure was carried out during the scoliosis surgery in patients who underwent posterior spinal fusion (PSF) after the nusinersen therapy was introduced, whereas for those who underwent PSF earlier, a second procedure was necessary to perform a laminotomy. A fat grafting was used to prevent bone overgrowth in the laminotomy. Markers were applied as radiographic references for the intrathecal injection. Five patients were enrolled, four females and one male. The mean age of the patients was 11 years. Three patients underwent PSF before the introduction of the nusinersen therapy. Two patients underwent PSF after the nusinersen therapy was available. All of them underwent a laminotomy with a fat grafting at the L3-L4 laminotomy level and received nusinersen therapy without complications. The procedure described is simple and effective in providing safe intrathecal access to make these patients eligible for such important therapy.

Background Knee pain has a variety of etiologies in the pediatric population, including septic arthritis, osteomyelitis, fracture, ligamentous injury, and neoplasms. Extrinsic sources of knee pain may also be intra-abdominal, although abdominal pathology is much more likely to manifest as hip or proximal thigh musculature pain. Case Report A 5-year-old healthy male presented with atraumatic right knee pain, discomfort with weightbearing, fever, and elevated inflammatory laboratory markers. Physical examination and magnetic resonance imaging findings of the knee were benign, leading to low clinical suspicion for knee septic arthritis. Blood cultures were positive for a gastrointestinal organism, Granulicatella adiacens, suggesting abdominal pathology leading to referred pain. Ultrasound evaluation and computed tomography (CT) of the abdomen revealed a large abscess secondary to perforated appendicitis, which was treated with CT-guided drainage and i.v. antibiotics. The patient's musculoskeletal pain subsided with treatment of the appendicitis. Why Should an Emergency Physician Be Aware of This? Acute appendicitis may present as knee pain, with other signs and symptoms mimicking septic arthritis, such as fever, inability to bear weight, and elevated inflammatory markers. Considering an array of differential diagnoses in pediatric patients with apparent knee septic arthritis is crucial to prevent delay in diagnosis of alternative infectious sources.

Developmental dysplasia of the hip (DDH) in the newborn describes a wide spectrum of pathologic disorders of the hip, ranging from subtle dysplasia of the acetabulum to irreducible hip dislocation. At all ages of treatment, the primary goal is to obtain a concentric reduction of the femoral head within the acetabulum while minimizing the risk for avascular necrosis or other complications. When recognized in the first 6 months of life, DDH is typically successfully treated with simple outpatient based harness therapy (Pavlik) and routinely results in excellent outcomes. After 6 months of age, closed reduction, open reduction, and femoral and pelvic osteotomies are more often required as treatment modalities. Each treatment decision should be considered thoughtfully in each unique patient encounter, with the overriding goal of obtaining a concentrically reduced hip joint while minimizing complications always at the forefront.

BACKGROUND CONTEXT The Minimize Implants Maximize Outcomes (MIMO) Clinical Trial randomized patients with Lenke 1A curve patterns to more versus fewer screws (high or low density) to determine a difference in percent coronal correction. Last year we presented the intention to treat (IT) analysis, and this report covers the as treated analysis (AT) and patient-reported outcomes. PURPOSE To determine if the use of more screws vs fewer screws in an as treated analysis would result in similar curve correction and patient-reported outcomes in patient with Lenke 1A curve patterns treated with PSF. STUDY DESIGN/SETTING Prospective randomized controlled trial of equivalence. PATIENT SAMPLE Patients with Lenke 1A curves who underwent posterior spinal fusion. OUTCOME MEASURES N/A METHODS Fourteen sites accrued patients in the MIMO Clinical Trial (NCT01792609). Patients with Lenke 1A curves between 45-65 degrees were randomized to high- (>1.8 screws per level fused, HD) vs low-implant density ( RESULTS There was no difference in age, gender, preop curve magnitude, or race between the 2 groups. For actual treatment, mean % Cobb correction at 3 months was 69% in HD vs 71% in LD (p=0.3), 65% in HD vs 67% in LD at 1 year (p=0.3), and 65% vs 66% at 2 years (p=0.6). Three patients underwent reoperation due to implant complications (1 HD, 2 LD), and 7 due to infection (p=1.0). Thoracic T2-T12 kyphosis was improved in the LD group at 2- years postop (34 vs 30 degrees, p=0.027). No difference in blood loss, operative time, or scoliometer at 1- and 2-years postop (p=0.67). Length of stay was longer in HD group (4.3 vs 3.8 days, p=0.03) and implant density correlated positively with length of stay (p=0.03). Mean SRS general function and total scores were improved in the HD group at 1-year postop (4.3 vs 4.1; p=0.24; 4.36 vs 4.2, p CONCLUSIONS For Lenke 1A curves between 45-65 degrees treated with low- vs high implant density, this prospective, randomized, controlled study showed equivalent % coronal curve correction with actual treatment. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

