Spinal deformity correction in Marfan syndrome versus adolescent idiopathic scoliosis: learning from the differences

Instrumentation of hypoplastic pedicles with patient-specific guides

PURPOSE

Hypoplastic pedicles of the thoracolumbar spine (<5 mm diameter) are often found in syndromic deformities of the spine and pose a challenge in pedicle screw instrumentation. 3D-printed patient-specific guides might help overcome anatomical difficulties when instrumenting pedicles with screws, thereby reducing the necessity for less effective fixation methods such as hooks or sublaminar wires. In this study, the surgical feasibility and clinical outcome of patients with hypoplastic pedicles following pedicle screw instrumentation with 3D-printed patient-specific guides were assessed.

METHODS

Hypoplastic pedicles were identified on preoperative computed tomography (CT) scans in six patients undergoing posterior spinal fusion surgery between 2017 and 2020. Based on these preoperative CT scans, patient-specific guides were produced to help with screw instrumentation of these thin pedicles. Postoperatively, pedicle-screw-related complications or revisions were analyzed.

RESULTS

93/105 (88.6%) pedicle screws placed with patient-specific guides were instrumented. 62/93 (66.7%) of these instrumented pedicles were defined as hypoplastic with a mean width of 3.07 mm (SD  ±0.98 mm, 95% CI [2.82-3.32]). Overall, 6 complications in the 62 hypoplastic pedicles (9.7%) were observed and included intraoperatively managed 4 cerebrospinal fluid leaks, 1 pneumothorax and 1 delayed revision due to 2 lumbar screws (2/62, 3.3%) impinging the L3 nerve root causing a painful radiculopathy. The mean follow-up time was 26.7 (SD  ±11.7) months. Complications were only noted when the pedicle-width-to-screw-diameter ratio measured less than 0.62.

CONCLUSION

Patient-specific 3D-printed guides can aid in challenging instrumentation of hypoplastic pedicles in the thoracolumbar spine, especially if the pedicle-width-to-screw-diameter ratio is greater than 0.62.

Paediatric syndromic scoliosis: proceedings of the half-day course at the 57th annual meeting of the Scoliosis Research Society

There are some syndromes that present with unique manifestations pertaining to the spinal column. A good working understanding of these common syndromes is useful for the spinal deformity surgeons and related healthcare providers. This review attempts to encompass these unique features and discuss them in three broad groups: hypermobility syndromes, muscle pathology-related syndromes, and syndromes related to poor bone quality. This review explores the features of these syndromes underpinning the aspects of surgical and medical management. This review represents the proceedings of the Paediatric Half-Day Course at the 57th Annual Meeting of the Scoliosis Research Society.

Opioid Utilization After Scoliosis Surgery is Greater in Marfan Syndrome Than Adolescent Idiopathic Scoliosis

STUDY DESIGN

Retrospective matched case cohort.

OBJECTIVE

Compare postoperative opioid utilization and prescribing behaviors between patients with Marfan syndrome (MFS) and adolescent idiopathic scoliosis (AIS) after posterior spinal fusion (PSF).

SUMMARY OF BACKGROUND DATA

Opioids are an essential component of pain management after PSF. However, due to the potential for opioid use disorder and dependence, current analgesic strategies aim to minimize their use, especially in younger patients. Limited information exists on opioid utilization after PSF for syndromic scoliosis.

PATIENTS AND METHODS

Twenty adolescents undergoing PSF with MFS were matched with patients with AIS (ratio, 1:2) by age, sex, degree of spinal deformity, and the number of vertebral levels fused. Inpatient and outpatient pharmaceutical data were reviewed for the quantity and duration of opioid and adjunct medications. Prescriptions were converted to morphine milligram equivalents (MMEs) using CDC's standard conversion factor.

RESULTS

Compared with patients with AIS, patients with MFS had significantly greater total inpatient MME use (4.9 vs . 2.1 mg/kg, P ≤ 0.001) and longer duration of intravenous patient-controlled anesthesia (3.4 vs . 2.5 d, P = 0.001). Within the first 2 postop days, MFS patients had more patient-controlled anesthesia boluses (91 vs . 52 boluses, P = 0.01) despite similar pain scores and greater use of adjunct medications. After accounting for prior opioid use, MFS was the only significant predictor of requesting an opioid prescription after discharge (odds ratio: 4.1, 95% CI: 1.1-14.9, P = 0.03). Patients with MFS were also more likely to be discharged with a more potent prescription (1.0 vs . 0.72 MME per day/kg, P ≤ 0.001) and to receive a longer-duration prescription (13 vs . 8 d, P = 0.005) with a greater MME/kg (11.6 vs . 5.6 mg/kg, P ≤ 0.001) as outpatients.

CONCLUSION

Despite a similar intervention, patients with MFS and AIS seem to differ in their postoperative opioid usage after PSF, presenting an opportunity for further research to assist clinicians in better anticipating the analgesic needs of individual patients, particularly in light of the ongoing opioid epidemic.

Comparison of baseline characteristics and postoperative complications in neuromuscular, syndromic and congenital scoliosis

Nonidiopathic scoliosis encompasses a group of diagnoses, including neuromuscular scoliosis, syndromic scoliosis and congenital scoliosis. The objective of this study was to compare the preoperative and postoperative clinical differences in pediatric nonidiopathic scoliosis patients with neuromuscular scoliosis vs. syndromic scoliosis/congenital scoliosis. This is a single-center retrospective review of all pediatric patients undergoing spinal instrumentation for nonidiopathic scoliosis during a 5-year period. Neuromuscular scoliosis patients ( n  = 144), syndromic scoliosis patients ( n  = 44) and congenital scoliosis patients ( n  = 52) were compared. Demographics, patient characteristics and outcomes were compared. Neuromuscular scoliosis patients had lower BMI z-scores and were more likely to have pulmonary disease, technology dependence and seizure disorder. Additionally, neuromuscular scoliosis patients underwent bigger procedures with more levels fused and a higher rate of pelvis fixation. By direct comparison, neuromuscular scoliosis patients tended to have more complications including deep surgical site infections, readmission in 30 days, return to operating room in 90 days and emergency care visits in 90 days. When controlling for the differences in their preexisting conditions and surgical procedure, we found that pelvic fixation was a major confounding factor, whereas the others had no effect. We further subanalyzed cerebral palsy patients and found this group to exhibit no difference in complications compared to other neuromuscular scoliosis subtypes. Neuromuscular scoliosis patients have different characteristics and subsequent postoperative complications than those with syndromic scoliosis and congenital scoliosis. The difference in complication profile is mainly due to differences in surgical procedure and a higher rate of pelvic fixation. This should be considered when planning nonidiopathic scoliosis surgery among multidisciplinary teams.

