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Thompson GH. CORR Insights®: Virtual Reality Distraction Is No Better Than Simple Distraction Techniques for Reducing Pain and Anxiety During Pediatric Orthopaedic Outpatient Procedures: A Randomized Controlled Trial. Clin Orthop Relat Res 2024; 482:864-866. [PMID: 38251972 PMCID: PMC11008669 DOI: 10.1097/corr.0000000000002970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 12/07/2023] [Indexed: 01/23/2024]
Affiliation(s)
- George H Thompson
- Professor Emeritus, Orthopaedic Surgery, Case Western Reserve University, Cleveland, OH, USA
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Thompson GH, Hensinger RN. Kaye Evan Wilkins, DVM, MD, 1934-2023. J Pediatr Orthop 2024; 44:e375-e376. [PMID: 38445714 DOI: 10.1097/bpo.0000000000002628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Affiliation(s)
- George H Thompson
- Rainbow and Babies and Children's Hospital Case Western Reserve University, Cleveland Ohio
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Heffernan MJ, Leonardi C, Andras LM, Fontenot B, Drake L, Pahys JM, Smith JT, Sturm PF, Thompson GH, Glotzbecker MP, Tetreault TA, Roye BD, Li Y. Lowest instrumented vertebrae in early onset scoliosis: is there a role for a more selective approach? Spine Deform 2024:10.1007/s43390-024-00842-x. [PMID: 38514530 DOI: 10.1007/s43390-024-00842-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 02/08/2024] [Indexed: 03/23/2024]
Abstract
PURPOSE This purpose of this study was to assess the impact of patient and implant characteristics on LIV selection in ambulatory children with EOS and to assess the relationship between the touched vertebrae (TV), the last substantially touched vertebrae (LSTV), the stable vertebrae (SV), the sagittal stable vertebrae (SSV), and the LIV. METHODS A multicenter pediatric spine database was queried for patients ages 2-10 years treated by growth friendly instrumentation with at least 2-year follow up. The relationship between the LIV and preoperative spinal height, curve magnitude, and implant type were assessed. The relationships between the TV, LSTV, SV, SSV, and the LIV were also evaluated. RESULTS Overall, 281 patients met inclusion criteria. The LIV was at L3 or below in most patients with a lumbar LIV: L1 (9.2%), L2 (20.2%), L3 (40.9%), L4 (29.5%). Smaller T1 - T12 length was associated with more caudal LIV selection (p = 0.001). Larger curve magnitudes were similarly associated with more caudal LIV selection (p = < 0.0001). Implant type was not associated with LIV selection (p = 0.32) including MCGR actuator length (p = 0.829). The LIV was caudal to the TV in 78% of patients with a TV at L2 or above compared to only 17% of patients with a TV at L3 or below (p < 0.0001). CONCLUSIONS Most EOS patients have an LIV of L3 or below and display TV-LIV and LSTV-LIV incongruence. These findings suggest that at the end of treatment, EOS patients rarely have the potential for selective thoracic fusion. Further work is necessary to assess the potential for a more selective approach to LIV selection in EOS. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Michael J Heffernan
- Jackie and Gene Autry Orthopaedic Center, Children's Hospital Los Angeles, 4650 Sunset Blvd, Mailstop #69, Los Angeles, CA, 90027, USA.
| | - Claudia Leonardi
- School of Public Health, LSU Health Sciences Center, New Orleans, LA, USA
| | - Lindsay M Andras
- Jackie and Gene Autry Orthopaedic Center, Children's Hospital Los Angeles, 4650 Sunset Blvd, Mailstop #69, Los Angeles, CA, 90027, USA
| | - Bailli Fontenot
- LSU Health Sciences Center, Children's Hospital New Orleans, New Orleans, LA, USA
| | - Luke Drake
- Jackie and Gene Autry Orthopaedic Center, Children's Hospital Los Angeles, 4650 Sunset Blvd, Mailstop #69, Los Angeles, CA, 90027, USA
| | - Joshua M Pahys
- Department of Orthopedics, Shriners Hospital for Children, Philadelphia, PA, USA
| | - John T Smith
- Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA
| | - Peter F Sturm
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - George H Thompson
- Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, OH, USA
| | - Michael P Glotzbecker
- Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, OH, USA
| | - Tyler A Tetreault
- Jackie and Gene Autry Orthopaedic Center, Children's Hospital Los Angeles, 4650 Sunset Blvd, Mailstop #69, Los Angeles, CA, 90027, USA
| | - Benjamin D Roye
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY, USA
- Pediatric Orthopaedic Surgery, New York-Presbyterian Morgan Stanley Children's Hospital, New York, NY, USA
| | - Ying Li
- Department of Orthopaedic Surgery, C.S. Mott Children's Hospital, Ann Arbor, MI, USA
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Prior A, Hardesty CK, Emans JB, Thompson GH, Sponseller PD, Smith JT, Skaggs DL, Vaughan M, Barfield WR, Murphy RF. A Comparative Analysis of Revision Surgery Before or After 2 Years After Graduation From Growth-friendly Surgery for Early Onset Scoliosis. J Pediatr Orthop 2023:01241398-990000000-00320. [PMID: 37400093 DOI: 10.1097/bpo.0000000000002467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/05/2023]
Abstract
INTRODUCTION After discontinuation of growth-friendly (GF) surgery for early onset scoliosis, patients are termed graduates: they undergo a spinal fusion, are observed after final lengthening with GF implant maintenance, or are observed after GF implant removal. The purpose of this study was to compare the rates of and reasons for revision surgery in two cohorts of GF graduates: before or after 2 years of follow-up from graduation. METHODS A pediatric spine registry was queried for patients who underwent GF spine surgery with a minimum of 2 years of follow-ups after graduation by clinical and/or radiographic evidence. Scoliosis etiology, graduation strategy, number of, and reasons for revision surgery were queried. RESULTS There were 834 patients with a minimum of 2-year follow-up after graduation who were analyzed. There were 241 (29%) congenital, 271 (33%) neuromuscular, 168 (20%) syndromic, and 154 (18%) idiopathic. 803 (96%) had traditional growing rod/vertical expandable titanium rib as their GF construct and 31 (4%) had magnetically controlled growing rod. Five hundred ninety-six patients (71%) underwent spinal fusion at graduation, 208 (25%) had GF implants retained, and 30 (4%) had GF implants removed.In the entire cohort, there were 108/834 (13%) patients who underwent revision surgery. Of the revisions, 71/108 (66%) occurred as acute revisions (ARs) between 0 and 2 years from graduation (mean 0.6 y), and the most common AR indication was infection (26/71, 37%). The remaining 37/108 (34%) patients underwent delayed revision (DR) surgery >2 years (mean 3.8 y) from graduation, and the most common DR indication was implant issues (17/37, 46%).Graduation strategy affected revision rates. Of the 596 patients with spinal fusion as a graduation strategy, 98/596 (16%) underwent revision, compared with only 8/208 (4%) patients who had their GF implants retained, and 2/30 (7%) that had their GF implants removed (P ≤ 0.001).A significantly higher percentage of the ARs had a spinal fusion as the graduation strategy (68/71, 96%) compared with 30/37 DRs, (81%, P = 0.015). In addition, the 71 patients who underwent AR undergo more revision surgeries (mean: 2, range: 1 to 7) than 37 patients who underwent DR (mean: 1, range: 1 to 2) (P = 0.001). CONCLUSION In this largest reported series of GF graduates to date, the overall risk of revision was 13%. Patients who undergo a revision at any time, as well as ARs in particular, are more likely to have a spinal fusion as their graduation strategy. Patients who underwent AR, on average, undergo more revision surgeries than patients who underwent DR. LEVEL OF EVIDENCE Level III, comparative.
