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Purpose: To examine if coronal deformity angular ratio (C-DAR) serves as a predictor for progression to surgical magnitude in patients with Adolescent Idiopathic Scoliosis (AIS) treated with thoracolumbar sacral orthosis (TLSO)., Methods: Patients with AIS, prescribed a full-time TLSO, Cobb angle 20-40°, Risser 0-2, who wore the brace ≥ 12.9 h and reached skeletal maturity/surgery were included retrospectively. C-DAR was defined as the Cobb angle divided by the number of vertebrae in the curve, yielding a larger value in short curves. The association between C-DAR and the risk of progression to surgical magnitude (> 45°) was assessed. Secondly, we evaluated the association between pre-treatment Cobb angle and in-brace correction on the risk of progression to > 45°., Results: We included 165 patients with a mean Cobb angle of 30 ± 6°. Of these, 46/165 (28%) progressed ≥ 6° and 26/165 (16%) reached surgical magnitude at the end of treatment. C-DAR was a significant predictor for risk of progression to surgical magnitude with an OR of 1.9 (CI 1.2-2.9) per unit increase in C-DAR. A threshold value of 5.15 was established and demonstrated an OR 5.9 (CI 2.1-17.9) for curve progression to a surgical magnitude. Likewise, pre-treatment Cobb angle showed a significant OR 1.3(CI 1.2-1.4) per degree increase in Cobb, whereas in-brace % correction showed OR 0.96 (CI 0.93-0.98)., Conclusion: C-DAR is an independent predictor for progression to a surgical magnitude in AIS patients treated with bracing. Patients with a higher C-DAR should be counseled to help set realistic expectations regarding the likelihood of curve progression despite compliance with brace wear., (© 2024. The Author(s).)

The understanding and treatment of prearthritic hip disease has evolved remarkably over the past 20 years. The principal investigator and the multicenter Academic Network of Conservational Hip Outcomes Research (ANCHOR) group have had a key role in improving the quality of care for these patients suffering from the three most common prearthritic conditions: femoroacetabular impingement, developmental dysplasia of the hip, and residual Legg-Calve-Perthes Disease. We aim to demonstrate that based on the six quality of care dimensions as defined by Donabedian, our 20-year academic journey has markedly improved the quality of care for young patients with prearthritic hip disease., (© 2024 Orthopaedic Research Society.)

Introduction: The purpose of this study is to determine the incidence of intraoperative neuromonitoring (IONM) changes and postoperative neurologic deficit in patients with Scheuermann's Kyphosis (SK) undergoing posterior spinal fusion (PSF)., Methods: Single-center, retrospective chart review of the clinical, surgical and IONM data (somatosensory evoked potential (SSEP) and neurogenic motor evoked potential (NMEP) or transcranial motor evoked potential (TcMEP)) from patients with SK undergoing PSF at our center from 1993 to 2021., Results: One hundred and four SK patients (mean 16.4 ± 1.9 years) underwent PSF with correction of kyphosis from mean 79.4 ± 10.8° to 35.4 ± 13.9°. MEP data were obtained using either NMEP in 34.6% of patients) or TcMEP in 65.4% of patients. Only 3.8% of cases had lower extremity (LE) IONM changes during surgery, with no postoperative neurologic deficits in those patients. IONM changes occurred more frequently in the upper extremities (UE) with 14 (13.4%) patients having changes in UE SSEPs. Patients with UE IONM changes had significantly longer surgical times (p = 0.0096) and higher number of levels fused (p = 0.003) compared to patients without changes. Their weight, but not BMI, was also significantly higher (p = 0.036). These UE IONM changes resolved with arm repositioning in all but one patient who had a postoperative UE neurapraxia that resolved by 6 weeks. There was 1 postoperative transient femoral nerve palsy without IONM changes thought to be due to patient positioning., Conclusion: The incidence of critical LE IONM changes during PSF for SK is 3.4%, which is similar to that reported in AIS. UE IONM changes are significantly more common at 13.4%, revealing that these patients are vulnerable to malpositioning of the arms during surgery., (© 2023. The Author(s), under exclusive licence to Scoliosis Research Society.)

Study Design: Multi-center, prospective, observational cohort., Objective: To compare myelopathic vs. non-myelopathic ambulatory patients in short- and long-term neurologic function, operative treatment, and patient-reported outcomes., Methods: Pediatric deformity patients from 16 centers were enrolled with the following inclusion criteria: aged 10-21 years-old, a Cobb angle ≥100° in either the coronal or sagittal plane or any sized deformity with a planned 3-column osteotomy, and community ambulators. Patients were dichotomized into 2 groups: myelopathic (abnormal preoperative neurologic exam with signs/symptoms of myelopathy) and non-myelopathic (no clinical signs/symptoms of myelopathy)., Results: Of 311 patients with an average age of 14.7 ± 2.8 years, 29 (9.3%) were myelopathic and 282 (90.7%) were non-myelopathic. There was no difference in age ( P = 0.18), gender ( P = 0.09), and Risser Stage ( P = 0.06), while more patients in the non-myelopathic group had previous surgery (16.1% vs. 3.9%; P = 0.03). Mean lower extremity motor score (LEMS) in myelopathic patients increased significantly compared to baseline at every postoperative visit: Baseline: 40.7 ± 9.9; Immediate postop: 46.0 ± 7.1, P = 0.02; 1-year: 48.2 ± 3.7, P < 0.001; 2-year: 48.2 ± 7.7, P < 0.001). The non-myelopathic group had significantly higher LEMS immediately postoperative ( P = 0.0007), but by 1-year postoperative, there was no difference in LEMS between groups (non-myelopathic: 49.3 ± 3.6, myelopathic: 48.2 ± 3.7, P = 0.10) and was maintained at 2-years postoperative (non-myelopathic: 49.2 ± 3.3, myelopathic: 48.2 ± 5.7, P = 0.09). Both groups improved significantly in all SRS domains compared to preoperative, with no difference in scores in the domains for pain ( P = 0.12), self-image ( P = 0.08), and satisfaction ( P = 0.83) at latest follow-up., Conclusion: In severe spinal deformity pediatric patients presenting with preoperative myelopathy undergoing spinal reconstructive surgery, myelopathic patients can expect significant improvement in neurologic function postoperatively. At 1-year and 2-year postoperative, neurologic function was no different between groups. While non-myelopathic patients had significantly higher postoperative outcomes in SRS mental-health, function, and total-score, both groups had significantly improved outcomes in every SRS domain compared to preoperative.

