Complications of growing-rod treatment for early-onset scoliosis: analysis of one hundred and forty patients

BACKGROUND

Previous reports have indicated high complication rates associated with non-fusion surgery in patients with early-onset scoliosis. This study was performed to evaluate the clinical and radiographic complications associated with growing-rod treatment.

METHODS

Data from the multicenter Growing Spine Study Group database were evaluated. Inclusion criteria were growing-rod treatment for early-onset scoliosis and a minimum of two years of follow-up. Patients were divided into treatment groups according to rod type (single or dual) and rod location (subcutaneous or submuscular). Complications were categorized as wound, implant, alignment, and general (surgical or medical). Surgical procedures were classified as planned and unplanned.

RESULTS

Between 1987 and 2005, 140 patients met the inclusion criteria and underwent a total of 897 growing-rod procedures. The mean age at the initial surgery was six years, and the mean duration of follow-up was five years. Eighty-one (58%) of the 140 patients had a minimum of one complication. Nineteen (27%) of the seventy-one patients with a single rod had unplanned procedures because of implant complications, compared with seven (10%) of the sixty-nine patients with dual rods (p ≤ 0.05). Thirteen (26%) of the fifty-one patients with subcutaneous rod placement had wound complications compared with nine of the eighty-eight patients (10%) with submuscular rod placement (p ≤ 0.05). The patients with subcutaneous dual rods had more wound complications, more prominent implants, and more unplanned surgical procedures than did those with submuscular dual rods (p ≤ 0.05). The risk of complications occurring during the treatment period decreased by 13% for each year of increased patient age at the initiation of treatment. The complication risk increased by 24% for each additional surgical procedure performed.

CONCLUSIONS

Regardless of treatment modality, the management of early-onset scoliosis is prolonged; therefore, complications are frequent and should be expected. Complications can be reduced by delaying initial implantation of the growing rods if possible, using dual rods, and limiting the number of lengthening procedures. Submuscular placement reduces wound and implant-prominence complications and reduces the number of unplanned operations.

Standardization of criteria for adolescent idiopathic scoliosis brace studies: SRS Committee on Bracing and Nonoperative Management

STUDY DESIGN

Literature review.

OBJECTIVE

To establish consistent parameters for future adolescent idiopathic scoliosis bracing studies so that valid and reliable comparisons can be made.

SUMMARY OF BACKGROUND DATA

Current bracing literature lacks consistency for both inclusion criteria and the definitions of brace effectiveness.

METHODS

A total of 32 brace treatment studies and the current bracing in adolescent idiopathic scoliosis proposal were analyzed to: (1) determine inclusion criteria that will best identify those patients most at risk for progression, (2) determine the most appropriate definitions for bracing effectiveness, and (3) identify additional variables that would provide valuable information.

RESULTS

Early brace studies lacked clarity in their inclusion criteria. In more recent studies, inclusion criteria have narrowed considerably to include primarily those patients most at risk for curve progression who may benefit from the use of a brace. Brace effectiveness was usually defined by various degrees of curve progression at maturity. Less frequently, it was defined by the resultant curve magnitude at maturity, whether or not surgical intervention was needed, or if there was change to another brace.

CONCLUSIONS

Optimal inclusion criteria for future adolescent idiopathic scoliosis brace studies consist of: age is 10 years or older when brace is prescribed, Risser 0-2, primary curve angles 25 degrees -40 degrees , no prior treatment, and, if female, either premenarchal or less than 1 year postmenarchal. Assessment of brace effectiveness should include: (1) the percentage of patients who have < or =5 degrees curve progression and the percentage of patients who have > or =6 degrees progression at maturity, (2) the percentage of patients with curves exceeding 45 degrees at maturity and the percentage who have had surgery recommended/undertaken, and (3) 2-year follow-up beyond maturity to determine the percentage of patients who subsequently undergo surgery. All patients, regardless of subjective reports on compliance, should be included in the results (intent to treat). Every study should provide results stratified by curve type and size grouping.

Birthweight and adult health outcomes in a biethnic population in the USA

Recent data indicate that low-birthweight adults are at a higher risk than their high-birthweight peers of developing ischemic heart disease or a cluster of conditions known as the IRS, which includes dyslipidaemias, hypertension, unfavorable body fat distribution and NIDDM. Thus far these observations have been limited to Caucasians from the United Kingdom. we extended these observations to a broader segment of the general population by studying the association of birthweight and adult health outcomes in a biethnic population of the United States. We divided a group of 564 young adult Mexican-American and non-Hispanic white men and women participants of the San Antonio Heart Study into tertiles of birthweight and compared metabolic, anthropometric, haemodynamic, and demographic characteristics across these tertile categories. Additionally, we studied birthweight as a predictor of the clustering of diseases associated with the IRS, defined as any two or more of the following conditions: hypertension, NIDDM or impaired glucose tolerance, dyslipidaemia. Normotensive, non-diabetic individuals whose birthweight was in the lowest tertile had significantly higher levels of fasting serum insulin and a more truncal fat deposition pattern than individuals whose birthweight was in the highest tertile, independently of sex, ethnicity, and current socioeconomic status. Also, the odds of expressing the IRS increased 1.72 times (95% confidence interval: 1.16-2.55) for each tertile decrease in birthweight. These findings were independent of sex, ethnicity, and current levels of socioeconomic status or obesity. In conclusion, low birthweight could be a major independent risk factor for the development of adult chronic conditions commonly associated with insulin resistance in the general population.