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Affiliation(s)
- Anjali Prior
- Department of Orthopaedics and Physical Medicine, Medical University of South Carolina, Charleston SC
| | | | | | | | | | | | | | | | - William R Barfield
- Department of Orthopaedics and Physical Medicine, Medical University of South Carolina, Charleston SC
| | - Robert F Murphy
- Department of Orthopaedics and Physical Medicine, Medical University of South Carolina, Charleston SC
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Poe-Kochert C, Ina J, Thompson GH, Hardesty CK, Son-Hing JP, Rubin K, Tripi PA. Safety and efficacy of intrathecal morphine in early onset scoliosis surgery. J Pediatr Orthop B 2023; 32:336-341. [PMID: 36125883 DOI: 10.1097/bpb.0000000000001006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Intrathecal morphine (IM) is a popular adjunct for pain management in spinal deformity surgery for idiopathic scoliosis. It has not been studied in patients with early onset scoliosis (EOS). We retrospectively reviewed EOS patients undergoing growth-friendly surgery who received IM or did not receive IM (non-IM). Data from initial insertion and final fusion procedures were studied. IM was not used for lengthening procedures, short procedures (<3 h), patients with significant underlying respiratory issues, paraplegia, unsuccessful access and anesthesiologist discretion. We assessed pediatric ICU (PICU) admission and IM complications (respiratory depression, pruritus and nausea/vomiting), time to first postoperative opiate, and pain scores. There were 97 patients including 97 initial insertions (26 IM and 71 non-IM) and 74 patients with final fusions (17 IM and 57 non-IM). The first dose of opioids following insertion and final fusion occurred at 16.8 ± 3.8 and 16.8 ± 3.1 h postoperatively in the IM group compared to 5.5 ± 2.8 and 8.3 ± 3.2 h in the non-IM group, respectively ( P < 0.001). Postoperative pain scores were lower in the IM groups ( P = 0.001). Two patients with IM developed mild respiratory depression following initial insertion ( P = 0.01) but did not require PICU admission. The rate of respiratory depression was not different between the final fusion groups. There was no difference between pruritus and nausea/vomiting at the final fusion. Preincision IM can provide well-tolerated and effective initial postoperative analgesia in select children with EOS undergoing spinal deformity surgery.
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Affiliation(s)
| | | | | | | | | | - Kasia Rubin
- Division of Pediatric Anesthesiology, Rainbow Babies and Children's Hospital at University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Paul A Tripi
- Division of Pediatric Anesthesiology, Rainbow Babies and Children's Hospital at University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
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Hensinger RN, Thompson GH. G. Paul DeRosa, MD Obituary 1939-2022. J Pediatr Orthop 2023; 43:e403-e404. [PMID: 37991719 DOI: 10.1097/bpo.0000000000002365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Affiliation(s)
- Robert N Hensinger
- Department of Orthopaedics, University of Michigan Health System, Ann Arbor, Michigan
| | - George H Thompson
- Director of Pediatrics Orthopaedics, Rainbow Babies and Children's Hospital, Cleveland, Ohio
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Kolin DA, Thompson GH, Blumenschein LA, Poe-Kochert C, Glotzbecker MP, Son-Hing JP, Hardesty CK, Mistovich RJ. Providence Bracing: Predicting the Progression to Surgery in Patients With Braced Idiopathic Scoliosis. J Pediatr Orthop 2023:01241398-990000000-00311. [PMID: 37340638 DOI: 10.1097/bpo.0000000000002452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
BACKGROUND Idiopathic scoliosis (IS) is a common spinal abnormality, in which orthotic management can reduce progression to surgery. However, predictors of bracing success are still not fully understood. We studied a large patient population treated with the nighttime Providence orthosis, utilizing multivariable logistic regression to assess results and predict future spine surgery. METHODS We retrospectively reviewed patients with IS meeting Scoliosis Research Society inclusion and assessment criteria presenting from April 1994 to June 2020 at a single institution and treated with a Providence orthosis. A predictive logistic regression model was developed utilizing the following candidate features: age, sex, body mass index, Risser classification, Lenke classification, curve magnitude at brace initiation, percentage correction in a brace, and total months of brace use. Model performance was assessed using the area under the receiver operating characteristic curve, accuracy, sensitivity, and specificity. The importance of individual features was assessed using the variable importance score. RESULTS There were 329 consecutive patients with IS with a mean age of 12.8 ± 1.4 years that met inclusion and assessment criteria. Of these, 113 patients (34%) ultimately required surgery. The model's area under the curve (AUC) was 0.72 on the testing set, demonstrating good discrimination. The initial curve magnitude (Importance score: 100.0) and duration of bracing (Importance score: 82.4) were the 2 most predictive features for curve progression leading to surgery. With respect to skeletal maturity, Risser 1 (Importance score: 53.9) had the most predictive importance for future surgery. For the curve pattern, Lenke 6 (Importance score: 52.0) had the most predictive importance for future surgery. CONCLUSION Out of 329 patients with IS treated with a Providence nighttime orthosis, 34% required surgery. This is similar to the findings of the BrAist study of the Boston orthosis, in which 28% of monitored braced patients required surgery. In addition, we found that predictive logistic regression can evaluate the likelihood of future spine surgery in patients treated with the Providence orthosis. The severity of the initial curve magnitude and total months of bracing were the 2 most important variables when assessing the probability of future surgery. Surgeons can use this model to counsel families on the potential benefits of bracing and risk factors for curve progression.
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Affiliation(s)
- David A Kolin
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - George H Thompson
- Department of Orthopedic Surgery, Division of Pediatric Orthopaedic Surgery, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine
| | - Lucas A Blumenschein
- Department of Orthopedic Surgery, Division of Pediatric Orthopaedic Surgery, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine
| | - Connie Poe-Kochert
- Department of Orthopedic Surgery, Division of Pediatric Orthopaedic Surgery, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine
| | - Michael P Glotzbecker
- Department of Orthopedic Surgery, Division of Pediatric Orthopaedic Surgery, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine
| | - Jochen P Son-Hing
- Department of Orthopedic Surgery, Division of Pediatric Orthopaedic Surgery, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine
| | - Christina K Hardesty
- Department of Orthopedic Surgery, Division of Pediatric Orthopaedic Surgery, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine
| | - R Justin Mistovich
- Department of Orthopedic Surgery, Division of Pediatric Orthopaedic Surgery, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine
- MetroHealth Medical Center, Cleveland, OH
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Affiliation(s)
| | - Jay Shapiro
- University Hospitals Cleveland Medical Center, Cleveland, USA
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Shapiro J, Thompson GH, Akbarnia BA. Alberto Ponte, MD : July 9, 1926-January 10, 2023. Spine Deform 2023; 11:267-268. [PMID: 36809649 DOI: 10.1007/s43390-023-00655-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Affiliation(s)
- Jay Shapiro
- University Hospitals Cleveland Medical Center, Cleveland, USA
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Marrache M, Prasad N, Thompson GH, Li Y, Glotzbecker M, Sponseller PD. Outcomes for patients with infantile idiopathic scoliosis by casting table type. J Child Orthop 2022; 16:285-289. [PMID: 35992520 PMCID: PMC9382706 DOI: 10.1177/18632521221115934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Serial casting is an effective treatment for infantile idiopathic scoliosis. The most common casting table types are Mehta, Risser, and spica tables. We compared major curve correction between patients with infantile idiopathic scoliosis treated using pediatric hip spica tables versus Risser or Mehta tables. METHODS In this multicenter retrospective study, we included 52 children younger than 3 years (mean ± standard deviation age, 1.6 ± 0.68 years) treated with ≥2 consecutive casts for infantile idiopathic scoliosis between September 2011 and July 2018. We compared major curve angle (measured using the Cobb method) before and after treatment and improvement in curve angle between the spica tables group (n = 12) and the Risser or Mehta tables group (n = 40). The primary outcome was the difference in percentage correction of the major curve according to radiographs taken after first casting and at final follow-up. RESULTS The mean major curve was 47° ± 18° before casting. A median of six casts (range: 2-14) were applied. Mean follow-up after treatment initiation was 22 months (range: 7-86 months). At baseline, the major curve was significantly larger in the spica tables group (58°) than in the Risser or Mehta tables group (43°) (p = 0.01). We found no differences in the percentage curve correction in the spica tables group versus Risser or Mehta tables group after first casting or at final follow-up. CONCLUSION Serial casting was associated with substantial major curve correction in patients with infantile idiopathic scoliosis. Curve correction did not differ between patients treated with a spica table versus a Risser or Mehta table. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Majd Marrache
- Department of Orthopaedic Surgery, The
Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Niyathi Prasad
- Department of Orthopaedic Surgery, The
Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - George H Thompson
- Rainbow Babies and Children’s Hospital,
Case Western Reserve University School of Medicine, University Hospitals Case
Medical Center, Cleveland, OH, USA
| | - Ying Li
- Department of Orthopaedic Surgery, C.