Background: Femoroacetabular impingement (FAI) is a condition caused by repetitive abutment of a morphologically abnormal proximal femur and/or acetabulum that may result in chondral and labral pathology. An understanding of radiographic parameters associated with successful primary surgery has not been well established., Purpose: To determine preoperative radiographic parameters that predict reoperation for FAI and correlate radiographic measurements with outcomes in these patients., Study Design: Case-control study; Level of evidence, 3., Methods: A prospectively collected institutional registry of adolescent patients (age, <19 years) who underwent surgery for FAI (arthroscopic/open) was reviewed. Preoperative standing anteroposterior pelvic radiographs were analyzed for femoroepiphyseal acetabular roof (FEAR) index, as well as lateral center-edge angle (LCEA) and alpha, Tönnis, and Sharp angles. Patient-reported outcomes (PROs) (modified Harris Hip Score, Hip disability and Osteoarthritis Outcome Score) were analyzed preoperatively and at 1- and 2-year followup. Radiographic indication of risk for reoperation was evaluated using receiver operating characteristic (ROC) analysis. Spearman correlation was calculated between radiographic measurements and PROs at 2 years postoperatively., Results: A total of 81 patients (91 hips) underwent primary surgery (57 surgical dislocations vs 34 arthroscopies) for FAI. The mean age at time of primary operation was 16.23 years (range, 10.4-19.6 years) (73.6% female). Eleven hips (12.1%) underwent reoperation at a mean of 20.6 months from primary surgery. The LCEA, FEAR index, Tönnis angle, and Sharp angle before index surgery were significantly different ( P < .05) between patients who underwent reoperation and those who did not. ROC analysis indicated that LCEA <22°, FEAR index >-8.7°, Tönnis angle >6.0°, and Sharp angle >44° were predictors for increased risk of reoperation. Using the cutoff values from the ROC analysis in this series, 43% of patients with an LCEA ≤22° had a repeat procedure, while only 8% of those with an LCEA >22° had a repeat procedure. Similar trends were seen with the other aforementioned acetabular radiographic measurements (FEAR index, Tönnis angle, Sharp angle). Patients who did not require a reoperation demonstrated significant improvement in all PRO categories from their preoperative to 2-year postoperative visits ( P < .0001)., Conclusion: In patients undergoing treatment for FAI, a reoperation was associated with radiographic signs of hip dysplasia, indicating that patients with a shallower acetabulum are at risk for a repeat operation.

Purpose: Intraoperative neuromonitoring (IONM) has historically been difficult to obtain in patients with Charcot-Marie-Tooth (CMT) disease. Transcranial motor-evoked potentials (TcMEPs) have been found to be safe and effective for other spinal deformity patients. Our objective was to determine the effectiveness of TcMEP monitoring in patients with CMT., Methods: An IRB-approved, retrospective review of CMT patients undergoing spinal deformity surgery assessing TcMEP, somatosensory-evoked potential (SSEP), and neurogenic motor evoked potential (NMEP) IONM was performed. A 2:1 matched cohort control group of idiopathic spinal deformity patients was used. A waveform grading system was applied to review baseline TcMEP reliability and quality, which was validated via intraclass correlation coefficient amongst five raters., Results: Twenty-three CMT patients (26 surgical cases) were identified. The use of TcMEP improved the ability to obtain baseline IONM when compared to SSEP (83% vs. 20%; p < 0.001) and NMEP (83% vs. 18%; p = 0.003). Baseline monitoring was obtained less often for CMT patients using SSEP (20% vs. 100%; p < 0.001) and TcMEP (83% vs. 100%; p = 0.111) compared to idiopathic patients. Sweep length (time from stimulation waveform evaluation) and maximum stimulation voltage were higher in the CMT group (289 ms vs. 111 ms p = 0.007 and 740 V vs. 345 V p = 0.089, respectively)., Conclusion: TcMEP monitoring significantly improves the ability to provide IONM for CMT patients undergoing spinal deformity surgery. Utilizing longer sweep lengths enhances the ability to attain baseline TcMEP readings, allowing surgeons to more safely proceed with surgery for these complex patients., Level of Evidence: Therapeutic-Level III., (© 2021. Scoliosis Research Society.)