In the context of the White Book of Physical and Rehabilitation Medicine (PRM), this paper deals with Research, the future of PRM. PRM students and specialists are mainly involved in biomedical research, investigating the biological processes, the causes of diseases, their medical diagnosis, the evaluation of their consequences on functioning, disability and health and the effects of health interventions at an individual and a societal level. Most of the current PRM research, often interdisciplinary, originates from applied research which, using existing knowledge, is directed towards specific goals. Translational medical research, research and development, implementation research and clinical impact research are in this field. PRM physicians, mainly master or PhD students, are nowadays increasing their participation in basic research and in pre- clinical trials. PRM physicians are involved in primary research, which is an original first hand research, but also in secondary research, which is the analysis and interpretation of primary research publications in a field, with a specific methodology. Secondary research remains an important activity of the UEMS PRM section and it will be the field of the new created Cochrane Rehabilitation. Secondary research with interest for persons with disabilities, will be developed world wide on the basis of evidence based medicine, with the participation of PRM physicians and of all other health and social professionals involved in rehabilitation. The development of research activities with interest for PRM in Europe is a challenge for the future, which has to be faced now. The European PRM schools, the European master and PhD program with their supporting research and clinical facilities, the European PRM organizations with their websites, the PRM scientific journals and European congresses are a strong basis to develop research activities, together with the development of Cochrane Rehabilitation field and of our cooperation with European high level research facilities, European and international scientific societies in different fields. PRM will be a leader in this field of research.

Case: We present two cases of successful staged placement of standard growing-rod instrumentation for early-onset scoliosis in children with metabolic bone disease and poor bone quality. Conclusion: Because use of growing-rod surgery is increasing throughout the world, we propose that a staged approach to placement of growing rods is a practical and safe option for surgeons who encounter patients with early-onset scoliosis and concomitant poor bone quality.

STUDY DESIGN Retrospective review of a prospective cohort. OBJECTIVE To determine the incidence, risk factors, and causes for 30-day unplanned readmission after pediatric spinal deformity surgery. SUMMARY OF BACKGROUND DATA The government has targeted 30-day readmissions as a quality of care measure. However, few studies have analyzed readmission in pediatric cohorts. METHODS A multicenter registry designed to collect pediatric surgical outcomes was queried for patients undergoing spinal deformity surgery in 2012. Patients were divided into groups of those with and without an unplanned readmission within 30 days postoperatively. Univariate and multivariate logistic regression analyses were used to compare the cohorts, and to identify variables associated with readmission. RESULTS In total, 75 of 1890 pediatric patients undergoing spinal fusion for deformity had an unplanned 30-day readmission (3.96%). Readmissions were highest in the neuromuscular group (6.83%) and lowest in the idiopathic (2.66%) and infantile (1.31%) cohorts, (P < 0.01). The top reasons for readmission included wound complications (73.3%) and gastrointestinal disturbances (13.3%). In the univariate analysis, increasing surgical complexity, particularly fusions to the pelvis and isolated anterior spinal fusions, as well as increasing medical comorbidity burden were each associated with readmission (P < 0.05 for each). In the subsequent multivariate analysis, isolated anterior spinal fusions (odds ratio, 7.65; 95% confidence interval, 1.32-44.3) structural pulmonary abnormalities (odds ratio, 2.53; 95% confidence interval, 1.22-5.23) and an American Society of Anesthesiologists class of 3 or 4 (odds ratio, 2.18; 95% confidence interval, 1.07-4.47) were independently associated with readmission. CONCLUSION The overall rate of 30-day unplanned readmissions after pediatric deformity surgery was low, but not insignificant. Surgeons should consider discharge optimization in the at-risk patient cohorts defined here, and should focus on wound complications and gastrointestinal disturbances to minimize readmissions. Quality reporting metrics should incorporate these risk factors to avoid unduly penalizing surgeons who take on complex cases. LEVEL OF EVIDENCE 3.