Thoracolumbar Scoliosis in Pediatric Patients With Loeys-Dietz Syndrome: A Case Series

Background Loeys-Dietz syndrome (LDS) is a genetic connective tissue disorder that predominantly affects cardiovascular, skeletal, and craniofacial structures. Associated thoracolumbar scoliosis in LDS can be challenging to manage, though other etiologies of pediatric scoliosis have better-defined management guidelines. We examined our institutional experience regarding the treatment of pediatric patients with LDS and scoliosis. Methodology In this retrospective study, all patients seen at our pediatric tertiary care center from 2004 through 2018 with a diagnosis of LDS were reviewed, and those with radiographic diagnoses of scoliosis (full-length scoliosis X-rays) were included. Demographic, clinical, and radiographic parameters were collected, and management strategies were reported. Results A total of 39 LDS patients whose ages ranged between seven and 13 years were identified. A total of nine patients were radiographically diagnosed with scoliosis, but three patients were excluded due to incomplete medical records, leaving six patients. The median age at scoliosis diagnosis was 11.5 years, with a median follow-up of 51 months. Two patients were successfully managed with observation (average initial Cobb angle (CA): 14°, average final CA: 20.5°). Two were braced, one successfully (initial CA: 15°, final CA: 30°) and one with a progressive disease requiring surgery (initial CA: 40°, final CA: 58°). Of the two who were offered surgical correction, one underwent surgery with a durable correction of spinal deformity (CA: 33° to 19°). One patient underwent a recent correction of aortic root dilatation and was not a candidate for scoliosis surgery. Conclusions Principles of adolescent idiopathic scoliosis management such as bracing for CA of 20-50° and surgery for CA of >50° can be applied to LDS patients with good outcomes. This augments our understanding of the treatment algorithm for pediatric patients with LDS.

Impact of pathogenic FBN1 variant types on the development of severe scoliosis in patients with Marfan syndrome

BACKGROUND

Among the several musculoskeletal manifestations in patients with Marfan syndrome, spinal deformity causes pain and respiratory impairment and is a great hindrance to patients' daily activities. The present study elucidates the genetic risk factors for the development of severe scoliosis in patients with Marfan syndrome.

METHODS

We retrospectively evaluated 278 patients with pathogenic or likely pathogenic FBN1 variants. The patients were divided into those with (n=57) or without (n=221) severe scoliosis. Severe scoliosis was defined as (1) patients undergoing surgery before 50 years of age or (2) patients with a Cobb angle exceeding 50° before 50 years of age. The variants were classified as protein-truncating variants (PTVs), which included variants creating premature termination codons and inframe exon-skipping, or non-PTVs, based on their location and predicted amino acid alterations, and the effect of the FBN1 genotype on the development of severe scoliosis was examined. The impact of location of FBN1 variants on the development of severe scoliosis was also investigated.

RESULTS

Univariate and multivariate analyses revealed that female sex, PTVs of FBN1 and variants in the neonatal region (exons 25-33) were all independent significant predictive factors for the development of severe scoliosis. Furthermore, these factors were identified as predictors of progression of existing scoliosis into severe state.

CONCLUSIONS

We elucidated the genetic risk factors for the development of severe scoliosis in patients with Marfan syndrome. Patients harbouring pathogenic FBN1 variants with these genetic risk factors should be monitored carefully for scoliosis progression.

Outcomes of Posterior Spinal Fusion in Pediatric Patients with Down Syndrome

BACKGROUND

Trisomy 21 or Down syndrome is associated with multiple orthopaedic manifestations. Although cervical instability is the most common spinal condition associated with Down syndrome, the prevalence of scoliosis has been estimated at 4.8% to 8.7%. Very few prior studies have documented the role of spinal fusion in this population, and all have included ≤10 patients.

METHODS

An institutional review board-approved multicenter retrospective analysis of patients with Down syndrome treated with spinal fusion between January 2009 and December 2019 was performed by cross-referencing Current Procedural Terminology (CPT) and International Classification of Diseases, Ninth and Tenth Revisions (ICD-9 and ICD-10) codes. Patients were followed for ≥2 years, with a mean follow-up of 3.77 years. Clinical and radiographic outcomes were collected, and complications were documented using the Clavien-Dindo-Sink (CDS) classification.

RESULTS

A total of 23 patients were included: 96% had ≥1 medical comorbidities, including 16 (70%) with congenital heart disease, of whom 88% had previous cardiac surgery, and 10 (44%) with thyroid disorders. All 23 patients underwent posterior spinal fusion. The mean estimated blood loss was 617 ± 459 mL, the mean length of the surgical procedure was 290 ± 92.7 minutes, and the mean length of hospital stay was 6.03 ± 2.91 days. The major Cobb angle measured 61.7° ± 17.6°, which corrected to 19.4° ± 14.8° (68.6% correction; p < 0.001), with well-maintained correction at 2 years of 22.0° ± 10.3° (64.3% correction; p = 0.158). Thirteen (57%) of 23 patients had a change in curve of >5°. There were no intraoperative complications; however, 12 patients (52%) sustained postoperative complications (e.g., need for reoperation, implant failure, and pulmonary complications), including 6 patients with CDS type 3 or 4 (e.g., wound dehiscence, late superficial abscess, pleural effusion, pseudarthrosis, and readmission for hypoxia). Four patients (17%) required a revision surgical procedure. One patient (4%) required an unplanned intensive care unit admission.

CONCLUSIONS

Although instrumented spinal fusion can effectively correct spinal deformity in these patients, complications are more frequent than in children with adolescent idiopathic scoliosis, with over half of patients sustaining a complication.

LEVEL OF EVIDENCE

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

Surgical outcome of scoliosis in patients with Marfan syndrome

PURPOSE

To evaluate clinical and radiographic outcomes after surgical scoliosis correction and posterior instrumented fusion in SMF patients.

METHODS

A single-center medical database was reviewed to identify MF patients who presented with scoliosis from 2000 to 2015. Patients who underwent spinal fusion surgery were included. Demographic, operative and clinical data were reviewed, and the preoperative, postoperative, and latest follow-up radiographic parameters were compared.

RESULTS

Twelve patients were identified (2 males, 10 females) with an average age at surgery of 14.4 ± 2.6 years. Comorbidities were found in 84.6%. Most patients (90.9%) presented with a right thoracic curve. The average preoperative Cobb angle was 75.6 ± 15.5 degrees. Posterior instrumented spinal fusion was performed in all patients (1 hook/pedicular screw and 11 pedicle screws only). The average follow-up period was 6.8 ± 3.1 years. The mean postoperative Cobb angle after surgery and at the final follow-up was 33.4 ± 18.0 degrees and 35.5 ± 18.4 degrees, respectively. There was a statistically significant difference among the preoperative and postoperative Cobb angles (p < 0.001), but no significant difference among the sagittal angles. Two perioperative complications including superficial wound infection and broken rods were observed.

CONCLUSIONS

Posterior scoliosis correction and instrumented spinal fusion resulted in a satisfactory outcome in MF patients. Perioperative complications are not uncommon; however, no neurological complication or spinal decompensation was observed in this study.

LEVEL OF EVIDENCE

IV.

Intraoperative hypotension during surgical treatment for Marfan syndrome scoliosis in children

PURPOSE

To explore the occurrence and risk factors of intraoperative hypotension during children's Marfan syndrome scoliosis surgery and summarize the associated hemodynamic features and handle measures.

METHODS

Twenty-two Marfan syndrome scoliosis patients who underwent spinal surgery at Beijing Children's Hospital were retrospectively reviewed between January 2001 and January 2020. Intraoperative hypotension is defined as the minimum mean arterial pressure ≤ 60 mm Hg. The patients were divided into the hypotension group and the control group. Clinical, radiographic, and operative data were compared between the two groups. The risk factors, hemodynamic features, and handle measures for intraoperative hypotension in Marfan syndrome scoliosis surgery were analyzed and summarized.