Comparison of single and dual growing rod techniques followed through definitive surgery: a preliminary study

STUDY DESIGN

Retrospective analysis of patients treated with single and dual growing rods who had completed their course of treatment, had definitive fusion, and had a minimum of 2 years follow-up.

OBJECTIVES

To determine which technique was the most effective in the management of severe spinal deformity in young children: control of the spinal deformity, spinal growth, and the incidence of complications.

SUMMARY OF BACKGROUND DATA

Growing rod techniques provide proximal and distal segmental "claw" foundations, but their overall results through definitive fusion have not been clearly determined.

METHODS

A total of 28 consecutive patients who had growing rod procedures followed through definitive spinal fusions were analyzed. There were three patient groups: Group 1 (N = 5), single submuscular rod and short apical fusion; Group 2 (N = 16), single growing rod alone; and Group 3 (N = 7), dual growing rods.

RESULTS

The interval between initial rod insertion and definitive spinal fusion was similar in all three groups. The best overall results occurred in Group 3, whereas the patients in Group 1 had the worse results. Both Groups 2 and 3 provided good initial correction of the spinal deformity and allowed spinal growth. Group 2 had better frontal and sagittal plane balance and the lowest complication rate.

CONCLUSION

The use of growing rods is effective in controlling severe spinal deformities and allowing spinal growth. Dual rods are stronger than single rods and, therefore, provide better initial correction and maintenance of correction. The use of an apical fusion does not appear to be effective over the course of treatment.

Development and initial validation of the Classification of Early-Onset Scoliosis (C-EOS)

BACKGROUND

Early-onset scoliosis is a heterogeneous condition, with highly variable manifestations and natural history. No standardized classification system exists to describe and group patients, to guide optimal care, or to prognosticate outcomes within this population. A classification system for early-onset scoliosis is thus a necessary prerequisite to the timely evolution of care of these patients.

METHODS

Fifteen experienced surgeons participated in a nominal group technique designed to achieve a consensus-based classification system for early-onset scoliosis. A comprehensive list of factors important in managing early-onset scoliosis was generated using a standardized literature review, semi-structured interviews, and open forum discussion. Three group meetings and two rounds of surveying guided the selection of classification components, subgroupings, and cut-points. Initial validation of the system was conducted using an interobserver reliability assessment based on the classification of a series of thirty cases.

RESULTS

Nominal group technique was used to identify three core variables (major curve angle, etiology, and kyphosis) with high group content validity scores. Age and curve progression ranked slightly lower. Participants evaluated the cases of thirty patients with early-onset scoliosis for reliability testing. The mean kappa value for etiology (0.64) was substantial, while the mean kappa values for major curve angle (0.95) and kyphosis (0.93) indicated almost perfect agreement. The final classification consisted of a continuous age prefix, etiology (congenital or structural, neuromuscular, syndromic, and idiopathic), major curve angle (1, 2, 3, or 4), and kyphosis (-, N, or +) variables, and an optional progression modifier (P0, P1, or P2).

CONCLUSIONS

Utilizing formal consensus-building methods in a large group of surgeons experienced in treating early-onset scoliosis, a novel classification system for early-onset scoliosis was developed with all core components demonstrating substantial to excellent interobserver reliability. This classification system will serve as a foundation to guide ongoing research efforts and standardize communication in the clinical setting.

Growing rod techniques in early-onset scoliosis

BACKGROUND

The surgical treatment of severe early-onset scoliosis (EOS) is controversial. Obtaining and maintaining deformity correction, achieving adequate spinal growth, allowing lung development, and the high complication rate make surgical treatment very challenging. Growing rods are the most common method of management.

METHODS

Currently, there are 3 systems being used for the surgical treatment of EOS: single growing rod, dual growing rods, and the vertical expandable titanium prosthetic rib implant. Each system has its advantages and disadvantages. These are presented and discussed in this review.

RESULTS

The current clinical and radiographic results indicate that all 3 techniques can be effective in the surgical management of EOS. Vertical expandable prosthetic titanium rib (VEPTR), which is not considered a true growing rod system, is particularly effective in congenital scoliosis with fused ribs.

CONCLUSIONS

The current expandable spinal implant systems appear effective in controlling progressive EOS, allowing for spinal growth and improving lung development. All have a moderate complication rate, especially rod breakage and hook displacement.