S. Mott Children’s Hospital, Michigan Medicine, Ann Arbor, MI, USA
| | - Michael Glotzbecker
- Department of Orthopaedic Surgery,
Boston Children’s Hospital, Boston, MA, USA
| | - Paul D Sponseller
- Department of Orthopaedic Surgery, The
Johns Hopkins University School of Medicine, Baltimore, MD, USA,Paul D Sponseller, Department of
Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N.
Caroline Street, JHOC 5223, Baltimore, MD 21287, USA.
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Bowker R, Morash K, Mishreky A, Yaszay B, Andras L, Sturm P, Sponseller PD, Thompson GH, El-Hawary R. Scoliosis flexibility correlates with post-operative outcomes following growth friendly surgery. Spine Deform 2022; 10:933-941. [PMID: 35147914 DOI: 10.1007/s43390-022-00481-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 01/22/2022] [Indexed: 10/19/2022]
Abstract
PURPOSE The purpose of this study was to determine the relationship between pre-operative scoliosis flexibility and post-operative outcomes, including curve correction and complications, for patients who have been treated with growth friendly surgery (GFS) for early onset scoliosis (EOS). METHODS The study was conducted as a retrospective review of prospectively collected data from an international, multicenter, EOS database. EOS patients with pre-operative flexibility radiographs (traction or bending) were identified. Pre-operative flexibility and immediate post-operative correction were calculated for each patient. Post-operative complications were recorded at final follow-up. Pearson correlations were determined for flexibility vs correction for all patients and were compared between etiologies and between device types (MCGR, TGR, VEPTR). RESULTS 107 patients (14 congenital, 43 neuromuscular, 31 syndromic, 19 idiopathic) with mean age 7.1 years at index surgery were identified. Mean pre-operative scoliosis was 77°. Mean flexibility of 36% was not significantly different between etiologies. Mean immediate post-operative scoliosis was 46° (p < 0.001 vs. pre-operative) with mean correction of 38%. Correction rate was not significantly different between etiologies; however, correction rate was different between device types (MCGR 45%, TGR 40%, VEPTR 14%; p = < 0.001). Pearson correlation for flexibility vs correction was fair (r = 0.37, p < 0.001). This correlation was observed for idiopathic (r = 0.53, p = 0.020) and neuromuscular (r = 0.46, p = 0.0020) scoliosis, but not for congenital or syndromic scoliosis. At a mean of 6.1 year follow-up (minimum 2 years to 15.5 years), 60 of 81patients (74%) experienced at least one complication. Odds ratio for developing a complication was 3.00 (1.03-8.76) for patients with pre-operative flexibility < 45% (p < 0.05). CONCLUSIONS As lower pre-operative flexibility was associated with less scoliosis correction and with a higher risk of post-operative complications, curve flexibility should be considered when deciding upon the timing of growth friendly surgery. LEVEL OF EVIDENCE Level III-retrospective comparative study.
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Affiliation(s)
- Riley Bowker
- Division of Orthopaedic Surgery, Department of Surgery, IWK Health Center, 5850 University Avenue, PO Box 9700, Halifax, NS, B3K-6R8, Canada
| | - Kevin Morash
- Division of Orthopaedic Surgery, Department of Surgery, IWK Health Center, 5850 University Avenue, PO Box 9700, Halifax, NS, B3K-6R8, Canada
| | - Amir Mishreky
- Division of Orthopaedic Surgery, Department of Surgery, IWK Health Center, 5850 University Avenue, PO Box 9700, Halifax, NS, B3K-6R8, Canada
| | - Burt Yaszay
- University of Washington School of Medicine, 4800 Sand Point Way NE, Seattle, WA, 98105, USA
| | - Lindsay Andras
- Children's Hospital of Los Angeles, 4650 Sunset Blvd, Los Angeles, CA, 90027, USA
| | - Peter Sturm
- Cincinnati Children's Hospital, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | - Paul D Sponseller
- Johns Hopkins University, 601 N Caroline St 5th Floor, Baltimore, MD, 21287, USA
| | - George H Thompson
- Rainbow Babies and Children's Hospital, 2500 Metrohealth Dr, Cleveland, OH, 44109, USA
| | - Ron El-Hawary
- Division of Orthopaedic Surgery, Department of Surgery, IWK Health Center, 5850 University Avenue, PO Box 9700, Halifax, NS, B3K-6R8, Canada.
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Dumaine AM, Yu J, Poe-Kochert C, Thompson GH, Mistovich RJ. Surgical site infections in early onset scoliosis: what are long-term outcomes in patients with traditional growing rods? Spine Deform 2022; 10:465-470. [PMID: 34536220 DOI: 10.1007/s43390-021-00412-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 09/04/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Deep surgical site infections (SSIs) are a common and potentially severe complication in early onset scoliosis (EOS) patients. We sought to identify the long-term outcomes following SSI, specific risk factors associated with recurrent infections, and if instrument retention is a prudent SSI management strategy in EOS. METHODS We performed a retrospective review of all EOS patients who underwent traditional growing rod spine procedures from 2003 to 2017. Infections were categorized as single or multiple SSIs. All infections were treated with operative irrigation and debridement (I&D) as well as antibiotics. Univariate analysis was performed using chi-square and ANOVA tests to assess differing factors between patients with single versus multiple infections. RESULTS Eighty-one patients underwent 638 growth-friendly traditional growing rod procedures. There were 21 patients (26%) who developed a total of 27 SSIs (4.2% SSI per procedure). Fifteen patients had a single infection and six patients had multiple infections. Demographics were not significantly different between these two groups. Patients with multiple infections had a significant difference in the number of procedures after initial infection (p value = 0.025) and positive preoperative nasal Staphylococcus aureus screen (p value = 0.0021) when compared to those with a single SSI. Of note, these results were not available at the time of pre-operative antibiotic selection. All 21 patients had resolution of their SSIs. Twenty patients reached final instrumented fusion. Two patients, both of whom had multiple infections, underwent complete removal of instrumentation. Reasons included one each, parental request resulting in termination of treatment and infection > 7 years after final fusion. CONCLUSION Most patients who develop SSIs during growing spine treatment are able to remain instrumented. Risk factors associated with developing multiple SSIs include infection earlier in the course of growing spine surgery, a resultant higher number of procedures following the initial infection and having a positive preoperative nasal Staphylococcus aureus screen. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Anne Marie Dumaine
- Division of Pediatric Orthopaedic Surgery, Rainbow Babies and Children's Hospital, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - James Yu
- Division of Pediatric Orthopaedic Surgery, Rainbow Babies and Children's Hospital, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Connie Poe-Kochert
- Division of Pediatric Orthopaedic Surgery, Rainbow Babies and Children's Hospital, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - George H Thompson
- Division of Pediatric Orthopaedic Surgery, Rainbow Babies and Children's Hospital, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - R Justin Mistovich
- Division of Pediatric Orthopaedic Surgery, Rainbow Babies and Children's Hospital, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH, 44106, USA.