RESULTS

Twenty-two patients were included in the study, with a mean age of 11.4 years at initial surgery. The follow-up period ranged from 24 to 152 months. Intraoperative hypotension occurred in 14 cases, with an incidence of 63.6%. The proportion of pulmonary dysfunction in the hypotension group was higher than in the control group (100.0% vs 50.0%, p < 0.05). The spinal flexibility was significantly lower in the hypotension group (28.3% ± 14.2% vs 46.5% ± 11.5%, p < 0.05). Fourteen patients with intraoperative hypotension had decreased intraoperative systolic blood pressure 21.0%-50.0% compared with baseline. One patient had a transient decrease in the muscle strength of the lower limbs. No complications were observed during the follow-up.

CONCLUSION

The incidence of intraoperative hypotension in Marfan syndrome scoliosis children who underwent surgery was 63.6%. The risk factors included preoperative pulmonary dysfunction and poor spinal flexibility. Comprehensive preoperative evaluation and effective hemodynamic handling measures should be undertaken to prevent further complications in children with Marfan syndrome scoliosis.

The Musculoskeletal Manifestations of Marfan Syndrome: Diagnosis, Impact, and Management

Purpose of Review

Marfan syndrome (MFS) is an autosomal dominant heritable disorder of fibrillin-1 (FBN1) with predominantly ocular, cardiovascular, and musculoskeletal manifestations that has a population prevalence of approximately 1 in 5–10,000 (Chiu et al. Mayo Clin Proc. 89(1):34–42, 146, Dietz 3, Loeys et al. J Med Genet. 47(7):476–85, 4).

Recent Findings

The vascular complications of MFS still pose the greatest threat, but effective management options, such as regular cardiac monitoring and elective surgical intervention, have reduced the risk of life-threatening cardiovascular events, such as aortic dissection. Although cardiovascular morbidity and mortality remains high, these improvements in cardiovascular management have extended the life expectancy of those with MFS by perhaps 30–50 years from an estimated mean of 32 years in 1972 (Dietz 3, Gott et al. Eur J Cardio-thoracic Surg. 10(3):149–58, 147, Murdoch et al. N Engl J Med. 286(15):804–8, 148). The musculoskeletal manifestations of MFS, which to date have received less attention, can also have a significant impact on the quality of life and are likely to become more important as the age of the Marfan syndrome population increases (Hasan et al. Int J Clin Pract. 61(8):1308–1320, 127). In addition, musculoskeletal manifestations are often critically important in the diagnosis of MFS.

Summary

Here, we review the main clinically relevant and diagnostically useful musculoskeletal features of MFS, which together contribute to the “systemic features score” (referred to hereafter as systemic score), part of the revised Ghent nosology for MFS. We discuss current treatment strategies and highlight the need for a multidisciplinary approach to diagnosis and management. Finally, we review new pharmacological approaches that may be disease modifying and could help to improve the outcome for individuals with this syndrome.

Surgical Evaluation and Management of Spinal Pathology in Patients with Connective Tissue Disorders

Connective tissue disorders represent a varied spectrum of syndromes that have important implications for the spine deformity surgeon. Spine surgeons must be aware of these diverse and global manifestations of disease because they have significant impact on perioperative and postoperative outcomes.

Interdisziplinäre Betreuung von Menschen mit Marfan-Syndrom – Pharmakologie, Schwangerschaft, Auge, Skelett und organisatorische Aspekte

Im ersten Teil des vorliegenden Beitrags wurde im Detail auf die Genetik, Diagnose, Differenzialdiagnose, die diagnostische Bildgebung, Follow-up, die kardiovaskulären Probleme sowie die Manifestation an Aorta und den großen Gefäßen bei Patienten mit dem Marfan-Syndrom (MFS) eingegangen. In diesem zweiten Teil werden die medikamentöse Therapie des MFS, seine Bedeutung im Zusammenhang mit einer Schwangerschaft, die Beteiligung von Augen und Wirbelsäule bei MFS-Patienten sowie die organisatorischen Aspekte einer Marfan-Sprechstunde erläutert. Das MFS ist mit einer Prävalenz von etwa 1–2:10.000 die häufigste hereditäre Bindegewebserkrankung mit vaskulärer Komponente. Ursache sind Mutationen im Gen, das für das extrazelluläre Matrixprotein Fibrillin‑1 kodiert. Die Erkrankung wird autosomal-dominant vererbt. Es handelt sich um eine Multisystemerkrankung mit Beteiligung der Aorta, der Mitralklappe, Augen- und Skelettveränderungen. Die Augen- und/oder die Wirbelsäulenbeteiligung sind nicht zu unterschätzen, da sowohl die Skoliose als auch die Linsendislokation etwa 60 % der Patienten mit MFS betreffen. Bis anhin konnte kein Wirkstoff einen klaren Vorteil hinsichtlich klinischer Ereignisse in MFS-Patienten zeigen. Es besteht jedoch der allgemeine Konsens, Patienten mit MFS einen β‑Rezeptoren- oder Angiotensinrezeptorblocker isoliert oder als Kombinationstherapie zu verabreichen. Bei bestehendem Kinderwunsch muss ein besonderes Augenmerk auf die Planung der Schwangerschaft gelegt werden. Im Fall eines Aortenwurzeldurchmessers > 4–4,5 cm empfiehlt sich, entweder einen prophylaktischen Aortenwurzelersatz zu erwägen oder von einer Schwangerschaft abzuraten. Eine strukturierte Langzeitbetreuung ist für Patienten mit MFS essenziell.

Predictive Physical Manifestations for Progression of Scoliosis in Marfan Syndrome

STUDY DESIGN

A retrospective study of the prospective cohort.

OBJECTIVE

To demonstrate the accurate distribution of the severity of scoliosis in patients with Marfan syndrome, and to identify the predictive physical features for progression of scoliosis in Marfan syndrome.

SUMMARY OF BACKGROUND DATA

To date, no study has unveiled the risk factors for the progression of scoliosis in Marfan syndrome.

METHODS

We retrospectively obtained data from a prospective cohort of the Marfan syndrome clinic at our institute. We enrolled patients whose whole spine radiographs in the standing position were evaluated at the age of 15 or above, from January 2014 to March 2020. The collected variables were physical manifestations defined as in the systemic score of the revised Ghent nosology. We classified the degree of scoliosis into four categories: "not apparent," "mild" (10° ≤ Cobb < 25°), "moderate" (25° ≤ Cobb < 40°), and "severe" (40° ≤ Cobb or surgery conducted). To identify the risk factors for progression of scoliosis in Marfan syndrome, we conducted univariate and multivariate association analyses between severe scoliosis and each physical manifestation.

RESULTS

We identified 131 eligible patients (61 men and 70 women) with a mean age of 31.2 years. Scoliosis with a Cobb angle of ≥10° was identified in 116 patients (88.5%). Moderate scoliosis was identified in 33 patients (25.2%) and severe scoliosis in 53 patients (40.5%). The prevalence of each physical manifestation was equivalent to that reported in previous studies. Multivariate logistic regression analysis revealed that female sex (odds ratio, 3.27) and positive wrist sign (4.45) were predictive factors for progression of scoliosis into severe state in patients with Marfan syndrome.

CONCLUSIONS

The present study demonstrated the accurate distribution of the severity of scoliosis and identified the predictive factors for progression of scoliosis in patients with Marfan syndrome.Level of Evidence: 3.

Iatrogenic injury to long thoracic nerve following thoracotomy for right thoracic scoliosis in Marfan syndrome: a case report

Background

Patients with Marfan syndrome commonly require spinal deformity surgery. The purpose of this case report is to present a rare thoracotomy complication. We present the management of such a patient.