Traditional Growing Rods Versus Magnetically Controlled Growing Rods for the Surgical Treatment of Early-Onset Scoliosis: A Case-Matched 2-Year Study

INTRODUCTION

Traditional growing rod (TGR) surgery is a treatment technique commonly used for progressive early-onset scoliosis. Studies have shown that repeated TGR lengthenings can significantly increase the risk of complications. Magnetically controlled growing rods (MCGR) are currently available outside of the United States and early results have been promising. The purpose of this study was to compare the effectiveness of MCGR versus TGR for the treatment of early-onset scoliosis.

METHODS

Magnetically controlled growing rod patients were selected based on the following criteria: aged less than 10 years, major curve greater than 30°, thoracic height less than 22 cm, no previous spine surgery, and minimum 2-year follow-up. A total of 17 MCGR patients met the inclusion criteria, 12 of whom had complete data available for analysis. Each MCGR patient was matched with a TGR patient by etiology, gender, single versus dual rods, preoperative age, and preoperative major curve.

RESULTS

Magnetically controlled growing rod patients had a mean age of 6.8 years and mean follow-up of 2.5 years. Mean follow-up was greater for TGR patients by 1.6 years. Major curve correction was similar between MCGR and TGR patients throughout treatment. The MCGR patients experienced an average of 8.1 mm/year increase in T1-S1 during the lengthening period, compared with 9.7 mm/year for TGR patients (p = .73). There was a mean increase in T1-T12 of 1.5 mm/year for MCGR patients and 2.3 mm/year for TGR patients (p = .83). The TGR patients had 73 open surgeries, 56 of which were lengthenings. The MCGR patients had 16 open surgeries and 137 noninvasive lengthenings. Three TGR patients underwent 5 unplanned revision surgeries whereas 3 MCGR patients underwent 4 unplanned revisions.

CONCLUSIONS

Major curve correction was similar between MCGR and TGR patients throughout treatment. Annual T1-S1 and T1-12 growth was also similar between groups. The MCGR patients had 57 fewer surgical procedures than TGR patients. Incidence of unplanned surgical revisions as a result of complications was similar between groups.

The effect of amicar on perioperative blood loss in idiopathic scoliosis: the results of a prospective, randomized double-blind study

STUDY DESIGN

A prospective, randomized, double-blind Institutional Review Board-approved study evaluating the efficacy of Amicar (epsilon aminocaproic acid), an antifibrinolytic agent, in decreasing perioperative blood loss in idiopathic scoliosis.

OBJECTIVES

To compare the perioperative (intraoperative and postoperative) blood loss and the need for autologous and homologous blood replacement in two groups of essentially identical patients undergoing a posterior spinal fusion for idiopathic scoliosis.

SUMMARY OF BACKGROUND DATA

Reducing perioperative blood loss and the need for transfusion in patients undergoing spinal surgery is important to orthopedic surgeons. Recently, there has been interest in pharmacologic agents, particularly Amicar and Aprotinin, to assist in decreasing perioperative blood loss. In 2001, in a preliminary study, we demonstrated that Amicar appeared to be effective in reducing perioperative blood loss in patients with idiopathic scoliosis undergoing a posterior spinal fusion and segmental spinal instrumentation. This was a study of 28 consecutive patients receiving Amicar compared to a historical control group of the 31 previous consecutive patients with the same study criteria. The current study was performed to confirm our preliminary findings.

METHODS

We analyzed the perioperative blood loss of 36 patients with idiopathic scoliosis who were blindly randomized by the operating room pharmacy into an Amicar and control group. The criteria to be included in the study was the same as the preliminary study: diagnosis of idiopathic scoliosis, age at surgery 11 to 18 years, posterior spinal fusion and segmental spinal instrumentation only, autogenous iliac crest bone graft or homologous cancellous bone graft, and a signed agreement to participate in the study. The patients in both groups had the same anesthetic technique, intraoperative procedure, instrumentation, postoperative management, and standardized indications for transfusions.

RESULTS

Before surgery, the patients in both groups were essentially identical. The distribution of patients and their results was not known until the completion of the study. Patients in the Amicar group demonstrated a statistically significant decrease in perioperative blood loss and the need for autologous blood transfusion. Interestingly, this decrease was predominantly in the postoperative suction drainage. This may be due to elevated fibrinogen levels induced by Amicar. The patients taking Amicar had no intraoperative or postoperative thromboembolic complications.

CONCLUSIONS

The results of this study confirmed that the use of intraoperative Amicar is a safe, effective, and inexpensive method to significantly reduce perioperative blood loss in patients with idiopathic scoliosis undergoing posterior spinal fusion and segmental spinal instrumentation. The results have allowed us to reduce our recommendation for perioperative autologous blood donation, thereby further decreasing costs.