Adolescent idiopathic scoliosis (AIS), or late-onset scoliosis, is a condition in adolescents defined by an abnormal coronal plane spine curvature with rotation, for which no cause can be established. The natural history of both adolescent idiopathic scoliosis (AIS) and other forms of scoliosis (i.e., due to neuromuscular or syndromic disorders) has been studied over the past 50 years. However, studies isolating patients with AIS have been relatively few in number. Understanding the natural history of this condition, including characteristics of the disease process and long-term outcomes, is crucial for effective treatment and patient education. This chapter discusses the etiopathogenesis, prevalence, diagnosis and classification, and outcomes in untreated individuals with AIS. Specifically, outcome measures such as back pain and disability, pulmonary function, mortality, psychosocial effects, and the effect of AIS on pregnancy are outlined and analyzed.

Object Spinal deformity in pediatric patients with intramedullary spinal cord tumors (IMSCTs) may be either due to neurogenic disability or due to secondary effects of spinal decompression. It is associated with functional decline and impairment in health-related quality-of-life measures. The authors sought to identify the long-term incidence of spinal deformity in individuals who had undergone surgery for IMSCTs as pediatric patients and the risk factors and overall outcomes in this population. Methods Treatment records for pediatric patients (age < 21 years) who underwent surgical treatment for histology-proven primary IMSCTs between 1975 and 2010 were reviewed. All patients were evaluated in consultation with the pediatric orthopedics service. Clinical records were reviewed for baseline and follow-up imaging studies, surgical fusion treatment, and long-term skeletal and disease outcomes. Results The authors identified 55 patients (30 males and 25 females) who were treated for pediatric IMSCTs between January 1975 and January 2010. The mean duration of follow-up (± SEM) was 11.4 ± 1.3 years (median 9.3 years, range 0.2–37.2 years). Preoperative skeletal deformity was diagnosed in 11 (20%) of the 55 patients, and new-onset postoperative deformity was noted in 9 (16%). Conservative management with observation or external bracing was sufficient in 8 (40%) of these 20 cases. Surgical fusion was necessary in 11 (55%). Posterior surgical fusion was sufficient in 6 (55%) of these 11 cases, while combined anterior and posterior fusion was undertaken in 5 (45%). Univariate and multivariate analysis of clinical and surgical treatment variables indicated that preoperative kyphoscoliosis (p = 0.0032) and laminectomy/laminoplasty at more than 4 levels (p = 0.05) were independently associated with development of spinal deformity that necessitated surgical fusion. Functional scores and 10-year disease survival outcomes were similar between the 2 groups. Conclusions Long-term follow-up is essential to monitor for delayed development of spinal deformity, and regular surveillance imaging is recommended for patients with underlying deformity. The authors' extended follow-up highlights the risk factors associated with development of spinal deformity in patients treated for pediatric IMSCTs. Surgical fusion allows patients who develop progressive deformity to achieve long-term functional and survival outcomes comparable to those of patients who do not develop progressive deformity.