Osteochondral lesions of the femoral head in young people are rare and present unique management challenges. Optimal treatment for these lesions is unclear. From 2009 to 2016, clinical and radiographic outcomes were prospectively collected within a series of symptomatic focal osteochondral lesions of the femoral head with a minimum follow-up of 2 years. A surgical hip dislocation followed by implantation of a size-matched fresh osteochondral femoral head allograft was performed. Nine hips in eight patients (6 female patients) underwent surgery at an average of 17 years (11 to 21 years). Individual allograft sizes ranged from 10 to 35 mm in diameter; with 2 of 9 hips receiving two allografts in a stacked or mosaicplasty technique at the time of treatment. The average graft implantation was 3536.5 mm2. Modified Harris hip scores improved by 13.4 (P = 0.018) from preoperative to final follow-up for all patients. Significant improvements in internal rotation (12° versus 23°, P = 0.011), external rotation (32° versus 50°, P = 0.041), and abduction (28° versus 40°, P = 0.042) were also achieved. Three patients (four hips) demonstrated poor radiographic healing (<50% incorporation at 2 years), which correlated with worse clinical outcomes and was associated with a lower preoperative lateral center edge angle (21.5° versus 30.4°, P = 0.049). Fresh osteochondral allograft treatment is a good option for focal osteochondral lesions of the femoral head with improved outcomes and motion; however, higher failure rates may be seen in those with a lower center edge angle., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Study Design: Longitudinal cohort., Objectives: Posterior spinal fusion (PSF) using all-pedicle screw constructs has become the standard procedure in the treatment of adolescent idiopathic scoliosis (AIS). However, there have been several reports that all-pedicle screw constructs or the use of pedicle screws at the upper instrumented vertebrae (UIV) increases the incidence of proximal junctional kyphosis (PJK). We aimed to evaluate the impact of instrumentation type on the incidence of PJK following PSF for AIS., Methods: We performed a stratified random sampling from 3654 patients enrolled in a multicenter database of surgically treated AIS to obtain a representative sample from all Lenke types. Patients were then allocated into 3 groups based on the instrumentation type: all-pedicle screw (PS), hook at UIV with pedicle screws distally (HT), and hybrid constructs (HB). We measured proximal junctional angle (PJA) and defined PJK as PJA ≥ 10° and PJA progression of >10° at the final follow-up., Results: Fifteen (4.3%) of 345 cases had PJK. PJK was significantly more common in PS (11%) compared with HB (1%) and HT (0%) ( P < .001). PJK patients were similar to non-PJK patients regarding age, sex, curve type, UIV, and preoperative coronal Cobb angle. Thoracic kyphosis was significantly higher in the PJK group before surgery. Patients who developed PJK had a statistically significantly larger negative sagittal balance compared with the non-PJK group., Conclusion: The incidence of PJK was 4.3% and was more common in all-pedicle screw constructs. Using hooks at UIV might be a treatment strategy to limit PJK.

Study Design: A retrospective analysis of a prospectively collected database was performed., Objective: The purpose of this study is to compare 3-dimensional correction associated with the anterior release (AR) and contemporary posterior instrumentation versus posterior-only surgery., Summary of Background Data: The role of AR as a tool in the treatment of adolescent idiopathic scoliosis (AIS) has seen a decline with the popularization of thoracic pedicle screw instrumentation., Methods: Five surgeons were queried for all surgical thoracic AIS cases from 2003 to 2010 treated with thoracoscopic AR/fusion and contemporary posterior instrumentation and fusion and thoracic pedicle screw instrumentation (>80% screws) with 2-year follow-up. These cases were then matched with posterior spinal fusion only cases from a multicenter prospective database. The 2 groups were matched on the basis of major curve magnitude within 5 degrees, T5-T12 kyphosis within 9 degrees, and angle of trunk rotation within 9 degrees. Radiographic and clinical parameters were compared for the 2 groups. Continuous variables were analyzed with analysis of variance and categorical dependent variables with the χ test., Results: A total of 47 cases of AR were matched to 47 (1:1 match) posterior spinal fusion cases. Preoperative parameters were similar between groups (P>0.05). Postoperatively, AR cases had a lower major curve (20 vs. 25 degrees, P=0.034; 72% vs. 66% correction, P=0.037). T5-T12 kyphosis was greater in the AR cases (26 vs. 20 degrees; P=0.005). The angle of trunk rotation was similar for the groups. Anchor density was lower in the AR group (1.6 vs. 1.9; P<0.0001). There were 3 complications associated with the AR: 1 pneumothorax and 2 conversions to minithoracotomies for failure to maintain single lung ventilation., Conclusions: AR improves coronal and sagittal plane correction in contemporary AIS surgery with a satisfactory complication profile with less pedicle screw density required for clinically similar corrections. A further prospective study on the benefits of AR may help define specific indications.

Study Design: Prospective multicenter study of the changes in Scoliosis Research Society Outcome Questionaire 22 (SRS-22) scores for 78 patients younger than 25 years old surgically treated for lumbosacral spondylolisthesis OBJECTIVE.: Report the change of health-related quality of life (HRQOL) in patients younger than 25 years after surgical treatment of lumbosacral spondylolisthesis., Summary of Background Data: There is a paucity of data with regard to the influence of surgical treatment on the HRQOL of patients with lumbosacral spondylolisthesis. Large prospective studies are needed to clearly define the benefits of surgery in the young patient population., Methods: A prospective multicenter cohort of 78 patients younger than 25 years (14.8 ± 2.9, range: 7.9-23.6 yr) undergoing posterior fusion for lumbosacral spondylolisthesis were enrolled. There were 17 patients with low-grade (<50%) and 61 with high-grade (≥50%) slips. SRS-22 scores calculated before surgery and after 2 years of follow-up were compared for all patients using two-tailed paired t tests. Subanalyses for low- and high-grade patients were done using two-tailed Wilcoxon signed ranked and paired t tests, respectively. The level of significance was set at 0.05., Results: HRQOL was significantly improved 2 years after surgery for all domains and for the total score of the SRS-22 questionnaire. The individual total score was improved in 66 patients (85%), and 52 patients (67%) improved by at least 0.5 point. All domains and the total score of the SRS-22 questionnaire were significantly improved for high-grade patients, whereas only pain, function, and total score were improved for low-grade patients., Conclusion: This is the largest study comparing the HRQOL before and after surgery in young patients with low- and high-grade lumbosacral spondylolisthesis. HRQOL significantly improves after surgery for the majority of patients, especially for high-grade patients. This study helps clinicians to better counsel patients with regard to the benefits of surgery for lumbosacral spondylolisthesis., Level of Evidence: 2.