Growing-rod graduates: lessons learned from ninety-nine patients who completed lengthening

BACKGROUND

Growing-rod spinal instrumentation systems are a valuable tool for managing severe early-onset scoliosis. There is little information about the end point of treatment.

METHODS

A multicenter early-onset-scoliosis database was searched to identify patients who had undergone treatment with growing rods and either had had a final operative procedure or were still being treated with the growing rods after reaching skeletal maturity (defined as fourteen years of age or older). Clinical, radiographic, and operative data were analyzed.

RESULTS

Ninety-nine patients met the inclusion criteria, and ninety-two (93%) of them had had a final operative procedure. The remaining seven patients (7%) were older than fourteen years but had not undergone a final procedure. Of the ninety-two patients who had a final procedure, seventy-nine (86%) had an instrumented fusion, nine (10%) had growing-rod exchanges and fusion in situ, three (3%) had the growing rods left in place and fusion in situ, and one (1%) had only growing-rod removal. The mean age (and standard deviation) at the final fusion was 12.4 ± 1.9 years. In forty-four (55%) of eighty patients for whom the information was available, the number of vertebral levels fused was the same as the number of vertebral levels spanned by the growing rods. The percent correction of the curve after final fusion was none or minimal (≤ 20 %) in eleven (18%) of the sixty-two patients for whom sufficient-quality radiographs were available, moderate (21% to 50%) in thirty (48%), and substantial (≥ 51 %) in nine (15%); the curve had worsened in twelve patients (19%). The mean duration of growing-rod treatment was 5.0 ± 2.6 years. Of fifty-eight operative reports made at final fusion that contained comments on spinal flexibility, eleven (19%) described the spine as being mobile, eleven (19%) described decreased flexibility, and thirty-six (62%) described the spine as being completely stiff. At final fusion, twenty-two patients (24%) had osteotomies and seven patients (8%) had a thoracoplasty.

CONCLUSIONS

Most patients underwent growing-rod removal and final instrumented fusion. The final fusion often included the same levels spanned by the growing rods and usually achieved <50% additional correction of the deformity remaining at the end of the growing-rod management.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The Effect of epsilon-aminocaproic acid on perioperative blood loss in patients with idiopathic scoliosis undergoing posterior spinal fusion: a preliminary prospective study

STUDY DESIGN

A prospective study evaluating the efficacy of epsilon-aminocaproic acid (EACA) in decreasing perioperative blood loss in idiopathic scoliosis.

OBJECTIVES

To compare the perioperative blood loss and need for blood replacement in two groups of patients undergoing surgery for idiopathic scoliosis. One group received intraoperative EACA; the other did not and served as controls.

SUMMARY OF BACKGROUND DATA

Excessive blood loss increases the operative time, risk for blood product disease transmission, postoperative complications, and costs associated with posterior spinal fusion and instrumentation. EACA is an antifibrinolytic agent that has been shown to be effective in reducing perioperative blood loss during pediatric cardiothoracic surgical procedures. We hypothesized that it would also be effective in lowering blood loss during posterior spinal fusion for idiopathic scoliosis.

METHODS

We compared the perioperative blood loss of 28 consecutive pediatric patients with idiopathic scoliosis who underwent posterior spinal fusion and received intraoperative EACA with 31 consecutive patients who did not receive this medication and served as a control group.

RESULTS

The patients in both groups were similar. Patients in the EACA group demonstrated statistically significant decreases in total estimated perioperative blood loss and the need for autologous blood transfusion. The patients in the EACA group had no intraoperative or postoperative complications related to the use of this medication.

CONCLUSIONS

Based on these preliminary findings, we believe that EACA is helpful in decreasing blood loss in patients undergoing posterior spinal fusion and instrumentation, and may decrease the number of autologous units needed to maintain safe perioperative hemoglobin levels, thereby improving safety and lowering cost associated with scoliosis surgery.

Deep Surgical Site Infection Following 2344 Growing-Rod Procedures for Early-Onset Scoliosis: Risk Factors and Clinical Consequences

BACKGROUND

Deep surgical site infection may change the course of growing-rod treatment of early-onset scoliosis. Our goal was to assess the effect of this complication on subsequent treatment.

METHODS

A multicenter international database was retrospectively reviewed; 379 patients treated with growing-rod surgery and followed for a minimum of two years were identified. Deep surgical site infection was defined as any infection requiring surgical intervention.

