Factors affecting the outcome in appearance of AIS surgery in terms of the minimal clinically important difference

Evaluating the Use of PROMs in Paediatric Orthopaedic Registries

Patient-reported outcome measures (PROMs) provide structured information on the patient's health experience and facilitate shared clinical decision-making. Registries that collect PROMs generate essential information about the clinical course and efficacy of interventions. Whilst PROMs are increasingly being used in adult orthopaedic registries, their use in paediatric orthopaedic registries is not well known. The purpose of this systematic review was to identify the frequency and scope of registries that collect PROMs in paediatric orthopaedic patient groups. In July 2023, six databases were systematically searched to identify studies that collected PROMs using a registry amongst patients aged under 18 years with orthopaedic diagnoses. Of 3190 identified articles, 128 unique registries were identified. Three were exclusively paediatric, 27 were majority paediatric, and the remainder included a minority of paediatric patients. One hundred and twenty-eight registries collected 72 different PROMs, and 58% of these PROMs were not validated for a paediatric population. The largest group of orthopaedic registries collected PROMs on knee ligament injuries (21%). There are few reported dedicated orthopaedic registries collecting PROMs in paediatric populations. The majority of PROMs collected amongst paediatric populations by orthopaedic registries are not validated for patients under the age of 18 years. The use of non-validated PROMs by registries greatly impedes their utility and impact. Dedicated orthopaedic registries collecting paediatric-validated PROMs are needed to increase health knowledge, improve decision-making between patients and healthcare providers, and optimise orthopaedic management.

Cervical and thoracic/lumbar motion and muscle strength in surgically treated adolescent idiopathic scoliosis patients

BACKGROUND

To date, only one study assessed the spinal mobility and muscle strength of patients who were treated either with fusion or brace treatment.

OBJECTIVE

The aim of this retrospective study was to evaluate the range of motion (ROM) and strength of the cervical and thoracic/lumbar spine in patients who underwent spinal fusion for the treatment of adolescent idiopathic scoliosis (AIS) in comparison to healthy individuals.

METHODS

Patients (n= 28) who were treated surgically for AIS were included in the study. An age and gender matched control group (n= 22) was included that consisted of healthy individuals. DAVID® Lumbar/Thoracic Extension, Lumbar/Thoracic Rotation, and Cervical Extension/Lateral Flexion devices were used to measure cervical and lumbar/thoracic ROM as well as muscle strength.

RESULTS

Significant differences were observed between groups in all ROM measurements except thoracic/lumbar sagittal flexion ROM measurement (p= 0.198). There were significant differences between groups in terms of muscle strength, except thoracic lumbar left rotation strength (p= 0.081).

CONCLUSIONS

The findings of the current study demonstrated that cervical and thoracic/lumbar range of motion, as well as muscle strength, were significantly decreased in surgically treated adolescent idiopathic scoliosis patients compared to healthy counterparts. However, trunk (thoracic/lumbar) flexion range of motion and trunk left rotation muscle strength were not significantly different.

Subjective perception of spinal deformity after selective versus non-selective fusion of Lenke 1C curves

PURPOSE

To assess the self-image perception and the Quality-of-Life (QoL) in female adolescents, with Lenke 1C scoliosis curves, treated with selective versus non-selective posterior spinal instrumentation and fusion (PSF).

METHODS

Patients undergoing PSF for idiopathic adolescent scoliosis (AIS) were recruited and divided into two groups: patients managed with selective thoracic fusion (STF) were included in Group A, whereas patients treated with non-selective fusion (N-STF) in Group B. Each patient completed the Italian version of the Scoliosis Research Society-22R questionnaire (SRS-22R), the Quality-of-Life Profile for Spinal Deformities questionnaire (QLPSD) and the Spinal Appearance Questionnaire (SAQ), before surgery and at 24-month follow-up.

RESULTS

One hundred and fifty seven female patients (mean age 16.38) were included in this study. 80 patients underwent STF, while 77 patients received N-STF. At 24-month follow-up, patients managed with N-STF showed better SRS-22R self-image mean score (p = .012), SRS-22R satisfaction mean score (p = .033), QLPSD body image mean score (p = .005), but worse SRS-22 function mean score (p = .006) and QLPSD back flexibility mean score (p = .007), compared with patients who underwent STF. In terms of self-image perception, patients undergoing STF showed significantly worse SAQ total mean score (p = .002), SAQ appearance mean score (p = .001) and SAQ expectation (p = .001). We found a significant correlation between SAQ appearance mean score and SRS-22R self-image (R = - 0.721), SRS-22 mental health (R = - 0.8), QLPSD psychosocial functioning (R = 0.7) and QLPSD back flexibility (R = 0.8).