Case summary

In a known case of Marfan syndrome, an 18-year-old Persian man was admitted to our hospital with scoliosis. The patient underwent radiological examinations, and thoracic scoliosis of 70° was diagnosed. A right thoracotomy for anterior spinal fusion from the sixth rib and posterior spinal fusion were performed successfully. Two months later, he was readmitted because of winging of the right scapula due to serratus anterior palsy. Electromyography and nerve conduction velocity confirmed long thoracic nerve injury. Conservative treatment was provided. Ultimately, the patient recovered completely in the last follow-up visit 6 months after the surgery.

Discussion

This is the first report of ipsilateral winged scapula after thoracotomy. Attention needs to be paid to surgical techniques in patients with Marfan syndrome.

A 16-Year-Old Male with Thoracic Compression following Posterior Spinal Instrumentation and Fusion for Marfan-Associated Syndromic Scoliosis

Introduction

Marfan syndrome is an autosomal dominant disorder caused by a mutation in the FBN1 gene which affects connective tissue. The features of Marfan syndrome include many musculoskeletal abnormalities which require orthopaedic surgical intervention. Given the expansive phenotypic variations and comorbidities associated with Marfan syndrome, knowledge of perioperative risk factors and potential complications is essential.

Case

In this case report, the authors describe a patient with Marfan syndrome who underwent spinal instrumentation and fusion from T3 to L4 for correction of syndromic scoliosis. The patient had a complicated perioperative course requiring significant fluid resuscitation and vasoactive medications to support blood pressure. He required intensive care unit level care for continued hemodynamic instability despite resuscitation in the postoperative period. Common causes of postoperative hypotension such as hypovolemic shock, sepsis, ongoing hemorrhage, and prolonged effects of anesthesia were diagnostically ruled out. Ultimately, the patient's refractory hypotension was determined to be from mechanical compression, both from prolonged intraoperative prone positioning exacerbated by pectus excavatum and from the surgically corrected spine decreasing the diameter of his thoracic cavity (as referenced by his postoperative Haller index).

Conclusion

Mechanical compression of thoracic contents as a result of a worsening chest wall deformity can be a complication of spinal deformity correction.

Spinal fusion in pediatric patients with marfan syndrome: a nationwide assessment on short-term outcomes and readmission risk

PURPOSE

The purpose of this study was to utilize the National Readmission Database (NRD) to determine estimates for complication rates, 90-day readmission rates, and hospital costs associated with spinal fusion in pediatric patients with Marfan syndrome.

METHODS

The 2012-2015 NRD databases were queried for all pediatric (< 19 years old) patients diagnosed with Marfan syndrome undergoing spinal fusion surgery. The primary outcome variables in this study were index admission complications and 90-day readmissions.

RESULTS

A total of 249 patients with Marfan syndrome underwent spinal fusion surgery between 2012 and 2015 (mean age ± standard deviation at the time of surgery: 14 ± 2.0, 132 (53%) female). 25 (10.1%) were readmitted within 90 days of the index hospital discharge date. Overall, 59.7% of patients experienced at least one complication during the index admission. Unplanned 90-day readmission could be predicted by older age (odds ratio 2.3, 95% confidence interval 1.3-4.2, p = 0.006), Medicaid insurance status (56.0, 3.8-820.0, p = 0.003), and experiencing an inpatient medical complication (42.9, 4.6-398.7, p = 0.001). Patients were readmitted for wound dehiscence (8 patients, 3.2%), nervous system related complications (3 patients, 1.2%), and postoperative infectious related complications (4 patients, 1.6%).

CONCLUSION

This study is the first to demonstrate on a national level the complications and potential risk factors for 90-day hospital readmission for patients with Marfan syndrome undergoing spinal fusion. Patients with Marfan syndrome undergoing spinal fusion often present with multiple medical comorbidities that must be managed carefully perioperatively to reduce inpatient complications and early hospital readmissions.

A scoping review presenting a wide variety of research on paediatric and adolescent patients with Marfan syndrome

Aim

The present study aimed to map and summarise the research on children, aged 0‐18 years, with Marfan syndrome, identify research gaps and point to research agendas.

Methods

A scoping review was systematically performed by searching multiple databases from January 1996 to April 2019. Primary studies presenting results on at least six individuals aged 0‐18 years with Marfan syndrome, diagnosed according to the Ghent nosology, were selected.

Results

From 2341 de‐duplicated records, 92 papers were included, mapped and described. Their topics were diagnostics (12%), cardiovascular matters (50%), skeletal matters (22%), ocular matters (9%), other medical aspects (5%) and psychosocial perspectives (2%). Most studies were from Europe and North America and published between 1999 and 2019 in subject‐specific or paediatric journals, while a few were published in genetics journals. All studies had quantitative designs, and very few were multicentre studies. Each study had six to 608 subjects for a total of approximately 5809.

Conclusion

A wide range of research topics on adolescent and paediatric Marfan syndrome was found, but qualitative studies and a focus on psychosocial matters were lacking. Future investigations addressing noncardiovascular consequences and patient experiences are needed, as well as studies reaffirming or replicating existing intervention study results.

Sublaminar fixation versus hooks and pedicle screws in scoliosis surgery for Marfan syndrome

Background:

In patients with Marfan syndrome (MFS), surgical correction of spinal deformities with hooks and/or pedicle screws involves a higher rate of complications than in patients with adolescent idiopathic scoliosis. Therefore, sublaminar instrumentation is often a last resort option. This study wants to assess the ability of sublaminar fixation to achieve three-dimensional scoliosis correction and spine stabilization compared with hook and/or pedicle screw systems.

Methods:

Twenty-one MFS patients who underwent posterior spinal fusion at a highly specialized medical center in 1995–2017 were divided into two different groups retrospectively evaluated at a minimum follow-up of 2 years. Group 1 (8 patients) was composed by hooks and screws instrumentation, while Group 2 (13 patients) was composed by hook or pedicle screw system associated to sublaminar wires/bands. Radiological (correction and long-term stability) and general endpoints (mean blood loss, surgery time, and complications) were compared between the groups.

Results:

The degree of correction compared with the preoperative status was satisfactory with both approaches, although the difference between them was not significant. No significant differences were found for general endpoints between groups.

Conclusion:

Our data suggest that scoliosis correction with sublaminar fixation is not inferior to treatment with hooks and/or pedicle screws.

Level of Evidence:

III.

Upregulation of cGMP-dependent Protein Kinase (PRKG1) in the Development of Adolescent Idiopathic Scoliosis

Objective

To explore the molecular regulatory mechanisms underlying fibroblast differentiation and dysfunction in the development of adolescent idiopathic scoliosis (AIS) in an effort to identify candidate therapeutic targets for AIS.

Methods

The GSE110359 dataset, obtained from the bone marrow stromal cells of 12 AIS patients and five healthy controls, was retrieved from the GEO database. The data were preprocessed and differentially expressed genes (DEGs) were identified. KEGG pathway and Gene Ontology (GO)‐Biological Process (BP) enrichment analyses were performed to identify the function of the DEGs. A protein–protein interaction (PPI) and a microRNA‐transcription factor (TF)‐target co‐regulatory network were constructed to identify hub genes in the development of AIS. In addition, hub DEGs were evaluated by quantitative PCR (qPCR) and immunohistochemical staining.