RESULTS

Forty-two patients (11.1%; twenty-five males and seventeen females) developed at least one deep surgical site infection. The mean age at the initial growing-rod surgery was 6.3 years (range, 0.6 to 13.2 years) and the mean duration of follow-up was 5.3 years (range, 2.2 to 14.3 years). The mean interval between the initial surgery and the first deep surgical site infection was 2.8 years (range, 0.02 to 7.9 years). Ten (2.6%) of the 379 patients developed deep surgical site infection before the first lengthening. Twenty-nine patients (7.7%) developed the infection during the course of the lengthening procedures, and three patients (0.8%) developed it after final fusion surgery. Thirty (13.6%) of 221 patients with stainless-steel implants had at least one deep surgical site infection compared with twelve (8%) of 150 patients with titanium implants (p < 0.05). (The remaining patients were treated with chromium-cobalt implants.) Twenty-two (52.4%) of the forty-two patients with deep surgical site infection underwent implant removal, which was complete in thirteen and partial in nine. Growing-rod treatment was terminated in two patients with partial removal and six patients with complete removal. An increased risk of deep surgical site infection was associated with stainless-steel implants (odds ratio [OR] = 5.7), non-ambulatory status (OR = 2.9), and the number of revisions before the development of deep surgical site infection (OR = 3.3). Neuromuscular etiology and non-ambulatory status increased the possibility of implant removal to treat infection (p < 0.05).

CONCLUSIONS

The prevalence of deep surgical site infection associated with growing-rod surgery is higher than that associated with standard pediatric spinal fusion (historical data). Non-ambulatory status, more revisions, and stainless-steel implants increased the risk of deep surgical site infection. After eight surgical procedures, the risk of deep surgical site infection increased to approximately 50%. When patients have implant removal, efforts should be made to retain one longitudinal implant to continue treatment.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

A comparison of the thoracolumbosacral orthoses and providence orthosis in the treatment of adolescent idiopathic scoliosis: results using the new SRS inclusion and assessment criteria for bracing studies

This is a retrospective cohort study comparing the effectiveness of the thoracolumbosacral orthosis (TLSO) and the Providence orthosis in the treatment of adolescent idiopathic scoliosis (AIS) using the new Scoliosis Research Society (SRS) Committee on Bracing and Nonoperative Management inclusion and assessment criteria for bracing studies. These new criteria will make future studies comparable and more valid and accurate.

METHODS

We have used a custom TLSO (duration, 22 hours/day) and the Providence orthosis (duration, 8-10 hours/night) to control progressive AIS curves. Only 83 of 160 patients met the new SRS inclusion criteria: age of 10 years and older at initiation of bracing; initial curve of 25 to 40 degrees; Risser sign 0 to 2; female; premenarcheal or less than 1 year past menarche; and no previous treatment. There were 48 patients in the TLSO group and 35 in the Providence group. The new SRS assessment criteria of effectiveness included the percentage of patients who had 5 degrees or less and 6 degrees or more of curve progression at maturity, the percentage of patients whose curve progressed beyond 45 degrees, the percentage of patients who had surgery recommended or undertaken, and a minimum of 2 years of follow-up beyond maturity in those patients who were thought to have been successfully treated. All patients are evaluated regardless of compliance (intent to treat).

RESULTS

There were no significant differences in age at brace initiation, initial primary curve magnitude, sex, or initial Risser sign between the 2 groups. In the TLSO group, only 7 patients (15%) did not progress (<or=5 degrees), whereas 41 patients (85%) progressed by 6 degrees or more, including the 30 patients whose curves exceeded 45 degrees. Thirty-eight patients (79%) required surgery. In the Providence group, 11 patients (31%) did not progress, whereas 24 patients (69%) progressed by 6 degrees or more, including 15 patients whose curves exceeded 45 degrees. Twenty-one patients (60%) required surgery. However, when the initial curve at initiation of bracing was 25 to 35 degrees, the results improved. Five (15%) of 34 patients in the TLSO group and 10 (42%) of 24 patients in the Providence group did not progress, whereas 29 patients (85%) and 14 patients (58%), respectively, progressed by 6 degrees or more, and 26 patients (76%) and 11 patients (46%), respectively, required surgery.

CONCLUSIONS

Using the new SRS bracing criteria, the Providence orthosis was more effective for avoiding surgery and preventing curve progression when the primary initial curves at bracing was 35 degrees or less. However, the overall success of orthotic management for AIS in both groups was inferior to previous studies. Our results raise the question of the effectiveness of orthotic management in AIS and support the need for a multicenter, randomized study using these new criteria.

Submuscular Isola rod with or without limited apical fusion in the management of severe spinal deformities in young children: preliminary report

STUDY DESIGN

Retrospective review of the results of submuscular rod placement with and without limited apical fusion for the treatment of severe spinal deformities in young children.

OBJECTIVES

To determine the success of this method for controlling severe deformities while allowing for spinal growth and to compare this method with previously reported results.

SUMMARY OF BACKGROUND DATA

A variety of methods for controlling scoliosis in young children have been reported, but complications including spontaneous fusion, loss of correction, instrumentation failure, and limited spinal growth are common.