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Sun MMG, Buckler NJ, Al Nouri M, Howard JJ, Vaughan M, St Hilaire T, Sponseller PD, Smith JT, Thompson GH, El-Hawary R. No Difference in the Rates of Unplanned Return to the Operating Room Between Magnetically Controlled Growing Rods and Traditional Growth Friendly Surgery for Children With Cerebral Palsy. J Pediatr Orthop 2022; 42:100-108. [PMID: 34619723 DOI: 10.1097/bpo.0000000000001892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Early-onset scoliosis (EOS) is common in children with cerebral palsy (CP). The effectiveness of magnetically controlled growing rods (MCGR) and the risk for unplanned return to the operating room (UPROR) remain to be studied in this patient population. The primary outcome of this study was to examine the frequency of UPROR between MCGRs as compared with traditional growth friendly (TGF) surgeries for children with EOS secondary to CP. METHODS Patients with EOS secondary to CP were prospectively identified from an international database, with data retrospectively analyzed. Scoliosis, kyphosis, T1-S1, and T1-T12 height were measured preoperation, immediate postoperation, and at minimum 2-year follow-up. The risk and etiology of UPRORs were compared between MCGR and TGF. RESULTS Of the 120 patients that met inclusion criteria, 86 received TGF (age 7.5±0. 1.8 y; mean follow-up 7.0±2.9 y) and 34 received MCGR (age 7.1±2.2 y, mean follow-up 2.8±0.0.5 y). Compared with TGF, MCGR resulted in significant improvements in maintenance of scoliosis (P=0.007). At final follow-up, UPRORs were 8 of 34 patients (24%) for MCGR and 37 of 86 patients (43%) for TGF (P=0.05). To minimize the influence of follow-up period, UPRORs within the first 2 years postoperation were evaluated: MCGR (7 of 34 patients, 21%) versus TGF (20 of 86 patients, 23%; P=0.75). Within the first 2 years, etiology of UPROR as a percentage of all patients per group were deep infection (13% TGF, 6% MCGR), implant failure/migration (12% TGF, 9% MCGR), dehiscence (4% TGF, 3% MCGR), and superficial infection (4% TGF, 3% MCGR). The most common etiology of UPROR for TGF was deep infection and for MCGR was implant failure/migration. CONCLUSION For patients with EOS secondary to CP, there was no difference in the risk of UPROR within the first 2 years postoperatively whether treated with TGF surgery or with MCGRs (23% TGF, 21% MCGR). LEVEL OF EVIDENCE Level III-retrospective cohort, therapeutic study.
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Affiliation(s)
- Margaret Man-Ger Sun
- Department of Medicine, Dalhousie University
- Department of Orthopaedics, IWK Health Centre, Halifax, NS, Canada
| | - Nicholas J Buckler
- Department of Medicine, Dalhousie University
- Department of Orthopaedics, IWK Health Centre, Halifax, NS, Canada
| | - Mason Al Nouri
- Department of Orthopaedics, IWK Health Centre, Halifax, NS, Canada
| | - Jason J Howard
- Department of Orthopaedics, A.I. Dupont Institute in Wilmington, Delaware
| | - Majella Vaughan
- Department of Orthopaedics, Pediatric Spine Foundation, Valley Forge, PA
| | - Tricia St Hilaire
- Department of Orthopaedics, Pediatric Spine Foundation, Valley Forge, PA
| | | | - John T Smith
- Department of Orthopaedics, University of Utah, Salt Lake City, UT
| | - George H Thompson
- Department of Orthopaedics, Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Ron El-Hawary
- Department of Orthopaedics, IWK Health Centre, Halifax, NS, Canada
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Saarinen AJ, Sponseller PD, Andras LM, Skaggs DL, Emans JB, Thompson GH, Helenius IJ. Matched Comparison of Magnetically Controlled Growing Rods with Traditional Growing Rods in Severe Early-Onset Scoliosis of ≥90°: An Interim Report on Outcomes 2 Years After Treatment. J Bone Joint Surg Am 2022; 104:41-48. [PMID: 34644282 DOI: 10.2106/jbjs.20.02108] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Severe early-onset scoliosis (EOS) is managed surgically but represents a challenge due to limited implant fixation points, large curve size, and fragile patients with comorbidities. Magnetically controlled growing rods (MCGRs) have the advantage of avoiding surgical intervention for routine lengthening, but their ability to address severe EOS has not been studied, to our knowledge. METHODS A retrospective review of a prospectively collected international database identified 44 children with severe (≥90°) EOS treated with MCGRs who met our study criteria. Etiology, age, and sex-matched patients treated with traditional growing rods (TGRs) were identified from the same database. Patients were evaluated at a 2-year follow-up. No patients with vertically expandable prosthetic titanium ribs (VEPTRs) were included. The health-related quality of life was evaluated with the 24-Item Early Onset Scoliosis Questionnaire (EOSQ-24). RESULTS The mean preoperative major coronal curve was 104° in the MCGR group and 104° in the TGR group. At the 2-year follow-up, the mean major coronal curves were 52° and 66° (p = 0.001), respectively. The mean T1-T12 heights were 155 mm and 152 mm preoperatively and 202 mm and 192 mm at the 2-year follow-up (p = 0.088). According to Kaplan-Meier analysis, the 2-year unplanned-revision-free survival was 91% in the MCGR group and 71% in the TGR group (p < 0.005). The 2-year score in the EOSQ-24 pulmonary function domain was better in the MCGR group. There were no other significant differences in the EOSQ-24 scores between the groups. CONCLUSIONS MCGRs for severe EOS provided significantly better major curve correction with significantly fewer unplanned revisions than TGRs at a 2-year follow-up. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Antti J Saarinen
- Department of Paediatric Orthopaedic Surgery, University of Turku and Turku University Hospital, Turku, Finland.,Department of Orthopaedics and Traumatology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Paul D Sponseller
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Lindsay M Andras
- Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, California
| | - David L Skaggs
- Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, California
| | - John B Emans
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - George H Thompson
- Division of Pediatric Orthopaedic Surgery, Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, Ohio
| | - Ilkka J Helenius
- Department of Orthopaedics and Traumatology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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15
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Roye BD, Fano AN, Matsumoto H, Fields MW, Emans JB, Sponseller P, Smith JT, Thompson GH, White KK, Vitale MG. The Impact of Unplanned Return to the Operating Room on Health-related Quality of Life at the End of Growth-friendly Surgical Treatment for Early-onset Scoliosis. J Pediatr Orthop 2022; 42:17-22. [PMID: 34739432 DOI: 10.1097/bpo.0000000000002006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Limiting complications, especially unplanned return to the operating room (UPROR), is a major focus in the surgical management of early-onset scoliosis (EOS). Although UPROR remains common in this population, its effect on long-term health-related quality of life (HRQoL) remains unclear. The purpose of this study was to investigate the association between UPROR and end-of-treatment HRQoL in EOS patients treated with growth-friendly instrumentation. METHODS Patients with EOS who underwent growth-friendly instrumentation at age less than 10 years from 1993 to 2018, and completed treatment, were identified in a multicenter EOS registry. UPROR events were recorded, and end-of-treatment (defined as skeletal maturity and/or definitive spinal fusion) HRQoL was assessed via the 24-item Early-Onset Scoliosis Questionnaire (EOSQ-24). RESULTS A total of 825 patients were identified, and 325 patients (age at surgery: 6.4 y, follow-up: 8.1 y) had end-of-treatment HRQoL data necessary for our investigation. Overall, 129/325 (39.7%) patients experienced 264 UPROR events; the majority (54.2%) were implant-related. Aside from age and etiology, no other variables were determined to be confounders or effect modifiers. Congenital patients with UPROR had worse pain/discomfort by 10.4 points (P=0.057) and worse pulmonary function by 7.8 points (P=0.102) compared with non-UPROR patients adjusting for age. Neuromuscular patients with UPROR had worse pulmonary function by 10.1 points compared with non-UPROR patients adjusting for age (P=0.037). Idiopathic and syndromic patients with UPROR reported consistently worse domain scores than their non-UPROR counterparts, but smaller (<5-point) differences were seen. CONCLUSIONS UPROR during growth-friendly surgical treatment for EOS is associated with worse HRQoL in all patients, but particularly in those with neuromuscular or congenital etiologies. Ongoing efforts to avoid UPROR are critical. LEVEL OF EVIDENCE Level II. This is a multicenter retrospective cohort study investigating the effect of UPROR on HRQoL (prognostic study).