Introduction: No clear practice guideline exists for the management of stable hip with ultrasonic dysplasia (UD). This study assessed the treatment patterns for stable UD and determined the outcomes of Pavlik harness (PH) treatment or observation (OB)., Methods: This is a prospective study of 80 infants (107 hips) aged ≤12 weeks at presentation diagnosed with stable UD., Results: Sixty-five hips were treated with PH, whereas 42 hips were observed. Patients who were older at the time of initial sonogram and those with lower head coverage were more likely to be treated with PH. The mean head coverage was lower in the PH group, indicating more severe UD. At a 2-year follow-up period, 93% of patients in the OB group and 87% in the PH group had a good radiographic outcome., Discussion: Head coverage and age at first sonogram had a significant influence on the treatment decision for PH. A milder ultrasonic hip dysplasia can be observed because 93% of the patients who were observed had a good outcome., Level of Evidence: Level II: prospective cohort study.

Background: We are unaware of any studies describing the immediate effects of scoliosis-specific exercises on the Cobb angle measured by radiograph. This study aimed to describe the differences between radiographs obtained with and without corrective exercises after initial training and after one year., Methods: A female with adolescent idiopathic scoliosis was first seen at age 13 years, 0 months with a Risser 0. She had a 43 o left lumbar, 15 o right thoracic curve. She was seen again after 6, 18 and 30 months and performed exercises from 18 to 30 months. She performed Barcelona Scoliosis Physical Therapy School (BSPTS) exercises for a four-curve type (lumbar dominant with pelvis deviation to the lumbar concave side). At 18 and 30 months, x-rays were obtained with and without performing corrective exercises., Results: At 6 months, her lumbar and thoracic curves measured 41 o and 28 o , respectively. At 18 months, her lumbar and thoracic curves measured 47 o and 30 o , respectively. Also at 18 months, immediately after her x-ray in the relaxed standing position, she performed her corrective exercises in standing with arms lowered for a second x-ray. Her lumbar and thoracic curves remained similar and measured 43 o and 32 o , respectively. At 30 months, she performed unsolicited corrective exercises during the x-ray. Her lumbar and thoracic curves measured 26 o and 41 o , respectively. Another x-ray in the relaxed position revealed lumbar and thoracic curves measuring 39 o and 35 o , respectively. The immediate effect of corrective exercises after a year of training was a 33 % improvement at the lumbar spine compared to only a 9 % improvement the previous year., Conclusion: After initial training, corrective exercises during a standing x-ray did not significantly improve the Cobb angle for the major lumbar curve compared to the relaxed standing x-ray. However, a year after performing exercises, unsolicited corrective exercises resulted in a significantly improved Cobb angle compared to relaxed standing for the curve primarily targeted by the exercise program. Improved exercise ability and spinal flexibility may have contributed to the improved Cobb angle.

Introduction: In Lenke 2 curves, there are conflicting data when to include the PTC into the fusion. Studies focusing on Lenke 2 curves are scant. The number of patients with significant postoperative shoulder height difference (SHD) or trunk shift (TS) is as high as 30 % indicating further research. Therefore, the purpose of the current study was to improve understanding of curve resolution and shoulder balance following surgical correction of Lenke 2 curves as well as the identification of radiographic parameters predicting postoperative curve resolution, shoulder and trunk balance in perspective of inclusion/exclusion of the proximal thoracic curve (PTC)., Methods: This is a retrospective study of a 158 Lenke 2 curves. Serial radiographs were analyzed for the main thoracic curve (MTC), PTC, and lumbar curve (LC), SHD, clavicle angle (CA), T-1 tilt, deviation of the central sacral vertical line (CSVL) off the C7 plumb line.Patients were stratified whether the PTC was included in the fusion (+PTC group, n = 60) or not (-PTC group, n = 98). Intergroup results were studied. Compensatory mechanisms for SHD were studied in detail. Adding-on distally was defined as an increase of the lowest instrumented vertebra adjacent disc angle (LIVDA) >3°. Stepwise regression analyses were performed to establish predictive radiographic parameters., Results: At follow-up averaging 24 months significant differences between the +PTC and -PTC group existed for the PTC (24° vs 28°, p < .01), PTC correction (42 vs 29 %, p < .01), rate of MTC-loss >5° (27 vs 53 %, p < .01), and spontaneous LC correction in patients with a selective thoracic fusion (STF) (80/93 %, p = .04). The number of patients with a new trunk shift (CSVL > 2 cm) was 9 (6 %): 7 in the -PTC vs 2 in the +PTC group (p = .03). Utilization of compensatory mechanisms (99 vs 83 %, p < .01) and adding-on (35 vs 20 %, p < .05) occurred more often in the +PTC vs the -PTC groups. Statistics showed postoperative SHD improvement in both the +PTC and -PTC groups. There were no significant differences regarding SHD, CA and T1-Tilt between groups. However, only in the -PTC group, a significant change between postoperative and follow-up SHD existed (p = .02). Statistics identified a preoperative 'left shoulder up' (p < .01) and CSVL (p = .03) predictive for follow-up SHD ≥1.5 cm. A statistical model only for the -PTC group showed 9 parameters highly predictive for a follow-up SHD ≥1.5 cm with highest prediction strength for a PTC >40° (p = .01), a preoperative 'left shoulder up' (p < .01) and anterior fusion (p = .02). To account for baseline differences between the +PTC and -PTC groups, 49 matched-pairs were studied. Postoperative differences remained significant between the +PTC and -PTC groups for the PTC (p < .01), MTC (p = .03) and the rate of loss of MTC >5° (p < .01)., Conclusion: Prediction of a successful surgical outcome for Lenke 2 curves depends on multiple variables, in particular a preoperative left shoulder up, preoperative PTC >40°, MTC correction, and surgical approach. Shoulder balance is not significantly different whether the PTC is included in the fusion or not. But, powerful compensation mechanisms utilized to balance shoulder in the -PTC group can impose changes of trunk alignment, main and compensatory lumbar curves.