Results

A total of 188 DEGs including 100 up‐regulated and 88 down‐regulated genes were obtained. The up‐regulated DEGs were related to “p53 signaling pathway”, “FoxO signaling pathway”, and “cGMP‐PKG signaling pathway” terms, while the down‐regulated DEGs were significantly enriched in seven terms including “protein processing in endoplasmic reticulum”. The key up‐regulated genes, PRKG1, CCNG2, and KAT2B, and the key down‐regulated genes, MAP2K1 and DUSP6, were identified by the PPI and miRNA‐TF‐Target regulatory network analyses. mRNA expression patterns for PRKG1, DUSP6, and KAT2B were successfully verified by qPCR. In addition, PRKG1 protein levels were found to be elevated during the immunohistochemical analysis.

Conclusion

Increased expression of PRKG1 in AIS patients might be an attractive therapeutic target for AIS. However, further gain or loss‐of‐function studies should be conducted.

Deep Infections After Pediatric Spinal Arthrodesis: Differences Exist with Idiopathic, Neuromuscular, or Genetic and Syndromic Cause of Deformity

BACKGROUND

Little is known about the rates, timing, and causative microorganisms of deep surgical site infections after spinal arthrodesis in patients with genetic and syndromic scoliosis compared with patients with adolescent idiopathic scoliosis and kyphosis or patients with neuromuscular scoliosis.

METHODS

We reviewed data from 1,353 patients who were <21 years of age and had undergone spinal arthrodesis for deformity correction by 1 surgeon from 2000 to 2015. Deformity causes were genetic, idiopathic, or neuromuscular. We identified patients who had undergone an unplanned surgical procedure for a deep surgical site infection that was early (≤90 days after the procedure) or late (>90 days after the procedure). We compared deep surgical site infection rates, timing, and causative microorganisms by deformity cause.

RESULTS

Deep surgical site infections occurred in 65 patients (4.8%): 4.2% for patients with genetic and syndromic scoliosis, 2.7% for patients with adolescent idiopathic scoliosis and kyphosis, and 10.0% for patients with neuromuscular scoliosis. Of the deep surgical site infections, 26 (40%) occurred early and 39 (60%) occurred late. The median times to deep surgical site infection onset were 51 days (range, 7 days to 7 years) in patients with genetic and syndromic scoliosis, 827 days (range, 10 days to 12 years) in patients with adolescent idiopathic scoliosis and kyphosis, and 45 days (range, 13 days to 6 years) in patients with neuromuscular scoliosis. Seventy-six microorganisms (41 gram-positive and 35 gram-negative) were isolated from 47 children with positive cultures; the most common was coagulase-negative Staphylococcus (n = 13). The ratio of gram-positive to gram-negative microorganisms was highest in patients with adolescent idiopathic scoliosis and kyphosis (4:1) and lowest in patients with genetic and syndromic scoliosis (0.5:1). In genetic and syndromic scoliosis, both early and late deep surgical site infections were more frequently caused by gram-negative bacteria. In neuromuscular scoliosis, early deep surgical site infections were more frequently caused by gram-negative bacteria, and late deep surgical site infections were more frequently caused by gram-positive bacteria. In adolescent idiopathic scoliosis and kyphosis, both early and late deep surgical site infections were more commonly caused by gram-positive bacteria. Methicillin-resistant Staphylococcus aureus was identified in 2 late deep surgical site infections in patients with neuromuscular scoliosis.

CONCLUSIONS

Deep surgical site infections were more common in genetic and syndromic scoliosis than in adolescent idiopathic scoliosis and kyphosis, but less common than in neuromuscular scoliosis. Adolescent idiopathic scoliosis and kyphosis had the highest ratio of late to early deep surgical site infections. Patients with genetic and syndromic scoliosis had predominantly gram-negative microorganisms, particularly in early deep surgical site infections. Methicillin-resistant S. aureus infection was rare, occurring in only 2 patients with neuromuscular scoliosis. Gram-negative and gram-positive prophylactic antibiotics may be indicated for patients with genetic and syndromic scoliosis after spinal arthrodesis.

LEVEL OF EVIDENCE

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

Correction of Scoliosis with Large Thoracic Curves in Marfan Syndrome: Does the High-Density Pedicle Screw Construct Contribute to Better Surgical Outcomes

Background

The aim of this study was to determine whether higher density screw constructs resulted in better surgical outcomes in patients with scoliosis secondary to Marfan syndrome (MF-S) with large thoracic curves (≥70°).

Material/Methods

There were 34 MF-S patients who met the inclusion criteria and were evaluated radiographically before surgery, 2 weeks after operation, and at the final follow-up. The mean screw density was taken as the boundary, and patients were categorized as either in the high density (HD) group or the low density (LD) group. Parameters measured included coronal Cobb angle, T5–T12 kyphosis (TK), and T12–S1 lordosis (LL). Additionally, the operation duration, estimated blood loss, screw accuracy, complication rate, and clinical outcomes were compared between the 2 groups.

Results

The mean screw density of all patients was 1.40±0.15 (range 1.13 to 1.67). Correction rate of the thoracic curve was closely related to the screw density at the concave side (r=0.783, P=0.007). Intergroup comparison showed a significantly higher correction rate of the thoracic coronal curve in HD group (56.59±4.80% versus 44.54±9.61%, P=0.036). At last follow-up, coronal correction loss of >5° occurred in 8 cases (47.1%) in the LD group and 3 cases (17.6%) in the HD group. Both groups demonstrated improvement in each domain of the SRS-22 questionnaire after surgery and no significant intergroup difference was found.

Conclusions

The high-density pedicle screw construct contributed to the significantly improved correction rate of thoracic curves in MF-S patients with large thoracic curves (≥70°). Additionally, increasing of pedicle screw number could help to enhance the structural stability and reduce the correction loss during the follow-up period.

Trends in spinal deformity surgery in Marfan syndrome

STUDY DESIGN

Analysis of a national database.

OBJECTIVE

To analyze trends in fusion surgery for spinal deformity in Marfan syndrome (MFS) patients, compare patients with and without Marfan, and evaluate differences in surgical approaches.

SUMMARY OF BACKGROUND DATA

National trends of fusion surgery for spinal deformities in MFS patients are not known. Given the rarity of MFS and the nuanced differences in the spinal deformity it causes, it is important to explore differences in fusion surgery between spinal deformity patients with and without MFS.

METHODS

We identified 314 patients (1,410 weighted) with a diagnosis of MFS and spinal deformity who underwent spinal fusion between the years 2003 and 2014. Our primary outcome was national trends in the use of posterior (PSF), anterior-posterior (APSF), and anterior (ASF) spinal fusions. We also compared perioperative complications, mortality rate, length of stay, and hospital charges in a propensity score matched sample of spinal fusion patients with and without a diagnosis of MFS.

RESULTS

The proportion of PSF surgeries increased significantly (p<.01) from 66.7% in 2003 to 92.0% in 2014. MFS patients were more likely to have higher neurologic (2.4% vs. 0.79%, p=.01) complications. There was a significant association between age and approach (p<.01). PSF had a mean age of 20.2, whereas APSF and ASF had mean ages of 27.1 and 35.2, respectively. Approximately 62% of cervical fusions used ASF.

CONCLUSIONS

Our study provides findings from the largest sample analyzed to date and is the only thus far that investigates national trends. Our results are largely consistent with those of other works in that MFS patients undergoing spinal fusion surgery have higher neurologic complications. We also report that surgical treatment has shifted toward a posterior approach. Our findings can give surgeons a better understanding of the postoperative complications and changing national trends in spinal fusion surgery for patients with MFS.