STUDY DESIGN: Retrospective review of prospectively collected data. OBJECTIVE: To determine whether anchor density is associated with curve correction and patient-reported outcomes. SUMMARY OF BACKGROUND DATA: There is limited information as to whether anchor density affects the results of adolescent idiopathic scoliosis surgery. METHODS: A total of 952 patients with adolescent idiopathic scoliosis met inclusion criteria (Lenke 1, 2, and 5 curves) with predominantly screw constructs (no. of screws/no. of total anchors >75%). Anchor density was defined as the number of screws, hooks, and wires per level fused, with less than 1.54 considered low density. Analysis of covariance was undertaken to determine association of anchor density with percent curve correction, Scoliosis Research Society (SRS), and Spinal Appearance Questionnaire (SAQ) scores, controlling for flexibility, fusion length, demographics, and surgeon. RESULTS: High- compared with low-anchor density was associated with increased percent curve correction in Lenke 1 curves at 1 year (69% vs. 66% correction, P = 0.0022), controlling for percent preoperative curve flexibility, length of fusion, and sex (model, P < 0.0001). Similar associations held at 2-year follow-up and for Lenke 2 curves. Decreased thoracic kyphosis was found with increased anchor density for Lenke 1 and 2 curve patterns. There were no associations found between anchor density and Lenke 5 curves. For Lenke 1 curve patterns at 2 years postoperatively, in the high- versus low-anchor density cohorts, there were statistically higher SRS Activity (4.3 vs. 4.2, P = 0.019), Appearance (4.3 vs. 4.1, P = 0.0005), Satisfaction (4.5 vs. 4.3, P = 0.028), and Total scores (4.3 vs. 4.2; P = 0.024). Similarly, the SAQ Appearance score at 1 year similarly was improved in the high-anchor density group (high: 14.1 vs. low: 15.0, P = 0.03) for Lenke 1 curve patterns only. CONCLUSION: For Lenke 1 and 2 curve patterns, improved percent correction of major coronal curve was noted in the high-screw density cohort. Although statistical significance was reached, it is unclear whether screw density resulted in clinically significant differences in patient-reported outcomes.

BACKGROUND CONTEXT Proximal junctional kyphosis (PJK) is an unsolved radiographic phenomenon after corrective spinal deformity surgery with a high, but variable reported incidence. While known to influence outcomes in adults, the long-term clinical significance and natural history in children has not been well defined.Identifying incidence, risk-factors and natural course of PJK based on several proposed definitions in the literature using a large cohort may aid in enhancing our understanding of the disease entity. PURPOSE In a single-surgeon series of AIS patients undergoing deformity correction using hybrid hooks or screw constructs, the study attempted to identify potential risk-factors associated with the long-term development of PJK. Additionally, the study also defines PJK incidence and highlights the natural course of PJK development in children based on commonly proposed definitions in the literature. STUDY DESIGN/SETTING Retrospective, single-surgeon series with a minimum 2-year follow-up. PATIENT SAMPLE Overall, 253 eligible AIS patients with complete information on the proximal junctional angle (PJA) that underwent spinal deformity fusion (PSF) surgery by a single surgeon (SLW) at the University of Iowa between 2006 and 2015 that met the minimal criteria of 2-year follow-up were included. OUTCOME MEASURES The primary outcome was to assess incidence of PJK development form preoperative to postoperative measurements based on two commonly utilized definitions: Glattes et al. that defines PJK as PJA> 10°, and Bridwell et al. classification that defines the disease entity based on the critical PJA above 20°. Secondary outcome was to investigate factors associated with PJK development based on patient demographics, radiological indices and outcomes, and describe the natural course of PJK development in AIS patients undergoing deformity correction. METHODS AIS patients aged between 9 and 18 years undergoing primary long-construct PSF (UIV T2-4) between 2006 and 2015 with a minimum 2 years follow-up were included. Proximal junctional kyphosis was defined as a change in the PJA, according to Glattes et al. and Bridwell et al. classification from preop to postop. The incidence of PJK was defined at 6-week and last follow-up. Multivariable regression models were used to assess risk factors (patient characteristics, disease severity, radiographic parameters) associated with long-term PJK development. RESULTS A total of 253 eligible patients (mean age: 13.7 years; 82% female) with an average follow-up of 3.7 years (range: 24-123 months). Proximal junctional kyphosis (10°) occurred in 10.3% at 6 weeks (PJK 20: 0.4%) and 25.7% at final FU (PJK 20: 4.3%). Based on Glattes definition, a high proportion of patients developing PJK had Risser grade 3(19 vs. 6%; p=.003) and Lenke 5(13% vs. 5%; p=.028) at baseline. In an unadjusted analysis, Risser grade 3(OR:3.6; p=.01), Lenke 5(OR:3.0; p=.03) and those with UIV as T4 (vs. T2) were associated with higher odds of PJK development. In multivariable model, we noted Risser grade 3(OR:4.6; p=.045) as a factor for PJK development. Low reoperation rate (0.04%;1/253) was noted. CONCLUSIONS PJK after AIS deformity surgery varies according to follow up time and definition. In contrast to adults, there does not appear to be any clear risk factors for PJK in an AIS population. Long-term reoperation for PJK appears to be exceedingly low at 0.4%. Radiographic PJK should be followed but generally thought of a benign condition in pediatric deformity surgery. Likely risk factors for PJK include short instrumentation (upto T4 compared to T2), Risser grade 3 and Lenke 5. Consensus on PJK definition is warranted to better define the pathological entity.