METHODS

The cases of 29 young children with progressive scoliosis or kyphoscoliosis as a result of a variety of diagnoses treated with a submuscular Isola rod and a postoperative orthosis were retrospectively reviewed. Eleven patients also had a short anterior and posterior apical fusion or convex hemiepiphysiodesis to aid in correction and stabilization of their deformity. The remaining 18 patients had a submuscular rod only.

RESULTS

The mean age at surgery was 6.7 years (range, 1-11 years). The initial preoperative mean magnitude of the major curve was 66 degrees (range, 42-112 degrees ). After surgery this decreased to a mean of 38 degrees (range, 16-70 degrees ). The most recent radiographs demonstrated a mean 47 degrees curve (range, 28-79 degrees ). The mean number of lengthenings per patient has been two (range, 0-5). Nine patients have reached a suitable age and have been converted to a posterior spinal fusion and segmental spinal instrumentation. Nine complications have occurred in seven patients (24%). These included five hook displacements and three rod breakages. These were treated by hook reinsertion and rod exchange or sleeve and a repeat lengthening. There was one superficial infection treated medically.

CONCLUSION

This technique is useful in the management of severe spinal deformities in young children who have either failed, or have a contraindication to, orthotic management. Complications are relatively frequent but well tolerated.

Pelvic fractures in a pediatric level I trauma center

OBJECTIVES

Assess the characteristics associated with the risk of complications and mortality in children sustaining pelvic fractures.

SETTING

Urban university pediatric Level I trauma center in a large metropolitan community.

PATIENTS/PARTICIPANTS

Retrospective analysis of 57 consecutive children with 66 pelvic fractures seen between 1993 and 1999.

INTERVENTION

Fifty-two patients were treated nonoperatively, and five patients required operative stabilization (four acetabular fractures and one partial sacroiliac joint disruption).

MAIN OUTCOME MEASURE

Type and cause of pelvic fracture, type of management used, incidence of associated injuries, hemorrhage requiring transfusion, and mortality.

RESULTS

Hemorrhage directly related to the pelvic fracture occurred in only one patient (2%), whereas 11 other patients required transfusions associated with other body-area injuries. Three patients with pelvic fractures died (5%), but deaths were due to other body-area injuries.

CONCLUSIONS

Children with pediatric pelvic fractures require careful evaluation for other body-area injuries, as these are most likely to be related to hemorrhage or mortality.

Compartment syndrome in ipsilateral humerus and forearm fractures in children

Ipsilateral fractures of the humerus and forearm are uncommon injuries in children. The incidence of compartment syndrome in association with these fractures is controversial. The authors reviewed 978 consecutive children admitted to the hospital with upper extremity long bone fractures during a 13-year period. Forty-three children with ipsilateral fractures of the humerus and forearm were identified. Of 33 children with a supracondylar humerus fracture and ipsilateral forearm fracture, three children (7%) had compartment syndrome develop and required forearm fasciotomies. All three cases of compartment syndrome occurred among nine children with ipsilateral displaced extension supracondylar humerus and displaced forearm fractures; the incidence of compartment syndrome was 33% in this group. These findings suggest that children who sustain a displaced extension supracondylar humerus fracture and displaced forearm fracture are at significant risk for compartment syndrome. These children should be monitored closely during the perioperative period for signs and symptoms of increasing intracompartmental pressures in the forearm.

Avoidance of "Final" Surgical Fusion After Growing-Rod Treatment for Early-Onset Scoliosis

BACKGROUND

Definitive "final" surgical fusion is the common end point for growing-rod treatment of early-onset scoliosis. However, final surgical fusion may be unnecessary for patients who have reached skeletal maturity with good alignment. This study characterizes patients who completed growing-rod treatment but did not undergo final surgical fusion.

METHODS

Using a multicenter early-onset-scoliosis database, we identified 167 patients who received growing-rod treatment from 1995 through 2010, reached skeletal maturity, and had a minimum 2-year follow-up after their last surgery. Thirty patients did not undergo final surgical fusion (observation group) and were compared clinically and radiographically with 137 patients who did undergo final fusion (final surgical fusion group).

RESULTS

No significant differences were found between the groups with regard to the age at which treatment was initiated (p = 0.127), distribution of diagnoses (p = 0.84), or number of lengthening procedures (p = 0.692). In the observation group, 26 patients retained the growing rods and 4 patients had them removed at the last surgery because of infection. The mean primary curve correction at the end of treatment was 48% (from an initial mean magnitude of 79° to a mean final curve of 41°) in the observation group compared with 38% (from 74° to 46°) in the final surgical fusion group. There was no significant difference in final curve magnitude (41° in the observation group and 46° in the final surgical fusion group; p = 0.182). The mean increase in trunk height was 30.5% in the observation group and 35% in the final surgical fusion group. The final trunk height in the observation group was not significantly less than that in the final surgical fusion group (p = 0.142).