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Affiliation(s)
- Benjamin D Roye
- Division of Pediatric Orthopaedic Surgery, Department of Orthopaedic Surgery, Columbia University Irving Medical Center
- Department of Pediatric Orthopaedic Surgery, New York-Presbyterian Morgan Stanley Children's Hospital
| | - Adam N Fano
- Division of Pediatric Orthopaedic Surgery, Department of Orthopaedic Surgery, Columbia University Irving Medical Center
| | - Hiroko Matsumoto
- Division of Pediatric Orthopaedic Surgery, Department of Orthopaedic Surgery, Columbia University Irving Medical Center
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY
| | - Michael W Fields
- Division of Pediatric Orthopaedic Surgery, Department of Orthopaedic Surgery, Columbia University Irving Medical Center
| | - John B Emans
- Department of Orthopedic Surgery, Boston Children's Hospital, Boston, MA
| | - Paul Sponseller
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - John T Smith
- Department of Orthopaedic Surgery, Primary Children's Hospital, Salt Lake City, UT
| | - George H Thompson
- Department of Orthopaedic Surgery, Rainbow Babies & Children's Hospital, Cleveland, OH
| | - Klane K White
- Department of Orthopedics and Sports Medicine, Seattle Children's Hospital, Seattle, WA
| | - Michael G Vitale
- Division of Pediatric Orthopaedic Surgery, Department of Orthopaedic Surgery, Columbia University Irving Medical Center
- Department of Pediatric Orthopaedic Surgery, New York-Presbyterian Morgan Stanley Children's Hospital
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16
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Akbarnia BA, Pawelek JB, Hosseini P, Salari P, Kabirian N, Marks D, Shah SA, Skaggs DL, Emans JB, Elsebaie H, Thompson GH, Sponseller PD. Treatment of Early-onset Scoliosis: Similar Outcomes Despite Different Etiologic Subtypes in Traditional Growing Rod Graduates. J Pediatr Orthop 2022; 42:10-16. [PMID: 34739435 DOI: 10.1097/bpo.0000000000001985] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND It is unclear whether traditional growing rod (TGR) treatment outcomes vary by early-onset scoliosis (EOS) subtype. The goal of this study was to compare radiographic outcomes and complications of TGR treatment by EOS subtype. METHODS We queried an international database of EOS patients from 20 centers to identify "graduates" who had (1) undergone primary TGR treatment from 1993 to 2014; (2) completed TGR treatment; and (3) had an uneventful clinical examination within 6 months after completion of TGR treatment with no anticipated further intervention. We included 202 patients in 4 etiologic subgroups: neuromuscular (n=65), syndromic (n=57), idiopathic (n=52), and congenital (n=28). Mean age at surgery was 7.1 years (range, 1.6 to 14.9 y); mean duration of follow-up was 8 years (range, 2 to 18.6 y). The groups did not differ by mean age, body mass index, sex, number of lengthenings, or duration of follow-up. The following preoperative differences were significant: (1) greater mean major curve in the neuromuscular versus idiopathic subgroup; (2) shorter spinal height (T1-S1) in the congenital versus idiopathic subgroup; and (3) smaller proportion of ambulatory patients in the neuromuscular subgroup versus all other subgroups. RESULTS We found no significant differences among subgroups in mean major curve correction or changes in thoracic height (T1-T12), spinal height, or global kyphosis at any point. Rates of deep surgical site infection, implant-related complications, and neurological complications were not different among subgroups. The medical complication rate was significantly lower in the idiopathic group compared with the other groups. CONCLUSIONS Major curve correction and spinal and thoracic height increases did not differ significantly at any point by EOS subtype. Rates of deep surgical site infection, implant-related complications, and neurological complications did not differ by subtype. Except for the lower rate of medical complications in the idiopathic group, our findings suggest that, after TGR treatment, patients can expect similar outcomes regardless of their EOS subtype. LEVEL OF EVIDENCE Level III, therapeutic.
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Affiliation(s)
- Behrooz A Akbarnia
- San Diego Spine Foundation, San Diego
- Department of Orthopaedic Surgery, University of California San Diego School of Medicine, La Jolla
| | | | | | | | | | - David Marks
- Birmingham Children's Hospital, Birmingham, UK
| | - Suken A Shah
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
| | - David L Skaggs
- Children's Orthopedic Center, Children's Hospital Los Angeles, Los Angeles, CA
| | - John B Emans
- Division of Spine Surgery, Department of Orthopedic Surgery, Harvard Medical School, Boston, MA
| | | | - George H Thompson
- Department of Orthopaedic Surgery, Division of Pediatric Orthopaedic Surgery, Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Paul D Sponseller
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
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17
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Thompson GH. Marr P. Mullen, MD, 1929-2020 : The SRS Losses another Founding Member. Spine Deform 2021. [PMID: 34902117 DOI: 10.1007/s43390-021-00456-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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18
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Erkilinc M, Dumaine AM, Du JY, Poe-Kochert C, Thompson GH, Liu RW, Mistovich RJ. Postoperative Correction in Idiopathic Scoliosis: Which Preoperative Imaging Technique Is Most Predictive? J Pediatr Orthop 2021; 41:e706-e711. [PMID: 34354030 DOI: 10.1097/bpo.0000000000001846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Preoperative radiographic assessment of curve flexibility in patients with idiopathic scoliosis is important to determine Lenke classification, operative levels, and potential postoperative correction. However, no consensus exists regarding the optimal technique. We compared measurements from supine side bending (SB) and intraoperative traction radiographs under general anesthesia (TUGA) with actual postoperative correction followed for 1 year. METHODS We identified 235 patients with idiopathic scoliosis who underwent posterior spinal fusion with pedicle screw instrumentation between 2010 and 2018 who had preoperative and postoperative radiographs including standing posterior-anterior (PA) and lateral radiographs, preoperative SB radiographs, and TUGA radiographs. Curves were categorized into proximal thoracic, main thoracic/thoracolumbar (MT), and distal thoracolumbar/lumbar (TL/L) curves. Flexibility was calculated from SB and TUGA radiographs. Correction rates were calculated from 1 month and 1 year radiographs postoperatively. Bending radiographs that correlated significantly with postoperative correction with P<0.10 were eligible for inclusion. Preoperative demographics, etiology, deformity details, and surgical details were included in the multivariate models. RESULTS On univariate analysis, TUGA radiographs correlated with postoperative correction at 1 month and 1 year on MT curves (r=0.214, P=0.001; r=0.209, P=0.001) and TL/L curves (r=0.280, P<0.001; r=0.181, P=0.006). Supine SB radiographs did not correlate with postoperative correction on either MT or T/TL curves. On multivariate analysis, major curve TUGA radiographs were independently associated with postoperative MT curve correction at 1 month (beta: 0.158, 95% confidence interval: 0.035-0.280, P=0.012) and 1 year (beta: 0.195, 95% confidence interval: 0.049-0.340, P=0.009). MT curve SB radiographs were not associated with postoperative major curve correction at 1 month (P=0.088). CONCLUSIONS TUGA radiographs independently correlated with postoperative main thoracic and distal thoracolumbar/lumbar curve correction at 1 month and 1 year postoperatively. SB radiographs independently correlated only with TL/L curve correction at 1 year postoperatively. However, this correlation was not as strong as TUGA correction (beta of 0.280 vs. beta of 0.092). TUGA radiographs appear superior to SB radiographs at predicting curve correction after surgery. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Mehmet Erkilinc
- Division of Pediatric Orthopaedic Surgery, Rainbow Babies and Children's Hospital, University Hospitals Cleveland Medical Center, CaseWestern Reserve University School of Medicine, Cleveland, OH
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19
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Clement RC, Yaszay B, McClung A, Bartley CE, Nabizadeh N, Skaggs DL, Thompson GH, Boachie-Adjei O, Sponseller PD, Shah SA, Sanders JO, Pawelek J, Mundis GM, Akbarnia BA. Growth-preserving instrumentation in early-onset scoliosis patients with multi-level congenital anomalies. Spine Deform 2021; 9:1491. [PMID: 34152580 DOI: 10.1007/s43390-021-00370-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 05/31/2021] [Indexed: 12/01/2022]
Affiliation(s)
- R Carter Clement
- Department of Orthopaedics, Children's Hospital of New Orleans, New Orleans, LA, USA
| | - Burt Yaszay
- Department of Orthopedics, Rady Children's Hospital, San Diego, CA, USA.