Background: As the Bernese periacetabular osteotomy (PAO) has grown in popularity, specific indications and the results in patients treated for those indications need to be evaluated. Currently, although many patients undergo PAO after having had prior pelvic osteotomy, there is limited information regarding the efficacy of the PAO in these patients., Questions/purposes: The purpose of this study was to compare the (1) early pain, function, activity, and quality of life outcomes; (2) radiographic correction; and (3) major complications and failures between patients who underwent PAO after prior pelvic reconstruction versus those who had a PAO without prior surgery., Methods: Between February 2008 and January 2012, 39 patients underwent PAO after prior pelvic osteotomy at one of 11 centers and were entered into a collaborative multicenter database. Of those, 34 (87%) were available for followup at a mean of 2.5 years (range 1-5 years). This group was compared with a matched group of 78 subjects, of whom 71 (91%) were available for followup at a similar interval. We compared clinical outcomes including UCLA activity score, SF-12, and Hip Disability and Osteoarthritis Outcome Score (HOOS); radiographic measures-anterior and lateral center-edge angle and acetabular inclination (AI)-and reoperations, major complications, and conversions to total hip arthroplasty., Results: Although both groups reached clinical improvement in all categorical measures, the revision PAO group demonstrated greater pain (HOOS pain, study 74 versus 85, p = 0.03; 95% confidence interval [CI], 18.58 to -0.95) and less function (HOOS activities of daily living, study 80 versus 92, p = 0.002; 95% CI, 018.99-4.45) than the primary cohort. The revision cohort achieved a smaller average radiographic correction than in patients undergoing PAO without prior pelvic surgery. The mean correction in AI was less dramatic when directly comparing the revision and comparison groups (-12° to -17°, p < 0.001, SD 2.3-8.5). Although there was no difference in severe complications requiring further surgery, there were two conversions to hip arthroplasty (p = 0.109; 95% CI, 0.004-2.042) in the study group., Conclusions: PAO performed after prior pelvic surgery is associated with improvements in pain, function, radiographic correction, and early complication rates, but the improvements observed at short-term followup were smaller and more variable than those seen in patients who had not undergone prior pelvic surgery. We recommend considering PAO for residual deformities after prior osteotomy to improve function and quality life but warning patients of potential ceiling effects with a second periacetabular surgery.

Background: The purpose of this prospective multicenter study was to determine and categorize all complications associated with the periacetabular osteotomy performed by experienced surgeons., Methods: We prospectively analyzed perioperative complications in 205 consecutive unilateral periacetabular osteotomies performed at seven institutions by ten surgeons. All perioperative complications were recorded at an average of ten weeks and one year after surgery in standardized fashion using a validated complication grading scheme applied to hip preservation procedures. The mean patient age was 25.4 years. There were 143 female and sixty-two male patients. The most common diagnosis was developmental acetabular dysplasia, and concomitant procedures most commonly included femoral osteochondroplasty (58%) or hip arthroscopy (20%), which could include labral repair or resection., Results: Major complications (grade III or IV) occurred in twelve patients (5.9%). Seven complications were evident at the ten-week visit and five at the one-year visit. Nine of the complications required a second surgical intervention, including repair for acetabular migration or implant adjustment (four patients), incision and drainage for a deep infection (two patients), and heterotopic bone resection, contralateral peroneal nerve decompression, and posterior column fixation (one patient each). Three thromboembolic complications were managed medically. There were no vascular injuries, permanent nerve palsies, intra-articular osteotomies and/or fractures, or acetabular osteonecrosis. The most common grade-I or II complication was asymptomatic heterotopic ossification., Conclusions: For surgeons experienced with the periacetabular osteotomy, it is a safe procedure but is associated with a 5.9% risk of grade-III or IV complications beyond the learning curve. The majority of these complications are resolved without permanent disability., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence., (Copyright © 2014 by The Journal of Bone and Joint Surgery, Incorporated.)

Study Design: Genetic engineering techniques were used to develop an animal model of juvenile scoliosis during a postnatal skeletal-growth stage., Objective: To investigate the effect of targeted SHP2 (Src homology-2) deficiency in chondrocytes on the development of scoliosis during a juvenile growth stage in mice., Summary of Background Data: Juvenile idiopathic scoliosis can lead to progressive severe spinal deformity. The pathophysiology and molecular mechanisms responsible for the deformity are unknown. Here, we investigated the role of SHP2 deficiency in chondrocytes as a potential cause of juvenile scoliosis., Methods: Genetically engineered mice with inducible deletion of SHP2 in chondrocytes were generated. The SHP2 function in chondrocytes was inactivated during a juvenile growth stage from the mouse age of 4 weeks. Radiographical, micro-computed tomographic, and histological assessments were used to analyze spinal changes., Results: When SHP2 deficiency was induced during the juvenile stage, a progressive kyphoscoliotic deformity (thoracic lordosis and thoracolumbar kyphoscoliosis) developed within 2 weeks of the initiation of SHP2 deficiency. The 3-dimensional micro-computed tomography analysis confirmed the kyphoscoliotic deformity with a rotational deformity of the spine and osteophyte formation. The histological analysis revealed disorganization of the vertebral growth plate cartilage. Interestingly, when SHP2 was disrupted during the adolescent to adult stages, no spinal deformity developed., Conclusion: SHP2 plays an important role in normal spine development during skeletal maturation. Chondrocyte-specific deletion of SHP2 at a juvenile stage produced a kyphoscoliotic deformity. This new mouse model will be useful for future investigations of the role of SHP2 deficiency in chondrocytes as a mechanism leading to the development of juvenile scoliosis., Level of Evidence: N/A.