CONCLUSION

Although the STF of Lenke 1C curves provides better functional outcomes, in the present study, female patients receiving STF revealed a worse perceived body image, compared with patients treated with N-STF, at 24-month follow-up. Particular attention should be addressed to the preoperative patient's mental health and body image perception, when choosing between STF and N-STF.

The use of statistical modelling to identify important parameters for the shape of the torso following surgery for adolescent idiopathic scoliosis

The surgical strategy in adolescent idiopathic scoliosis (AIS) aims to recreate the symmetry of the torso. This requires the minimisation of both the size of the scoliosis and the angulation between the sides of the torso, along with the recreation of a normal thoracic kyphosis. This study uses predictive modelling to identify the significance of the value of the pre-operative parameters, and the change in the magnitude of the parameters as a result of an operation on the shape of the torso using the 'most prominent points'; two areas of maximum prominence on either side of the spine with x, y and z coordinates. The pre-operative values, and the change in magnitude between the pre and post-operative values, for scoliosis, kyphosis and skin angulation from a group of Lenke 1 convex to the right AIS were analysed with measures collected using Integrated Spine Imaging System 2 surface topography and compared with those without visible spinal deformity. The models best explained the z coordinate and least well explained the x coordinate, although there was a contribution to all of the models that remained unexplained. The parameters that affected the position of the coordinates in the model differed between the models. This confirms that surgically altering the shape of the spine and torso whilst correcting an AIS does not lead to a symmetrical torso. There are as yet, undefined factors which contribute to the shape of the torso and which if identified and corrected surgically would lead to greater symmetry post-operatively.

Predictors of spontaneous lumbar curve correction in thoracic-only fusions: 3D analysis in AIS

PURPOSE

To evaluate how 3D parameters of the instrumented thoracic spine relate to the uninstrumented lumbar spine following thoracic-only fusion (TOF) for adolescent idiopathic scoliosis (AIS) and determine the factors predictive of lumbar correction.

METHODS

A multi-center retrospective review was conducted of AIS patients with Lenke 1-4 B or C curves undergoing fusion of their thoracic spine only with minimum 2-year follow-up and 3D spine reconstructions from biplanar radiography. Pre-operative to 2-year post-operative differences were evaluated. Pearson's correlations were used to identify 3D coronal, sagittal and axial relationships at 2 years post-operative. Multivariate linear regression was used to identify variables most predictive of lumbar curve correction.

RESULTS

Eighty-four AIS patients met inclusion (54 B modifiers, 30 C modifiers). Average pre-operative thoracic and lumbar curves were 54 ± 9° and 41 ± 7° and corrected to 19 ± 7° and 21 ± 7°, respectively. 3D T5-T12 thoracic kyphosis increased from 6 ± 13° to 26 ± 8°. Thoracic and lumbar apical rotation decreased from - 14 ± 6° to -5 ± 6° and 13 ± 5° to 11 ± 6°, respectively. Thoracic curve correction correlated with lumbar curve correction (r = 0.67, p = 0.001) and decreased LIV tilt correlated with smaller residual lumbar curve magnitude (r = 0.63, p < 0.001). Increasing 3D kyphosis of the instrumented segment correlated with increased percentage lumbar curve correction (r = 0.29, p = 0.009). Multivariate linear regression showed LIV tilt and thoracic curve magnitude as the most predictive variables of post-operative residual lumbar curve magnitude, and percent correction of the thoracic curve and change in 3D instrumented kyphosis as most predictive of percent correction of the lumbar curve.

CONCLUSIONS

Analysis of 3D data highlights several considerations for AIS patients undergoing TOF. Maximizing thoracic curve correction, leveling the LIV, and to a lesser extent, restoring kyphosis in the instrumented segment are the factors most likely to result in greater correction of the instrumented lumbar curve following thoracic-only fusions in Lenke 1-4 B and C curves.