| | | | - Carrie E Bartley
- Department of Orthopedics, Rady Children's Hospital, San Diego, CA, USA
| | - Naveed Nabizadeh
- Department of Orthopedics, Rady Children's Hospital, San Diego, CA, USA
| | - David L Skaggs
- Children's Orthopedic Center, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - George H Thompson
- Rainbow Babies and Childrens Hospital, Case Western Reserve University, Cleveland, OH, USA
| | | | - Paul D Sponseller
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Suken A Shah
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - James O Sanders
- Department of Orthopedics, University of North Carolina, Chapel Hill, NC, USA
| | | | - Gregory M Mundis
- Department of Orthopaedics, Children's Hospital of New Orleans, New Orleans, LA, USA
| | - Behrooz A Akbarnia
- Department of Orthopeadics, University of California, San Diego, San Diego, CA, USA
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20
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Compton E, Gupta P, Gomez JA, Illingworth KD, Skaggs DL, Sponseller PD, Samdani AF, Hwang SW, Oetgen ME, Schottler J, Thompson GH, Vitale MG, Smith JT, Andras LM. How low can you go? Implant density in posterior spinal fusion converted from growing constructs for early onset scoliosis. Spine Deform 2021; 9:1479-1488. [PMID: 34228310 DOI: 10.1007/s43390-021-00321-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 02/22/2021] [Indexed: 10/20/2022]
Abstract
STUDY DESIGN Retrospective, multicenter comparative. OBJECTIVES Our purpose was to compare early onset scoliosis (EOS) patients treated with ultra-low, low, and high implant density constructs when undergoing conversion to definitive fusion. Larson et al. demonstrated that implant density (ID) at fusion does not correlate with outcomes in the treatment of adolescent idiopathic scoliosis, but did not address growth-friendly graduates. METHODS EOS patients treated with growth-friendly constructs converted to fusion between 2000 and 2017 were reviewed from a multicenter database. ID was defined as number of pedicle screws, hooks, and sublaminar/bands per level fused. Patients were divided into ultra-low ID (< 1.3), low (≥ 1.3 and < 1.6), and high ID (≥ 1.6). EXCLUSION CRITERIA < 2 years follow-up from fusion or inadequate radiographs. RESULTS A total of 152 patients met inclusion criteria with 39 (26%) patients in the high ID group, 33 (22%) patients in the low ID group, and 80 (52%) in the ultra-low ID group. Groups were similar in operative time (p = 0.61), pre-fusion major curve (p = 0.71), mean number of levels fused (p = 0.58), clinical follow-up (p = 0.30), and radiographic follow-up (p = 0.90). Patients in the low ID group (11.6 ± 1.5 years) were slightly younger at the time of definitive fusion than patients in the ultra-low ID group (12.9 ± 2.2 years) and high ID group (12.5 ± 1.7 years) (p = 0.009). There was significantly more blood loss in the high ID group than the other two groups (high ID: 946.8 ± 606.0 mL vs. low ID: 733.9 ± 434.5 mL and ultra-low ID: 617.4 ± 517.2 mL; p = 0.01), but there was no significant difference with regard to percent of total blood volume lost (high ID: 59.3 ± 48.7% vs. low ID: 54.5 ± 37.5% vs. ultra-low ID: 51.7 ± 54.9%; p = 0.78). There was a difference in initial improvement in major curve between the groups (high ID: 21.6° vs. low ID: 18.0° vs. ultra-low ID: 12.6°; p = 0.01). However, during post-fusion follow-up, correction decreased 7.1° in the high ID group, 2.6 in the low ID group, and 2.8 in the ultra-low ID group (p = 0.19). At final follow-up, major curve correction from pre-fusion was similar between groups (high ID: 14.5° vs. low ID: 15.5° vs. ultra-low ID: 9.7°, p = 0.14). At final follow-up, there was no difference in T1-T12 length gain (p = 0.85), T1-S1 length gain (p = 0.68), coronal balance (p = 0.56), or sagittal balance (p = 0.71). The revision rate was significantly higher in the ultra-low ID group (13.8%; 11/80) versus the high ID group (2/39; 5.1%) and low ID group (0/33; 0%) (p = 0.04). CONCLUSIONS Although an ID < 1.3 in growth-friendly graduates produces similar outcomes with regard to curve correction and spinal length gain as low and high ID, this study suggests that an ID < 1.3 is associated with an increased revision rate. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Edward Compton
- Children's Orthopaedic Center, Children's Hospital Los Angeles, 4650 Sunset Blvd, MS#69, Los Angeles, CA, 90027, USA
| | | | - Jaime A Gomez
- Division of Pediatric Orthopaedics, Children's Hospital At Montefiore Medical Center, Bronx, NY, USA
| | - Kenneth D Illingworth
- Children's Orthopaedic Center, Children's Hospital Los Angeles, 4650 Sunset Blvd, MS#69, Los Angeles, CA, 90027, USA
| | - David L Skaggs
- Children's Orthopaedic Center, Children's Hospital Los Angeles, 4650 Sunset Blvd, MS#69, Los Angeles, CA, 90027, USA
| | | | - Amer F Samdani
- Shriners Hospitals for Children-Philadelphia, Philadelphia, PA, USA
| | - Steven W Hwang
- Shriners Hospitals for Children-Philadelphia, Philadelphia, PA, USA
| | | | | | - George H Thompson
- Division of Pediatric Orthopaedic Surgery, Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, OH, USA
| | - Michael G Vitale
- Division of Pediatric Orthopedics, Columbia University Medical Center, New York, NY, USA
| | - John T Smith
- Department of Orthopedic Surgery, University of Utah, Salt Lake City, UT, USA
| | | | - Lindsay M Andras
- Children's Orthopaedic Center, Children's Hospital Los Angeles, 4650 Sunset Blvd, MS#69, Los Angeles, CA, 90027, USA.