Healed Legg-Calvé-Perthes disease may cause both intra-articular and extra-articular impingement, resulting in a symptomatic hip prior to the onset of osteoarthritis. Various impingement-relieving surgeries have been used in the past; however, the development of the safe surgical dislocation technique has allowed a better understanding of complex deformity that may be present in these hips and hence may improve treatment of these symptomatic prearthritic hips. This article outlines the range of deformities possible in a Perthes hip, and treatment strategies to surgically address these deformities. For Perthes disease good preoperative clinical and radiographic assessment is essential, and intraoperative assessment vital., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: Surgical hip dislocation enables complete exposure of the hip joint for treatment of various hip disorders.There is limited information regarding the complications associated with this procedure. Our purpose is to report the incidence of complications associated with surgical dislocation of the hip in a large, multicenter patient cohort., Methods: A retrospective, multicenter analysis of patients who had undergone surgical hip dislocation was performed.Patients who had undergone a simultaneous osteotomy were excluded. Complications were recorded, with specific assessment for osteonecrosis, trochanteric nonunion, femoral neck fracture, nerve injury, heterotopic ossification, and thromboembolic disease. We graded complications with a validated classification scheme that includes five grades based on the treatment required to manage the complication and any long-term morbidity. With this classification, a Grade-I complication is one that requires no change in the routine postoperative course, Grade II requires a change in outpatient management, Grade III requires invasive surgical or radiologic management, Grade IV is associated with long-term morbidity or is life-threatening,and Grade V results in death., Results: The study included 334 hips in 302 patients seen at eight different North American centers. There were eighteen complications (5.4%) that were classified as Grade I (not clinically relevant and required no deviation from routine postoperative care). There were six complications (1.8%) classified as Grade II (treated on an outpatient basis or with close observation and resolved). There were nine complications (2.7%) classified as Grade III (treatable and resolved with surgery or inpatient management). There was one complication (0.3%) classified as Grade IV (resulting in a long-term deficit). A total of thirty hips had one or more complications, for an overall incidence of 9%. Excluding heterotopic ossification, the complication rate was sixteen (4.8%) of 334., Conclusions: Surgical hip dislocation is a safe procedure with a low complication rate. Many of the complications were clinically unimportant heterotopic ossification. There were no cases of femoral head osteonecrosis or femoral neck fracture, and, with the exception of one sciatic neurapraxia that partially resolved, no other complication resulted in long-term morbidity.

Background: Venous thromboembolism, a known complication of orthopaedic procedures, is thought to be more prevalent following hip surgery. Venous thromboembolism risk assessment and appropriate prophylaxis according to the American College of Chest Physicians guidelines has become the standard of care. However, it is accepted that venous thromboembolism prophylaxis is associated with potential adverse sequelae including hematoma, wound drainage, and infection. Little is known regarding the incidence of venous thromboembolism following periacetabular osteotomy and the necessity for and method of routine prophylaxis., Methods: A total of 1067 periacetabular osteotomies performed at six North American centers utilizing different methods of prophylaxis against venous thromboembolism were analyzed for type of prophylaxis and incidence of clinically symptomatic venous thromboembolism., Results: There were four cases of pulmonary embolus and seven cases of deep vein thrombosis. There were no reported deaths. The crude incidence of clinically symptomatic venous thromboembolism was 9.4 per 1000 procedures., Conclusions: The risk from chemoprophylaxis and the development of hematoma may be greater than the risk of clinically important venous thromboembolism in patients undergoing periacetabular osteotomy.

Scoliosis corrective surgery requires the application of significant multidirectional stress forces, including distraction, for correction of the curved spine deformity and the application of fixation rods. If excessive, spine distraction may result in the development of new neurological deficits, some as severe as permanent paralysis. Current animal models of spinal cord injury, however, are limited to contusion, transection, or unidirectional distraction injuries, which fail to replicate the multidirectional forces that occur during spine corrective surgery. To address such limitation, we designed a novel device that relies on intervertebral grip fixation and linear actuators to induce controllable bidirectional distraction injuries to the spine. The device was tested in three (i.e., 3, 5, and 7 mm) distention paradigms of the rat T9-T11 vertebra, and the resulting injuries were evaluated through electrophysiological, behavioral, and histological analysis. As expected, 3mm bilateral spine distractions showed no neurological deficit. In contrast, those with 5 and 7 mm showed partial and complete paralysis, respectively. The relationship between the severity of the spine distraction and injury to the spinal cord tissue was determined using glial fibrillary acidic protein immunocytochemistry for visualization of reactive astrocytes and labeling of ED1-positive activated macrophages/microglia. Our results demonstrate that this device can produce bidirectional spine distraction injuries with high precision and control and, thus, may be valuable in contributing to the testing of neuroprotective strategies aimed at preventing unintended new neurological damage during corrective spine surgery., (Copyright © 2011 Elsevier B.V. All rights reserved.)