Syndromic Scoliosis: National Trends in Surgical Management and Inpatient Hospital Outcomes: A 12-Year Analysis

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Evaluate the trends in management and inpatient outcomes in patients with syndromic scoliosis undergoing spinal deformity correction.

SUMMARY OF BACKGROUND DATA

Syndromic scoliosis (SS) refers to scoliosis that is most commonly associated with systemic disease including Ehler Danhlos syndrome (EDS), Marfan syndrome (MF), Down syndrome (DS), Achondroplasia (AP), and Prader-Willi syndrome (PWS). Limited data exist evaluating hospital outcomes in patients with SS undergoing spinal deformity correction.

METHODS

The Kids' Inpatient Database (KIDS) was queried from 2001 to 2012 to identify all pediatric patients with scoliosis undergoing spinal fusion. These patients were then sub-divided into two cohorts: (1) patients with idiopathic scoliosis (IS) and (2) patients with syndromic scoliosis. Trends in surgical management, and postoperative morbidity and mortality were assessed. Length of stay and total hospital charges were additionally analyzed. A sub-analysis to characterize outcomes in each syndrome was also performed.

RESULTS

An estimated 1071 patients with SS were identified and compared with 24,989 pediatric patients with IS. MF (36.8%), Down syndrome (16.0%), and PWS (14.9%) were the most common diagnoses among patients with SS. Between 2001 and 2012, there was a significant decline in the number of anterior procedures performed in both cohorts. Conversely, the number of posterior based procedures increased. SS was associated with increased major complications (2.7% compared with 1.0% in IS; P < 0.001) and minor complication rates (41.0% compared with 28.5% in IS; P < 0.001). Patients with AP incurred the highest rate of major complications (10.7%), minor complications (60.8%), and intraoperative durotomies (6.1%). Total hospital charges increased significantly over the 12-year span.

CONCLUSION

Trends in management of syndromic scoliosis have paralleled that of idiopathic scoliosis. Syndromic scoliosis is associated with increased risks with surgical deformity correction. Further prospective studies are warranted to evaluate the reasons for these differences.

LEVEL OF EVIDENCE

3.

Occiput-to-Pelvis Spinal Arthrodesis: A Case Series

STUDY DESIGN

Retrospective case series.

OBJECTIVES

To describe the indications, operative course, and outcomes in eight pediatric patients who underwent occiput-to-pelvis (O-P) spinal arthrodesis.

SUMMARY

Spinal arthrodesis from the occiput to pelvis is needed for some children with extensive spine deformity. There are few reports of patients with O-P arthrodesis.

METHODS

We reviewed records of pediatric patients who underwent spinal arthrodesis to treat spine deformity between 1987 and 2017 at one institution. Eight patients (six girls) who underwent staged O-P arthrodesis were identified. Underlying conditions, indications for surgery, medical comorbidities, operative courses, complications, and imaging of these patients were recorded.

RESULTS

Diagnoses were neuromuscular disorders in five patients and syndromic disorders in three patients. Mean ages were 9.7 ± 4.1 years at index surgery and 16.8 ± 4.6 years at completion of O-P arthrodesis. Patients underwent a mean of three operations (range, two to five). Occipitocervical arthrodesis was the final operation in six of eight patients (all but the two patients with Loeys-Dietz syndrome). Mean follow-up after the last procedure was 8.5 ± 7.1 years. Two patients underwent revision for protruding occipital implants, and one patient underwent revision for thoracic pseudarthrosis. No patients developed postoperative infections or new neurologic deficits. At final follow-up, Scoliosis Research Society-22r questionnaire scores were lowest for Function (2.6 ± 1.0 of 5 possible points) and highest for Satisfaction (4.1 ± 1.4).

CONCLUSIONS

O-P arthrodesis can benefit patients with extensive spine deformity from neuromuscular or syndromic causes. Patients were young at first operation, which may suggest that younger patients are at higher risk than older patients of major progression of deformity in other spinal regions after deformity correction. Health-related quality of life and radiographic outcomes suggest that patients who underwent O-P arthrodesis had satisfactory outcomes and maintenance of correction during a mean of 8.5 years of follow-up.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

[Etiology and significance of growth disturbances of the spine]

BACKGROUND

The majority of growth disturbances of the spine are acquired and their etiology is still unknown. Both scolioses and sagittal profile disorders are most commonly of idiopathic origin.

ETIOLOGY

The etiology is multifactorial and besides genetic, hormonal and mechanical factors also metabolic components seem to be involved. The risk of progression of an existing deformity is particularly high during the pubertal growth spurt. Accordingly, regular clinical and radiological controls should be carried out in this vulnerable period. Recently, spinal deformities have been classified according to the time of diagnosis rather than according to their etiology, considering the increasing knowledge about the correlation between spinal and thoracic growth and the associated maturation of the lungs. Therefore, the term "early onset scoliosis" considers all deformities of the spine diagnosed before the age of 10 years.

TREATMENT

In the case of failure of conservative treatment options, which have to be applied for as long as possible, definitive spinal fusion surgery should be delayed by the use of growth-sparing surgical techniques, aiming to achieve as normal pulmonary function as possible.

Do Overweight Adolescent Idiopathic Scoliosis (AIS) Patients Have an Increased Perioperative Risk for Posterior Spinal Fusion (PSF) Surgery?: A Propensity Score Matching Analysis of 374 AIS Patients

STUDY DESIGN

A retrospective study.

OBJECTIVE

The aim of this study was to compare the perioperative outcome of posterior spinal fusion (PSF) between overweight (OW) adolescent idiopathic scoliosis (AIS) patients and the healthy-weight (HW) patients using propensity score matching analysis.

SUMMARY OF BACKGROUND DATA

Obesity was found to increase postoperative surgical complications compared with the nonobese group. In scoliosis correction surgery, association of OW and perioperative risks had been explored, but most studies were retrospective in nature.

METHODS

From 374 patients, two comparable groups were matched using propensity score matching analysis with one-to-one nearest neighbor matching and a caliper of 0.2. There were 46 HW and OW patients in each group. The main outcome measures were intraoperative blood loss, use of allogeneic blood transfusion, operative time, duration of hospital stay post-surgery, total patient-controlled analgesia (PCA) morphine usage, perioperative complications, side bending flexibility (SBF), and correction rate (%).

RESULTS

The mean age was 13.3 ± 1.7 and 13.2 ± 1.7 years for HW and OW groups, respectively. The majority of the patients were Lenke 1 curves; 32.6% (HW) and 26.1% (OW) with an average Cobb angle of 69.0 ± 19.1° and 68.8 ± 18.4° for each group, respectively. The two groups were comparable. The operation time was 145.2 ± 42.2 and 154.4 ± 48.3 minutes for HW and OW groups, respectively (P > 0.05). The intraoperative blood loss was almost similar in both groups; 955.1 ± 497.7 mL (HW group) and 1011.8 ± 552.7 mL (OW group) (P > 0.05). Total PCA morphine used was higher in OW group (30.4 ± 22.7 mg) than in the HW group (16.2 ± 11.3 mg). No complication was observed in HW group, while in OW group, one patient (2.2%) developed intraoperative seizure.

CONCLUSION

OW AIS patients (≥85th percentile) had similar mean operative time, intraoperative blood loss, allogeneic transfusion rate, length of stay, and perioperative complications compared with HW AIS patients.