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21
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Verhofste BP, Emans JB, Miller PE, Birch CM, Thompson GH, Samdani AF, Sanchez Perez-Grueso FJ, McClung AM, Glotzbecker MP. Growth-Friendly Spine Surgery in Arthrogryposis Multiplex Congenita. J Bone Joint Surg Am 2021; 103:715-726. [PMID: 33475309 DOI: 10.2106/jbjs.20.00600] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Arthrogryposis multiplex congenita (AMC) is a condition that describes neonates born with ≥2 distinct congenital contractures. Despite spinal deformity in 3% to 69% of patients, inadequate data exist on growth-friendly instrumentation (GFI) in AMC. Our study objectives were to describe current GFI trends in children with AMC and early-onset scoliosis (EOS) and to compare long-term outcomes with a matched idiopathic EOS (IEOS) cohort to determine whether spinal rigidity or extremity contractures influenced outcomes. METHODS Children with AMC and spinal deformity of ≥30° who were treated with GFI for ≥24 months were identified from a multicenter EOS database (1993 to 2017). Propensity scoring matched 35 patients with AMC to 112 patients with IEOS with regard to age, sex, construct, and curve. Multivariable linear mixed modeling compared changes in spinal deformity and the 24-item Early Onset Scoliosis Questionnaire (EOSQ-24) across cohorts. Cohort complications and reoperations were analyzed using multivariable Poisson regression. RESULTS Preoperatively, groups did not differ with regard to age (p = 0.87), sex (p = 0.96), construct (p = 0.62), rate of nonoperative treatment (p = 0.54), and major coronal curve magnitude (p = 0.96). After the index GFI, patients with AMC had reduced percentage of coronal correction (35% compared with 44%; p = 0.01), larger residual coronal curves (49° compared with 42°; p = 0.03), and comparable percentage of kyphosis correction (17% compared with 21%; p = 0.52). In GFI graduates (n = 81), final coronal curve magnitude (55° compared with 43°; p = 0.22) and final sagittal curve magnitude (47° compared with 47°; p = 0.45) were not significantly different at the latest follow-up after definitive surgery. The patients with AMC had reduced T1-S1 length (p < 0.001), comparable T1-S1 growth velocity (0.66 compared with 0.85 mm/month; p = 0.05), and poorer EOSQ-24 scores at the time of the latest follow-up (64 compared with 83 points; p < 0.001). After adjusting for ambulatory status and GFI duration, patients with AMC developed 51% more complications (incidence rate ratio, 1.51 [95% confidence interval (CI), 1.11 to 2.04]; p = 0.009) and 0.2 more complications/year (95% CI, 0.02 to 0.33 more; p = 0.03) compared with patients with IEOS. CONCLUSIONS Patients with AMC and EOS experienced less initial deformity correction after the index surgical procedure, but final GFI curve magnitudes and total T1-S1 growth during active treatment were statistically and clinically comparable with IEOS. Nonambulatory patients with AMC with longer GFI treatment durations developed the most complications. Multidisciplinary perioperative management is necessary to optimize GFI and to improve quality of life in this complex population. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Bram P Verhofste
- Department of Orthopaedic Surgery, Boston Children's Hospital (Harvard Teaching Hospital), Boston, Massachusetts
| | - John B Emans
- Department of Orthopaedic Surgery, Boston Children's Hospital (Harvard Teaching Hospital), Boston, Massachusetts
| | - Patricia E Miller
- Department of Orthopaedic Surgery, Boston Children's Hospital (Harvard Teaching Hospital), Boston, Massachusetts
| | - Craig M Birch
- Department of Orthopaedic Surgery, Boston Children's Hospital (Harvard Teaching Hospital), Boston, Massachusetts
| | - George H Thompson
- Department of Orthopaedic Surgery, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Amer F Samdani
- Shriners Hospital for Children, Philadelphia, Pennsylvania
| | | | | | - Michael P Glotzbecker
- Department of Orthopaedic Surgery, Rainbow Babies and Children's Hospital, Cleveland, Ohio
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Napora JK, Morris WZ, Gilmore A, Hardesty CK, Son-Hing J, Thompson GH, Liu RW. Purposeful Closed Reduction and Pinning in Unstable Slipped Capital Femoral Epiphysis Results in a Rate of Avascular Necrosis Comparable to the Literature Mean. Orthopedics 2021; 44:92-97. [PMID: 33561873 DOI: 10.3928/01477447-20210201-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The standard treatment of stable slipped capital femoral epiphysis (SCFE) is generally accepted to be in situ pinning. Controversy exists regarding the treatment of unstable SCFE, including the role of a purposeful closed reduction or open reduction. The objective of this study was to investigate the rate of avascular necrosis (AVN) with purposeful closed reduction and in situ pinning of unstable SCFE. The authors retrospectively reviewed 221 patients with 302 SCFE hips treated with in situ pinning between 2000 and 2014. Forty-eight patients (50 hips) presented with an unstable SCFE. All unstable SCFEs were treated by a gentle reduction method with traction and hip internal rotation followed by pinning. Southwick angles were measured prior to reduction and at the first postoperative visit. No stable SCFEs developed AVN. Thirteen (26%) unstable SCFEs developed AVN. Avascular necrosis developed in 7 of 17 (41%) hips screened with magnetic resonance imaging vs 6 of 33 (18%) hips screened with plain radiographs alone. Mean change in Southwick angle was 28°±8° in the AVN group vs 18°±18° in the no AVN group (P=.18). Despite potentially inflating the rate with the use of early detection magnetic resonance imaging, the authors found an AVN rate comparable to that in the published literature with the use of gentle purposeful reduction on a fracture table, and no statistical differences in reduction amount between patients with and without AVN. Gentle purposeful reduction appears to be a reasonable low morbidity option in the treatment of unstable SCFE without a clear increase in risk of AVN. [Orthopedics. 2021;44(2):92-97.].
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Li Y, Swallow J, Gagnier J, Thompson GH, Sturm PF, Emans JB, Sponseller PD, Glotzbecker MP. A report of two conservative approaches to early onset scoliosis: serial casting and bracing. Spine Deform 2021; 9:595-602. [PMID: 32989617 DOI: 10.1007/s43390-020-00213-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 09/12/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE Previous reports have demonstrated the effectiveness of casting for EOS. Brace treatment for EOS has not been studied. The purpose of this multicenter retrospective study was to compare radiographic outcomes, complications, and rates of conversion to surgery in children with EOS treated with casting or bracing. METHODS Children aged 2-6 years with idiopathic or neuromuscular EOS treated with casting or bracing with minimum follow-up of 2 years were identified. RESULTS 68 patients (36 cast, 32 brace) were analyzed. Diagnosis, age at start of treatment, and duration of follow-up were similar. Although the cast patients had a larger pre-treatment major curve magnitude (50° vs 31°, p < 0.001), both groups had a similar major curve magnitude at most recent follow-up (36° vs 32°, p = 0.456). T1-T12 and T1-S1 length increased in both groups. The cast and brace patients had similar complications and conversions to surgery. Sub-analysis showed that while casting resulted in curve improvement regardless of etiology, bracing was able to prevent curve progression in patients with idiopathic EOS but not in patients with non-idiopathic EOS (Δ- 15° vs 27°, p = 0.006). Regression analysis (significance p = 0.10) controlling for baseline age, major curve magnitude, and T1-T12 and T1-S1 length showed that treatment method was associated with difference in major curve magnitude (p = 0.090) and T1-T12 length (p = 0.024). CONCLUSION In our study, serial casting led to curve improvement in children with idiopathic and neuromuscular EOS, whereas brace treatment appeared to prevent curve progression in patients with idiopathic EOS but did not appear to control the curve in neuromuscular EOS.