Accurate prediction of spontaneous lumbar curve correction following posterior selective thoracic fusion in adolescent idiopathic scoliosis using logistic regression models and clinical rationale

INTRODUCTION

Accurate prediction of spontaneous lumbar curve correction (SLCC) after selective thoracic fusion (STF) remains difficult. This study sought to improve prediction accuracy of SLCC. The hypothesis was preoperative and intraoperative variables could predict SLCC < 20°.

METHODS

A multicenter observational prospective analysis was conducted to determine predictors of SLCC in AIS patients that had posterior STF. Curve types included major thoracic curves (Lenke 1, 3-4).The primary outcome variable was to establish prediction models, and a postoperative lumbar curve (LC) ≤ 20° was defined as the target variable. Multivariate logistic regression models were established to study the relationship between selected variables and a LC ≤ 20° versus a LC > 20° at ≥ 2-year follow-up. Single and dual thresholds models in perspective of clinical rationales were applied to find models with the highest positive/negative predictive values (PPV/NPV). The secondary outcome measure was SRS scores at ≥ 2-year follow-up.

RESULTS

410 patients were included. At ≥ 2-year follow-up 282 patients had LC ≤ 20°. These patients had better SRS-22 scores than those with LC > 20° (P = 0.02). The postoperative LC and LC ≤ 20° were predicted by preoperative LC and LC-bending Cobb angle (P < 0.01, r = 0.4-0.6). Logistic regression models could be established to identify patients at risk for failing the target LC ≤ 20°.For preoperative LC and LC-bending, the prediction model achieved a NPV/PPV of 80%/72%. If the postoperative main thoracic curve is combined with the preoperative LC and a gray area for difficult decisions was allowed, model accuracy could even be improved (NPV/PPV = 96%/81%).

CONCLUSION

An accurate prediction model for postoperative SLCC was established based on a large analysis of prospective STF cases. These models can support prediction and understanding of postoperative SLCC aiding in surgical decision making when contemplating a selective thoracic fusion. These slides can be retrieved under Electronic Supplementary Material.

Adolescent idiopathic scoliosis: risk factors for complications and the effect of hospital volume on outcomes

OBJECTIVE

Adolescent idiopathic scoliosis (AIS) is the most common form of scoliosis. Limited literature exists defining risk factors associated with outcomes during initial hospitalization in these patients. In this study, the authors investigated patient demographics, clinical and hospital characteristics impacting short-term outcomes, and costs in adolescent patients undergoing surgical deformity correction for idiopathic scoliosis. Additionally, the authors elucidate the impact of hospital surgical volume on outcomes for these patients.

METHODS

Using the National Inpatient Sample database and appropriate International Classification of Diseases, 9th Revision codes, the authors identified adolescent patients (10–19 years of age) undergoing surgical deformity correction for idiopathic scoliosis during 2001–2014. For national estimates, appropriate weights provided by the Agency of Healthcare Research and Quality were used. Multivariable regression techniques were employed to assess the association of risk factors with discharge disposition, postsurgical neurological complications, length of hospital stay, and hospitalization costs.

RESULTS

Overall, 75,106 adolescent patients underwent surgical deformity correction. The rates of postsurgical complications were estimated at 0.9% for neurological issues, 2.8% for respiratory complications, 0.8% for cardiac complications, 0.4% for infections, 2.7% for gastrointestinal complications, 0.1% for venous thromboembolic events, and 0.1% for acute renal failure. Overall, patients stayed at the hospital for an average of 5.72 days (median 5 days) and on average incurred hospitalization costs estimated at $54,997 (median $47,909). As compared with patients at low-volume centers (≤ 50 operations/year), those undergoing surgical deformity correction at high-volume centers (> 50/year) had a significantly lower likelihood of an unfavorable discharge (discharge to rehabilitation) (OR 1.16, 95% CI 1.03–1.30, p = 0.016) and incurred lower costs (mean $33,462 vs $56,436, p < 0.001) but had a longer duration of stay (mean 6 vs 5.65 days, p = 0.002). In terms of neurological complications, no significant differences in the odds ratios were noted between high- and low-volume centers (OR 1.23, 95% CI 0.97–1.55, p = 0.091).

CONCLUSIONS

This study provides insight into the clinical characteristics of AIS patients and their postoperative outcomes following deformity correction as they relate to hospital volume. It provides information regarding independent risk factors for unfavorable discharge and neurological complications following surgery for AIS. The proposed estimates could be used as an adjunct to clinical judgment in presurgical planning, risk stratification, and cost containment.