Study Design Prognostic study and validation using prospective clinical trial data. Objective To derive and validate a model predicting curve progression to ≥45° before skeletal maturity in untreated patients with adolescent idiopathic scoliosis (AIS). Summary of Background Data Studies have linked the natural history of AIS with characteristics such as sex, skeletal maturity, curve magnitude, and pattern. The Simplified Skeletal Maturity Scoring System may be of particular prognostic utility for the study of curve progression. The reliability of the system has been addressed; however, its value as a prognostic marker for the outcomes of AIS has not. The BrAIST trial followed a sample of untreated AIS patients from enrollment to skeletal maturity, providing a rare source of prospective data for prognostic modeling. Methods The development sample included 115 untreated BrAIST participants. Logistic regression was used to predict curve progression to ≥45° (or surgery) before skeletal maturity. Predictors included the Cobb angle, age, sex, curve type, triradiate cartilage, and skeletal maturity stage (SMS). Internal and external validity was evaluated using jackknifed samples of the BrAIST data set and an independent cohort (n = 152). Indices of discrimination and calibration were estimated. A risk classification was created and the accuracy evaluated via the positive (PPV) and negative predictive values (NPV). Results The final model included the SMS, Cobb angle, and curve type. The model demonstrated strong discrimination (c-statistics 0.89–0.91) and calibration in all data sets. The classification system resulted in PPVs of 0.71–0.72 and NPVs of 0.85–0.93. Conclusions This study provides the first rigorously validated model predicting a short-term outcome of untreated AIS. The resultant estimates can serve two important functions: 1) setting benchmarks for comparative effectiveness studies and 2) most importantly, providing clinicians and families with individual risk estimates to guide treatment decisions. Level of Evidence Level 1, prognostic.