CONCLUSIONS

Because of progressive ankylosis, avoiding final surgical fusion at skeletal maturity is a viable option for patients treated with growing rods for all diagnostic subgroups of early-onset scoliosis who have satisfactory final alignment and trunk height, a minimal gain in length at the last distraction, and no clinical or radiographic evidence of implant-related problems.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Spinal exostoses: analysis of twelve cases and review of the literature

STUDY DESIGN

Retrospective review of spinal exostoses treated at our institution and literature review.

OBJECTIVES

Review of 12 cases of spinal exostoses treated at our institution compared with 165 cases of spinal exostoses reported in the literature.

SUMMARY OF BACKGROUND DATA

Spinal exostoses are uncommon. Most reports consist of 1 to 3 cases. The relationship between solitary exostoses and those associated with multiple hereditary exostoses (MHE), as well as the incidence of intraspinal and extraspinal location, symptoms presentation, and results of treatment are unclear.

METHODS

The medical records, operative reports, and diagnostic imaging of 12 patients with spinal exostoses treated at our institution between 1972 and 2002 were reviewed. The literature was reviewed using MEDLINE search of English literature and bibliographies of published manuscripts.

RESULTS

Solitary spinal exostoses were more common than those associated with MHE. Lesions were most common in the upper cervical spine and originated from the posterior elements. Patients with exostoses associated with MHE were significantly younger and had a higher incidence of symptoms consistent with neural structure compression than patients with solitary exostoses. Complete excision resulted in resolution of preoperative symptoms. Intralesional excision resulted in recurrence in all cases.

CONCLUSIONS

Spinal exostoses are more common than reported previously. Patients with MHE that present with back pain or neurological symptoms should produce a high index of suspicion. Evaluation should include both computed tomography and magnetic resonance imaging to define the origin of the exostosis and the presence of neural structure compression. Surgical excision should be preformed en bloc.

Predictive value of pelvic incidence in progression of spondylolisthesis

STUDY DESIGN

Retrospective analysis of pelvic incidence and other radiographic parameters as a predictor of progression of isthmic spondylolisthesis.

OBJECTIVES

To evaluate the predictive value of various radiographic parameters, including pelvic incidence, in determining the risk for progression of lumbosacral isthmic spondylolisthesis. SUMMARY OF BACKGROUND DATA Although pelvic incidence has recently been shown to be positively correlated to the severity of spondylolisthesis, it has not been confirmed as a predictor of spondylolisthetic progression.

MATERIALS AND METHODS

Thirty-six patients who have undergone primary posterior lumbosacral fusion for isthmic spondylolisthesis at our institution from 1977 to 2001 were retrospectively analyzed. There were 24 females and 12 males with a mean age of 21.3 +/- 2.0 years (range, 12 to 53 y). Twenty-two patients had high-grade (Meyerding class III, IV, V) and 14 patients had low-grade (Meyerding class I, II) spondylolisthesis, respectively. Factors evaluated included age, gender, neurologic deficits, reason for surgery, and documented evidence of progression. Slip percentage, high-grade or low-grade slip, slip angle, sacral inclination, sacral rounding, trapezoidal L5 vertebra, and pelvic incidence were measured from immediate preoperative standing lateral radiographs. These factors were statistically analyzed for risk of progression. Continuous variables were analyzed using one-way analysis of variance. Nominal variables were analyzed using chi2 test.

RESULTS

Pelvic incidence (P = 0.66) was not predictive of spondylolisthetic progression. Of the other radiographic measurements, slip percentage (P < 0.001), slip angle (P = 0.016), and high-grade spondylolisthesis (P < 0.0001) were highly predictive of progression. Interestingly, sacral inclination (P = 0.33) was not predictive of progression.

CONCLUSIONS

Pelvic incidence cannot adequately predict the probability of spondylolisthetic progression. Analysis of the other clinical and radiographic parameters revealed that slip percentage and high-grade spondylolisthesis remain the most positive predictors of progression.

Child and family functioning 6 and 12 months after a serious pediatric fracture

BACKGROUND

Previous findings indicate that pediatric fractures can have adverse consequences for child adjustment and family functioning immediately after injury. However, longer term effects of the fractures are unknown. The purposes of the present prospective study were to examine the child and family outcomes of pediatric traumatic fractures at 6 months and 1 year after injury, and to identify injury and treatment factors associated with these outcomes.

METHODS

We evaluated 57 children 6 to 12 years of age with traumatic fractures requiring hospitalization. Using standardized measures and parent interview, we obtained measures of pre- and postinjury child and family functioning.

RESULTS

Although outcomes were primarily positive at 1 year after injury, child functional limitations and family stress were observed up to 6 months after injury. Lower extremity fractures had a more negative impact on families across all three assessment points. Children with fracture interventions that involved prolonged immobilization had more functional limitations at 6 months than children who were ambulatory. Family burden was higher at 1 month for the immobilized children, but not at later follow-up.