LEVEL OF EVIDENCE

3.

Anterior Surgical Treatment of Scoliosis in a Patient With Loeys-Dietz Syndrome

Loeys-Dietz syndrome (LDS) is an autosomal dominant disorder affecting the connective tissue, resulting in laxity, and can be challenging if surgical treatment is needed. Literature concerning scoliosis and its treatment in LDS is limited. This is a report of scoliosis surgery in a 12-year-old girl with LDS. She underwent anterior instrumented spinal fusion of the segments T12 to L3 because of a left-sided thoracolumbar scoliosis of 42° with dysplastic pedicles. The scoliosis was reduced by 40%, from 42° to 25°, resulting in a satisfactory clinical outcome with a minimal amount of surgical invasion and lack of complications. A minimal approach and anterior instrumented spinal fusion surgery can be considered a valuable surgical treatment alternative for scoliosis in patients with LDS, avoiding the placement of pedicle screws in dysplastic pedicles and using the abnormal laxity of the connective tissue as an advantage.

Marfan Syndrome: A Clinical Update

Marfan syndrome is a connective tissue disorder that can affect many organ systems. Affected patients present with orthopaedic manifestations of the syndrome during all phases of life. Pain caused by musculoskeletal abnormalities often requires definitive orthopaedic treatment. Orthopaedic surgeons must understand the phenotypes of Marfan syndrome so they can recognize when screening is warranted and can appropriately address the skeletal manifestations. Through medical advancements, patients with Marfan syndrome are living longer and more active lives. Knowledge of the latest diagnostic criteria for the disorder, as well as of advances in understanding the skeletal phenotype, clinical trials of medication therapy, and lifestyle considerations is important for orthopaedic surgeons who treat these patients because these clinicians often are the first to suspect Marfan syndrome and recommend screening.

Final Fusion After Growing-Rod Treatment for Early Onset Scoliosis: Is It Really Final?

BACKGROUND

Final fusion is thought to be the end point for patients with early onset scoliosis following treatment with the use of growing rods. But is it? The purpose of this study was to determine the incidence and cause of any reoperation after final fusion.

METHODS

A multicenter database of patients with early onset scoliosis was retrospectively analyzed to identify patients treated with growing rods with a minimum of 2 years of follow-up after final fusion. All reoperations were recorded. Reoperation was defined as a return to the operating room for any complication related to the final fusion surgery or etiology of the spinal deformity.

RESULTS

One hundred (84%) of 119 patients met the inclusion criteria: for 38 of the patients, the etiology of scoliosis was neuromuscular; for 31, syndromic; for 22, idiopathic; and for 9, congenital. The mean age at final fusion was 12.2 years (range, 8.5 to 18.7 years). The mean follow-up after final fusion was 4.3 years (range, 2 to 11.2 years). Twenty (20%) of the patients had 30 complications requiring reoperation (57 procedures). There was a mean of 1.5 complications per patient after final fusion. Eight patients with neuromuscular scoliosis, 8 with syndromic, 4 with idiopathic, and no patient with congenital scoliosis required reoperation. Nine (9%) of the patients experienced infection (33 reoperation procedures); 6 (6%) had instrumentation failure (8 procedures); 5 (5%) had painful or prominent instrumentation (6 procedures); 3 (3%) each had coronal deformity (3 procedures), pseudarthrosis (3 procedures), or sagittal deformity (3 procedures); and 1 (1%) had progressive crankshaft chest wall deformity requiring a thoracoplasty (1 procedure).

CONCLUSIONS

A higher-than-anticipated percentage of patients treated with growing rods required unplanned reoperation following final fusion. Long-term follow-up after final fusion is necessary to determine true final results. Patients and parents need to be counseled regarding the possibility of further surgery after final fusion.

LEVEL OF EVIDENCE

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

Perioperative Outcome in Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis: A Prospective Study Comparing Single Versus Two Attending Surgeons Strategy

STUDY DESIGN

Prospective study.

OBJECTIVE

To evaluate the perioperative outcome of posterior spinal fusion in adolescent idiopathic scoliosis (AIS) patients comparing a single attending surgeon strategy (G1) versus a dual attending surgeon strategy (G2).

SUMMARY OF BACKGROUND DATA

The complication rate for surgical correction in AIS is significant. There are no prospective studies that investigate dual attending surgeon strategy for posterior spinal fusion in AIS.

METHODS

A total of 60 patients (30 patients in each arm) were recruited. The patients were comparable for age, gender, Lenke classification, major Cobb angle magnitude, and number of fusion levels. The anesthetic, surgical, and postoperative protocol was standardized. The outcome measures included the operative duration, blood loss, postoperative hemoglobin, need for transfusion, morphine usage, duration of hospital stay, intraoperative lactate levels, and pH. The timing of the operation at six critical stages of the operation was recorded.

RESULTS

The mean operative time for G2 was 173.6 ± 27.0 minutes versus 248.0 ± 49.9 minutes in G1 (P < 0.000). Mean blood loss in G2 was 0.92 ± 0.4 L and 1.25 ± 0.6 L in G1 (P < 0.05). None of the patients in G2 required any allogenic transfusion. Four patients in G1 (13.3%) required allogenic blood product transfusion. The day 2 postoperative hemoglobin levels in both groups were similar, but this was taken after blood product transfusion in G1. The amount of morphine usage was 20.4 ± 11.5 mg in G2 and 42.5 ± 24.0 mg in G1 (P < 0.000). G2 patients had a shorter hospital stay. One patient in G1 had superficial wound infection. G2 was faster than G1 during exposure, instrumentation, facetectomy, and bone grafting.

CONCLUSION

The involvement of two attending surgeons significantly reduced operative time, blood loss, need for allogenic blood transfusion, patient-controlled analgesia morphine requirement and led to faster patient recovery during the perioperative period.

LEVEL OF EVIDENCE

2.

Generation of heterozygous fibrillin-1 mutant cloned pigs from genome-edited foetal fibroblasts

Marfan syndrome (MFS) is an autosomal dominant genetic disease caused by abnormal formation of the extracellular matrix with an incidence of 1 in 3, 000 to 5, 000. Patients with Marfan syndrome experience poor quality of life caused by skeletal disorders such as scoliosis, and they are at high risk of sudden death from cardiovascular impairment. Suitable animal models of MFS are essential for conquering this intractable disease. In particular, studies employing pig models will likely provide valuable information that can be extrapolated to humans because of the physiological and anatomical similarities between the two species. Here we describe the generation of heterozygous fibrillin-1 (FBN1) mutant cloned pigs (+/Glu433AsnfsX98) using genome editing and somatic cell nuclear transfer technologies. The FBN1 mutant pigs exhibited phenotypes resembling those of humans with MFS, such as scoliosis, pectus excavatum, delayed mineralization of the epiphysis and disrupted structure of elastic fibres of the aortic medial tissue. These findings indicate the value of FBN1 mutant pigs as a model for understanding the pathogenesis of MFS and for developing treatments.

Aortic issues in scoliosis and scoliotic operations

The spatial relations between the aorta and vertebrae are changing with posture, surgical techniques, and operative maneuvers. "Risky screws" (within 1-3 mm proximity to the aorta or other adjacent tissues) were found in 5.8-15.2% screws. In order to avoid early and later aortic complications secondary to scoliotic operations, careful preoperative metrology of aorto-vertebrae relations is of crucial importance. Compared with patients with idiopathic scoliosis, Marfan-related scoliosis is characterized by faster progression and it is more bracing-resistant due to the particular developmental anomalies in Marfan syndrome, implying the refractory nature of the latter. The present study aims to highlight the clinical impact of preoperative aorto-vertebra metrology in the scoliotic operations.