Systematic review of clinical studies.To critically evaluate existing literature to determine whether increased anchor or implant density (screws, wires, and hooks per level fused) results in improved curve correction for adolescent idiopathic scoliosis (AIS) surgery.Wide variability exists in the number of screws used for AIS surgery. High numbers of pedicle screws are increasingly used, but there is limited evidence to support this as best practice.Online English-language databases were searched to identify articles addressing anchor density. Articles were reviewed for anchor type/number, radiographic measures, and patient-reported outcomes.Of 196 references identified, 10 studies totaling 929 patients met the inclusion criteria. Reported mean anchor density varied from 1.06 to 2.0 implants per level fused. Mean percent coronal curve correction varied from 64% to 70%. Two studies (463 patients) analyzed hook, hybrid (combined hooks and screws), and screw constructs as a single cohort. Both found increased correction with high-density constructs (p = .01, p.001), perhaps as a result of the hooks and hybrid constructs. Eight retrospective studies and 1 prospective randomized, controlled trial had predominantly screw constructs (466 patients). Increased anchor density was not associated with improved curve correction. The studies evaluating screw density are significantly underpowered to detect a difference in curve correction.Wide heterogeneity in anchor density exists in the surgical treatment of AIS. Reports evaluating the effects of increased anchor density are mostly retrospective and significantly underpowered to detect a difference in curve correction and patient outcomes. At this time, there is insufficient evidence to show that anchor density affects clinical outcomes in AIS.

Study design A systematic review. Objective The aim of this study was to provide an evidence-based recommendation for when and how to employ imaging studies when diagnosing back pain thought to be caused by spondylolysis in pediatric patients. Summary of background data Spondylolysis is a common structural cause of back pain in pediatric patients. The radiologic methods and algorithms used to diagnose spondylolysis are inconsistent among practitioners. Methods A literature review was performed in PubMed and Cochrane databases using the search terms "spondylolysis," "pediatric," "adolescent," "juvenile," "young," "lumbar," "MRI," "bone scan," "CT," and "SPECT." After inclusion criteria were applied, 13 articles pertaining to diagnostic imaging of pediatric spondylolysis were analyzed. Results Ten papers included sensitivity calculations for comparing imaging performance. The average sensitivity of magnetic resonance imaging (MRI) with computed tomography (CT) as the standard of reference was 81.4%. When compared with single-photon emission CT (SPECT), the average sensitivity of CT was 85% and the sensitivity of MRI was 80%. Thirteen studies made a recommendation as to how best to perform diagnostic imaging of patients with clinically suspected spondylolysis. When compared with two-view plain films, bone scans had seven to nine times the effective radiation dose, while four-view plain films and CT were approximately double. Of the diagnostic methods examined, MRI was the most expensive followed by CT, bone scan, four-view plain films, and two-view plain films. Conclusion Due to their efficacy, low cost, and low radiation exposure, we find two-view plain films to be the best initial study. With unusual presentations or refractory courses, practitioners should pursue advanced imaging. MRI should be used in early diagnosis and CT in more persistent courses. However, the lack of rigorous studies makes it difficult to formulate concrete recommendations. Level of evidence 3.

In 2002, the U.S. Bone and Joint Decade coalition presented compelling evidence to President George W. Bush that musculoskeletal disorders are the leading cause of physical disability. President Bush declared 2002-2011 the National Bone and Joint Decade to help bring attention to the societal impact of this increasing burden of musculoskeletal conditions1,2. The aims of the campaign were to raise awareness of the increasing societal impact of musculoskeletal injuries and disorders, to empower patients to participate in decisions about their care, to increase funding for prevention activities and …

Background Research indicates that healthcare providers frequently fail to adequately address patients’ health information needs. Therefore, it is not surprising that patients or parents of a sick child are seeking health information on the internet, in particular in online support groups (OSGs). In order to improve our understanding of the unmet health information needs of families dealing with adolescent idiopathic scoliosis (AIS), this study assessed and compared the types of information that adolescents and parents are seeking in OSGs. Methods This study used two publicly accessible AIS-related OSGs on the National Scoliosis Foundation (NSF) website that targeted those who are receiving brace treatment and those under observation without treatment. Information exchanges were coded as providing or seeking information. Types of information being exchanged were categorized into several AIS-specific and brace-specific categories. Through a review of over 8,000 messages, 305 adolescents with AIS and 300 parents of a child with AIS were identified and categorized based on stage of illness/treatment. One message from each individual was randomly selected and coded for analysis. Results There were significantly more (p