STUDY DESIGN.: Multicenter, prospective clinical series. OBJECTIVE.: To investigate the effect of preoperative bracing on postoperative outcome of posterior spine fusion with instrumentation for adolescent idiopathic scoliosis. SUMMARY OF BACKGROUND DATA.: Bracing is the standard of care for adolescent idiopathic scoliosis between 25° and 45°, yet the efficacy of bracing is questionable. It is important to evaluate the effect of bracing on outcomes in the adolescent idiopathic scoliosis population. METHODS.: We reviewed the outcomes of 281 before surgery braced and 328 before surgery nonbraced patients who underwent posterior spine fusion with instrumentation for adolescent idiopathic scoliosis before operation and at 2 years after operation using the Scoliosis Research Society instrument (SRS-30) and the Spinal Appearance Questionnaire. RESULTS.: At 2 years after operation, nonbraced patients demonstrated a greater improvement in the SRS-30 Pain domain score (0.23 vs. 0.08, P < 0.001), more improvement in back pain at rest (26.7% vs. 20.5%, P = 0.0009), and more improvement in back pain in the past 6 months (42.4% vs. 32.6%, P = 0.039) compared to braced patients. Also at 2 years after operation, nonbraced patients reported higher SRS-30 Activity domain scores (4.38 vs. 4.32, P = 0.031), Satisfaction domain scores (4.53 vs. 4.42, P = 0.007), and Total scores (4.27 vs. 4.35, P = 0.036) compared with braced patients. The 2-year Spinal Appearance Questionnaire scores showed that nonbraced patients reported a greater "decrease in importance" than braced patients in having "more even shoulders" (79.4% vs. 70.5%, P = 0.03), "more even hips" (74.6% vs. 71.6%, P = 0.042), and "more even ribs in back" (78.4% vs. 69.5%, P = 0.05). CONCLUSION.: Before surgery braced patients have more pain, lower activity levels, lower satisfaction, and lower total SRS-30 scores at 2 years after operation. Braced patients also have more "spine-specific" appearance concerns compared to nonbraced patients. These results suggest a negative impact of preoperative bracing on outcomes after posterior spinal fusion for adolescent idiopathic scoliosis. This "brace signature" should be taken into account when brace treatment is being considered.

There are few good surgical options that allow for continued spinal growth in patients with early-onset scoliosis. The "Shilla" is a growth guidance system that does not require repeated surgical lengthenings. The Shilla system guides growth at the ends of dual rods with the apex of the curve corrected, fused, and fixed to the rods. The growth occurs through the extraperiosteally implanted pedicle screws that slide along the rods at either end of the construct. We implanted 11 2-month-old immature goats with the dual rod system and euthanized all 11 goats 6 months postoperatively. We evaluated plain radiographs, regular computed tomography, microcomputed tomography, physical and histologic examinations, and a microscopic wear analysis. All of the goat spines grew with the implants in place; growth occurred in both the thoracic and lumbar ends of the rods for a total average of 48 mm. None of the implants failed, although we observed minor wear at the rod/screw interface. Growth guidance with the Shilla rod system allowed for continued growth in this goat model.

Study Design: Retrospective review., Objective: To compare the results of spinal fusion in patients with open triradiate cartilages (OTRC) and closed triradiate cartilages (CTRC)., Summary of Background Data: Patients with OTRC at the time of spinal fusion may be at increased risk of developing postoperative changes related to growth., Methods: From a database of patients with adolescent idiopathic scoliosis, we identified 44 patients with OTRC (mean age, 11.6 years) and 450 patients with CTRC (mean age, 15.6 years) and a minimum follow-up of 2 years. Patients in both groups were treated with anterior-only, posterior-only, or combined anterior and posterior spinal fusion; none had all-pedicle screw posterior instrumentation., Results: In the OTRC group, anterior or posterior instrumentation, but not the combined approach, resulted in a significant mean late increase in the main curve (4.4 degrees and 7.3 degrees vs. 0 degrees , respectively; P = 0.002), an approach-related difference not seen in the CTRC group. Significantly more OTRC patients had proximal levels added on after surgery than did CTRC patients (18% vs. 8%, respectively; P = 0.02), and there was a trend toward this phenomenon distally (29% vs. 19%, respectively; P = 0.10). Proximal and distal junctional kyphosis was not significantly different between the 2 groups. Reoperation rate was 11% and 7% for OTRC and CTRC patients, respectively. For the selectively fused Lenke 1C curves in OTRC and CTRC patients, there was a trend in the uninstrumented lumbar curve toward a smaller lumbar curve before surgery (36 degrees and 41 degrees , respectively; P = 0.07) and a larger curve after surgery (27 degrees and 24 degrees , respectively; P = 0.07)., Conclusion: Patients with scoliosis and OTRC have a greater risk of adding-on proximally and of loss of correction with anterior-only instrumentation; they may also have less predictable lumbar correction from selective thoracic fusion. However, after combined surgery, they have results similar to those of more skeletally mature patients.

The 3D Bezier Curve is used to model the simplified 3D human spine for analyzing and classifying the scoliotic deformity. This 3D spine model is based on two orthogonal spinal radiographic images taken from coronal and sagittal planes. Superimposed on these two images, the 3D Bezier curves are fitted interactively onto the center of the spine from coronal and sagittal images. After the 3D Bezier Curve fitting, a series of simplified 3D vertebrae are implemented onto the 3D Bezier Curve proportional in size to its axis. The Lenke Classification system is applied to this 3D spine model. In order to identify the Lenke Classification for each individual spine model, the left side bending and right side bending images are added. Bending the 3D spine model interactively to the left and right determines the stiffness of the spinal deformity and whether the curves are structural. Thus the Lenke Classification could be determined.

Fifty patients with Ewing's sarcoma of the pelvis were treated using a multidisciplinary approach; followup of surviving patients averaged 137 months (range, 40-276 months). The addition of surgical resection to the multidisciplinary treatment for all patients was associated with improved survival compared with survival of patients treated with chemotherapy and radiation therapy alone; the addition of surgery to the treatment regimen of 37 patients without metastases also was associated with improved survival. There were no significant differences between the surgical and nonsurgical groups in terms of tumor size, stage of disease, patient age, duration of symptoms before diagnosis, or anatomic site. Surgery was used more often in recently treated patients, but the year of diagnosis and treatment did not significantly affect overall survival, secondary to large confidence intervals. The Short Form-36 and the Musculoskeletal Tumor Society functional evaluation instruments showed a superior level of function in the nonsurgical group, but this difference was not statistically significant. There have been many advances in the treatment of patients with Ewing's sarcoma during the past 3 decades, resulting in improved survival for patients with Ewing's sarcoma of the pelvis. The addition of surgery significantly improved survival and did not show a significant difference in functional outcome.