Halogravity traction in the preoperative treatment of scoliosis in twins with Marfan syndrome

We report on the influence of the duration of halogravity traction for achieving curve correction in monozygotic twins with Marfan syndrome who underwent posterior spinal fusion. Review of the medical charts and standard radiograph analysis of twin girls treated at our department was performed. Halogravity traction with a four-pin skull construct was applied for 3 weeks in twin A and for 2 weeks in twin B with a maximum of 20% body weight used. Both were on a 24-hours-day halogravity traction regime. Achieved thoracic curve correction after halogravity traction was 31% in twin A and 18% in twin B. Although less curve correction after traction was achieved in twin B, this had no significant implications on final postoperative curve correction. Halogravity traction can be a useful tool in the preoperative treatment of scoliosis in patients with Marfan syndrome if applied for 3 weeks. In order to avoid complications, we propose that lower weights be used with a starting weight of 1.5 kg increased by 1 kg daily until 20% body weight is reached.

Comparison of posterior correction results between Marfan syndrome scoliosis and adolescent idiopathic scoliosis-a retrospective case-series study

Background

The X-ray films of the patients with Marfan syndrome scoliosis (MSS) look like those with adolescent idiopathic scoliosis (AIS). In literature, there are many reports on the correction results of AIS, while there are a few studies focused on the difference of the correction results between MSS and AIS. This study aims to analyze whether there are differences of posterior correction surgery in MSS and AIS.

Methods

All the patients included underwent posterior correction surgery. The radiographic data, operation duration, estimated blood loss, transfusion, fusion levels, and correction rate were retrospectively reviewed and analyzed between the two groups.

Results

Group MSS included 42 patients, 11 male and 31 female, with an average age of 15.2 years old. Group AIS included 168 patients (ratio, 1:4), 34 male and 134 female, with an average age of 14.5 years old. Twenty-three patients in group MSS and 94 patients in group AIS were followed up regularly, with an average time of 18.4 and 18.5 months, respectively. The mean coronal Cobb angle of the major curve before operation and at final follow-up, the correction rate, fusion level, operation duration, estimated blood loss during operation, and transfusion between the two groups were 60.4 and 57.5°, 14.6 and 15.2°, 76.4 and 74.1 %, 11.5 and 11.0 vertebrae, 4.6 and 4.0 h, 845 and 698 ml, and 1151 and 894 ml, respectively. The age, gender ratio, curve type, and coronal Cobb angle of the major curve were all matched (all P > 0.05). Group MSS had a longer operation duration and more estimated blood loss compared with those of group AIS (both P < 0.05), while there was no significant difference in terms of fusion level, transfusion, coronal Cobb angle of the major curve at final follow-up, and the correction rate (all P > 0.05).

Conclusions

When performing posterior correction for scoliosis, the surgeons should be aware that the patients with Marfan syndrome scoliosis had more estimated blood loss and longer operation duration than AIS patients, while the correction rate was similar.

Complications associated with surgical repair of syndromic scoliosis

Background

There are a number of syndromes that have historically been associated with scoliosis e.g.: Marfan, Down, and Neurofibromatosis. These syndromes have been grouped together as one etiology of scoliosis, known as syndromic scoliosis. While multiple studies indicate that these patients are at high risk for perioperative complications, there is a paucity of literature regarding the collective complication rates and surgical needs of this population.

Methods

PubMed and Embase databases were searched for literature encompassing the surgical complications associated with the surgical management of patients undergoing correction of scoliosis in the syndromic scoliosis population. Following exclusion criteria, 24 articles were analyzed for data regarding these complications.

Results

The collective complication rates and findings of these articles were categorized based on specific syndrome. The rates and types of complications for each syndrome and the special needs of patients with each syndrome are discussed. Several complication trends of note were observed, including but not limited to the universally nearly high rate of wound infections (>5% in each group), high rate of pulmonary complications in patients with Rett syndrome (29.2%), high rate (>10%) of dural tears in Marfan and Ehlers-Danlos syndrome patients, high rate (>20%) of implant failure in Down and Prader-Willi syndrome patients, and high rate (>25%) of pseudarthrosis in Down and Ehlers-Danlos patients.

Conclusions

Though these syndromes have been classically grouped together under the umbrella term “syndromic,” there may be specific needs for patients with each of these ailments. Given the high rate of complications, further research is necessary to understand the unique needs for each of these patient groups in the preoperative, intraoperative, and postoperative settings.

Improving the measurement of health-related quality of life in adolescent with idiopathic scoliosis: the SRS-7, a Rasch-developed short form of the SRS-22 questionnaire

Scoliosis Research Society-22 (SRS-22) questionnaire was developed to evaluate health-related quality of life (HRQL) in adolescent idiopathic scoliosis (AIS) patients. Rasch analysis (RA) is a statistical procedure which turns questionnaire ordinal scores into interval measures. Measures from Rasch-compatible questionnaires can be used, similar to body temperature or blood pressure, to quantify disease severity progression and treatment efficacy. Purpose of the current work is to present Rasch analysis (RA) of the SRS-22 questionnaire and to develop an SRS-22 Rasch-approved short form. 300 SRS-22 were randomly collected from 2447 consecutive IS adolescents at their first evaluation (229 females; 13.9 ± 1.9 years; 26.9 ± 14.7 Cobb°) in a scoliosis outpatient clinic. RA showed both disordered thresholds and overall misfit of the SRS-22. Sixteen items were re-scored and two misfitting items (6 and 14) removed to obtain a Rasch-compatible questionnaire. Participants HRQL measured too high with the rearranged questionnaire, indicating a severe SRS-22 ceiling effect. RA also highlighted SRS-22 multidimensionality, with pain/function not merging with self-image/mental health items. Item 3 showed differential item functioning (DIF) for both curve and hump amplitude. A 7-item questionnaire (SRS-7) was prepared by selecting single items from the original SRS-22. SRS-7 showed fit to the model, unidimensionality and no DIF. Compared with the SRS-22, the short form scale shows better targeting of the participants' population. RA shows that SRS-22 has poor clinimetric properties; moreover, when used with AIS at first evaluation, SRS-22 is affected by a severe ceiling effect. SRS-7, an SRS-22 7-item short form questionnaire, provides an HRQL interval measure better tailored to these participants.

Orthopedic aspects of collagen disorders

PURPOSE OF REVIEW

The purpose of this article is to provide the pediatrician with a review of disorders that have the orthopedic manifestation of joint hypermobility. Hypermobility, also termed ligamentous laxity, may present in different parts of the body at different times throughout childhood and adolescence. It may be symptomatic or incidentally found on the physical examination. Many conditions that cause joint hypermobility resolve with nonoperative management, but occasionally operative intervention is required for the best patient outcome.

RECENT FINDINGS

In addition, hypermobility may be associated with collagen disorders that affect vital organ systems. Recognition of hypermobility combined with a thorough patient evaluation may be the initial opportunity for the pediatrician to uncover disease that may be managed promptly.

SUMMARY

Heightened awareness of subtle hypermobility or symptomatic joint laxity on physical examination facilitates optimal management and favorable outcomes in children with this condition.