CONCLUSION

Some children and families experience adverse effects during the year after a serious pediatric fracture, especially if sustained in a lower extremity. Fracture stabilization that allows for greater ambulation may offer some benefits related to functional outcomes and family impact.

CT during arterial portography: diagnostic pitfalls

Computed tomography (CT) during arterial portography (CTAP) is an important technique for evaluating the liver before hepatic tumor resection. With this technique, most tumors are of low attenuation compared with that of enhancing parenchyma. At times, low-attenuation lesions are encountered that represent perfusion abnormalities rather than tumor deposits. These perfusion abnormalities can be categorized as (a) those resulting from improper technique; (b) those extending from hilum to capsule (straight-line sign), with or without an obstructing mass; (c) perihilar and periligamentous abnormalities; (d) subcapsular defects (linear or wedge shaped); and (e) those seen with cirrhosis or regenerating nodules. Adjuvant use of delayed CT, magnetic resonance imaging, and intraoperative ultrasound aids in characterization of these nontumorous defects, thereby improving specificity. The authors conclude that when potential candidates are evaluated for hepatic tumor resection, knowledge of the existence of the various diagnostic pitfalls of CTAP and their imaging characteristics is imperative to avoid inadvertent false results.

Tibialis anterior tendon transfer after clubfoot surgery

Recurrent dynamic and structural deformities following clubfoot surgery are commonly due to residual muscle imbalance from a strong tibialis anterior muscle and weak antagonists. We asked whether subcutaneous tibialis anterior tendon transfer effectively treated recurrent deformities following clubfoot surgery and whether the presence of structural deformities influenced the outcome. The patients were divided into two groups: Group I, dynamic supination deformity only (51 patients, 76 feet); and Group II, dynamic supination with other structural deformities (44 patients, 61 feet). The mean age at surgery was 4.3 years (range, 1.4-10.7 years); the minimum followup was 2 years (mean, 5.2 years; range, 2-12.5 years) for both groups. The results were graded according to our subjective rating system of restoration of muscle balance: good, restoration of muscle balance; fair, partial restoration of muscle balance; and poor, no improvement. The two groups had similar outcomes: in Group I, there were 65 good (87%), 11 fair (13%), and no poor results and in Group II, there were 54 good (88%), seven fair (12%), and no poor results. Our data suggest the tibialis anterior tendon transfer restores muscle balance in recurrent clubfeet; we observed no recurrences. This transfer improves function and may prevent secondary osseous changes. We believe the muscle imbalance supports, at least in part, the neuromuscular etiological aspects of congenital clubfeet.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Acute psychosocial impact of pediatric orthopedic trauma with and without accompanying brain injuries

BACKGROUND

The acute psychosocial effects of orthopedic injuries on children and their families are poorly understood. Previous studies have relied on retrospective reports or failed to take into account accompanying brain injuries. The purpose of the present study was to examine prospectively the psychosocial impact of pediatric orthopedic traumatic fractures with and without accompanying brain injuries.

METHODS

Participants were 108 children 6 to 12 years old with orthopedic injuries requiring hospitalization: group 1 (n=80) had fractures only, group 2 (n=28) also had moderate or severe brain injuries. Using standardized measures and parent interviews, we obtained preinjury estimates of family functioning and child behavior problems and postinjury measures of parental distress, family stresses, and child behavior.

RESULTS

Parents reported significant clinical distress (35% in group 1, 57% in group 2), family burdens (group 2 > group 1), and child behavioral changes (41% in group 1, 89% in group 2). Multiple regression analyses indicated that preinjury family status and brain injuries predicted postinjury parental and family distress.

CONCLUSION

Pediatric orthopedic injuries have greater social effects on children with accompanying brain injuries and poorer preinjury family functioning.

A randomized prospective study of music therapy for reducing anxiety during cast room procedures

BACKGROUND

Cast room procedures, such as cast application and removal, pin removal, and suture removal can cause significant anxiety in young children. The use of music therapy in the cast room to decrease anxiety has not been previously reported.

METHODS

We performed a randomized, prospective study of soft lullaby music compared with no music in 69 children 10 years or younger undergoing cast room procedures. Heart rates (beats per minute) were recorded in the waiting room and cast room using a pulse oximeter.

RESULTS

A total of 28 children were randomized to music and 41 children to no music. The mean rise in heart rate between the waiting room and entering the cast room was -2.7 beats/min in the music group and 4.7 beats/min in the no music group (P = 0.001). The mean difference in heart rate between the waiting room and during the procedure was 15.3 beats/min in the music group and 22.5 beats/min in the no music group (P = 0.05). There were 7 patients in the no music group with heart rate increases of greater than 40 beats/min. No patient in the music group had an increase of this magnitude.

CONCLUSIONS

Playing soft music in the cast room is a simple and inexpensive option for decreasing anxiety in young children during cast room procedures.

LEVEL OF EVIDENCE

Randomized Clinical Trial, Level II.