A study of ninety-nine patients who had a unilateral, displaced, isolated closed fracture of the tibial shaft was performed to determine the effect of the type of treatment on the clinical outcome. Forty-seven patients were managed with closed intramedullary nailing with reaming, and fifty-two were managed with closed reduction and a cast. The two groups were comparable with regard to the ages of the patients, the locations and amounts of displacement of the fractures, and the number of patients who had a history of smoking. The time to union was shorter in the patients who had been managed with intramedullary nailing than in those who had been managed with a cast (mean, eighteen compared with twenty-six weeks; p = 0.02). A non-union occurred in one patient (2 per cent) who had been managed with nailing and in five patients (10 per cent) who had been managed with a cast. There were no infections in either group. Removal of the nail was performed electively in twenty-six patients. Twenty-five patients who had been managed with nailing and twenty-five who had been managed with a cast were followed for a mean of 4.4 years. With use of the Iowa Knee Evaluation and the Ankle-Evaluation Rating System, the patients who had had nailing had mean scores of 96 points (range, 68 to 100 points) and 97 points (range, 74 to 100 points) for the knee and the ankle, respectively, compared with 89 points (range, 62 to 100 points) and 84 points (range, 62 to 100 points) for those who had been managed with a cast (p < 0.05). Administration of the Medical Outcomes Study Short Form-36 Health Survey to the twenty-five matched pairs of patients yielded scores that were significantly better after nailing than after treatment with a cast (a mean of 85 points [range, 27 to 99 points] compared with a mean of 74 points [range, 20 to 97 points]; p < 0.05). We concluded that the treatment of displaced closed fractures of the tibial shaft with closed intramedullary nailing with reaming provides functional results that are superior to those obtained with use of a cast.

A rabbit antiserum raised against the 14.5-kilodalton (kDa) subunit of human splenic galaptin was used to probe protein blots of several tissue extracts. For all tissues examined, the only immunoreactive species detected was a 14.5-kDa polypeptide. This antiserum and a rabbit antiserum raised against native lung galaptin were used in immunohistochemical assays to determine the localization of galaptin in selected tissues and cells. In normal colon, galaptin was found prominently in the basement membrane and in the stroma. The cytoplasm of epithelial cells stained lightly for galaptin whereas mucous granules and secreted mucin were uniformly negative for galaptin. Hemagglutination inhibition assays also failed to demonstrate an interaction between galaptin and mucin. Macrophages stained conspicuously for galaptin in colonic and cutaneous tissue as did some capillary walls. In cutaneous tissue, the extracellular matrix and hair follicle cells contained abundant galaptin. Galaptin was absent in basal cell carcinoma and associated stroma. Galaptin was found throughout the cytoplasm of carcinoma cells of gynecologic origin present in effusions. Protein blot analysis of extracts of extracellular matrix synthesized in vitro by endothelial cells confirmed the presence of galaptin in matrix. The results show that: (1) galaptin is variably expressed by different cells and tissues; (2) its cellular location is not restricted to the cell surface; (3) galaptin is not associated with normal mucin; (4) the extracellular matrix is a major site of galaptin deposition, and (5) some malignant tissue may be characterized by a deficiency of galaptin.

Immunohistochemical studies indicated that galaptin is a major protein of ovarian carcinoma cells present in patient effusions and it is distributed throughout the cytoplasm. Enzyme-linked immunoadsorbent assay (ELISA) and immunoprecipitation experiments demonstrated that galaptin is also a major protein of the A121 ovarian carcinoma cell line, constituting less than or equal to 1% of extractable protein bound by DEAE Sephacel. Western blot analyses revealed that the galaptin present in ovarian carcinoma consists of a 14.5 KD subunit. Ovarian carcinoma and mesothelial cells isolated from patient effusions display surface receptors for galaptin with an apparently greater density of receptors present on the carcinoma cells. A121 cells also display surface receptors for galaptin: binding sites/cell = 3 X 10(8) and Ka = 1.2 X 10(9) M-1. The presence of galaptin in bovine corneal endothelial cells (BCEC) and BCEC-derived extracellular matrix (ECM) was demonstrated by ELISA. Of the total ECM-bound galaptin, about 75% appears to be insoluble in phosphate-buffered saline (PBS) lactose. ECM was also found to contain abudnant receptors for galaptin. Treatment of ECM with lactose increased the apparent galaptin receptor density:binding sites/cm2 = 7 X 10(13) and Ka = 2.6 X 10(9) M-1. Pretreatment of A121 cells with galaptin inhibited adhesion to ECM. The addition of exogenous galaptin to ECM had variable effect on cell adhesion. The data presented here suggest that early adhesion events may be carbohydrate-specific involving interaction between ECM-bound galaptin and cell surface galaptin receptors.

Lactose-inhibitable lectin activity has been analyzed by hemagglutination assay in a variety of human tissues and cells obtained at surgery and autopsy. The lectin activity was detected in surgically removed melanoma, sarcoma, colon carcinoma, breast carcinoma, adjacent non-malignant tissues, non-malignant tissues obtained at autopsy and in cells isolated from malignant effusions. Although, on average, malignant tissue had a higher hemagglutinating titer than non-malignant tissue, similar tissues from different individuals varied widely in their apparent lectin content. The lectin was isolated from lung by affinity chromatography and was found to have a native molecular mass of 31,000 daltons and a subunit molecular mass of 14,000 daltons. Utilizing rabbit anti-lung lectin serum in an immunohistochemical assay, the lectin was found to be distributed throughout the cytoplasm of lung epithelial cells. Ouchterlony immunodiffusion analysis confirmed the presence of this lectin in a variety of tissues and in some body fluids. In vitro metabolic radiolabelling experiments showed that the presence of lectin in tissues was most likely due to endogenous synthesis rather than absorption from body fluids. Lectin isolated from several tissues was found to bind to human buffy coat cell receptors.