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Affiliation(s)
- Ying Li
- Department of Orthopaedic Surgery, C.S. Mott Children's Hospital, Michigan Medicine, 1540 E. Hospital Dr., SPC 4241, Ann Arbor, MI, 48109-4241, USA.
| | - Jennylee Swallow
- Department of Orthopaedic Surgery, C.S. Mott Children's Hospital, Michigan Medicine, 1540 E. Hospital Dr., SPC 4241, Ann Arbor, MI, 48109-4241, USA
| | - Joel Gagnier
- Department of Orthopaedic Surgery, C.S. Mott Children's Hospital, Michigan Medicine, 1540 E. Hospital Dr., SPC 4241, Ann Arbor, MI, 48109-4241, USA
| | - George H Thompson
- Department of Orthopaedic Surgery, Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - Peter F Sturm
- Department of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - John B Emans
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Paul D Sponseller
- Department of Orthopaedic Surgery, Johns Hopkins Medicine, Baltimore, MD, USA
| | - Michael P Glotzbecker
- Department of Orthopaedic Surgery, Rainbow Babies and Children's Hospital, Cleveland, OH, USA
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Du JY, Poe-Kochert C, Thompson GH, Hardesty CK, Pawelek JB, Flynn JM, Emans JB. Risk Factors for Reoperation Following Final Fusion After the Treatment of Early-Onset Scoliosis with Traditional Growing Rods. J Bone Joint Surg Am 2020; 102:1672-1678. [PMID: 33027120 DOI: 10.2106/jbjs.20.00312] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although there is a high rate of reoperation after final fusion following the treatment of early-onset scoliosis with use of traditional growing rods, the risk factors for reoperation are unknown. The purpose of the present study was to identify risk factors associated with the need for reoperation after final fusion for the treatment of early-onset scoliosis. METHODS A multicenter database for patients with early-onset scoliosis was retrospectively analyzed. Patients managed with traditional growing rods and final fusion were identified (n = 248). The inclusion criteria were ≥1 lengthening procedure with traditional growing rods and ≥2 years of follow-up after final fusion or revision surgery within 2 years after final fusion (167 patients; 67%). Patients requiring reoperation following final fusion were compared with patients who did not require reoperation. The data that were analyzed included demographic characteristics, comorbidities, spinal deformity characteristics, radiographic measurements, perioperative details, and complications during all stages of treatment. A multivariate regression model was used to identify independent risk factors. RESULTS The mean duration of follow-up from the initial visit to the latest visit was 10.7 ± 4.1 years, and the mean duration of follow-up after final fusion was 4.9 ± 3.1 years. Thirty-two (19%) of the 167 patients required reoperation following final fusion. Curve progression requiring revision surgery during lengthening with traditional growing rods (adjusted odds ratio [aOR], 21.137 per event; p = 0.028), the number of levels spanned with traditional growing rods (aOR, 1.378 per level; p = 0.007), and the duration of treatment with traditional growing rods (aOR, 1.220 per year; p = 0.035) were independently associated with revision surgery after final fusion. CONCLUSIONS Independent risk factors for curve progression requiring reoperation during lengthening with traditional growing rods that require operative intervention include increasing number of levels spanned with traditional growing rods and longer duration of treatment with traditional growing rods. These findings may help with patient counseling and potentially guide surgeon decision-making. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Jerry Y Du
- Division of Pediatric Orthopaedics, Rainbow Babies and Children's Hospitals, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Connie Poe-Kochert
- Division of Pediatric Orthopaedics, Rainbow Babies and Children's Hospitals, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - George H Thompson
- Division of Pediatric Orthopaedics, Rainbow Babies and Children's Hospitals, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Christina K Hardesty
- Division of Pediatric Orthopaedics, Rainbow Babies and Children's Hospitals, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | | | - John M Flynn
- Division of Orthopedics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - John B Emans
- Division of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts
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Du JY, Poe-Kochert C, Thompson GH, Son-Hing JP, Hardesty CK, Mistovich RJ. One stage or two? A cohort analysis of anterior-posterior spinal fusions for severe pediatric scoliosis. Spine Deform 2020; 8:939-949. [PMID: 32399683 DOI: 10.1007/s43390-020-00128-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 04/20/2020] [Indexed: 10/24/2022]
Abstract
STUDY DESIGN Retrospective case-series study of prospectively collected data. OBJECTIVE We sought to identify the differences in outcomes between one-stage (single surgical episode) and two-stage (separate day) anterior and posterior spinal fusion and segmental spinal instrumentation surgeries in severe non-idiopathic and idiopathic scoliosis cases. BACKGROUND Patients with severe pediatric spine deformity may require combined anterior and posterior fusion procedures. Given their increased complexity and morbidity, surgeons may consider staging these procedures on separate days. METHODS A retrospective cohort study was performed on a prospective Pediatric Spine Database. Patients 21 years of age or under with pediatric scoliosis who underwent primary anterior and posterior spinal deformity correction surgery either through a one-stage or planned two-stage sequence with greater than 2-year follow-up were included. Differences in demographics, comorbidities, surgical details, perioperative morbidity, complications, and outcomes were assessed based on scoliosis etiology. Multivariate models were utilized to control for confounders. RESULTS There were 70 non-idiopathic (14 two-stage vs. 56 one-stage) and 65 idiopathic scoliosis (8 two-stage vs. 57 one-stage) patients. Mean follow-up was 90.1 ± 54.7 months. In non-idiopathic scoliosis patients, two-stage surgery was independently associated with a 140-min increased surgical time (95% confidence interval: 52-229 min, p = 0.002) and an 8.2-day (95% confidence interval: 2.3-14.1 days, p = 0.007) increased hospital length of stay. In idiopathic scoliosis patients, two-stage surgery was independently associated with a 2108 ml increase in crystalloid use (95% confidence interval: 834-3381 ml p = 0.002) and a 5.3-day increased hospital length of stay (95% confidence interval: 4.0-6.5 days, p < 0.001). There were no significant differences in blood loss, transfusions, complications, or post-operative curves on multivariate analysis between one-stage and two-stage surgery cohorts in either non-idiopathic or idiopathic scoliosis patient groups. CONCLUSION Two-stage surgery was associated with increased crystalloid use in idiopathic scoliosis patients and longer operative times in non-idiopathic scoliosis patients, and longer hospital length of stay in both populations, without significant difference in complications or deformity correction. In the appropriate patient, one-stage anterior-posterior scoliosis surgery may be preferable to two-stage surgery. LEVEL OF EVIDENCE Level III Retrospective Comparative Study.
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Affiliation(s)
- Jerry Y Du
- Division of Pediatric Orthopedics, Rainbow Babies and Children's Hospitals/ University Hospitals Cleveland Medical Center; Case Western Reserve University, 11100 Euclid Ave., Cleveland, OH, 44106, USA. .,Department of Orthopedic Surgery, University Hospitals Cleveland Medical Center/Case Western Reserve University, 11100 Euclid Ave., Cleveland, OH, 44106, USA.
| | - Connie Poe-Kochert
- Division of Pediatric Orthopedics, Rainbow Babies and Children's Hospitals/ University Hospitals Cleveland Medical Center; Case Western Reserve University, 11100 Euclid Ave., Cleveland, OH, 44106, USA
| | - George H Thompson
- Division of Pediatric Orthopedics, Rainbow Babies and Children's Hospitals/ University Hospitals Cleveland Medical Center; Case Western Reserve University, 11100 Euclid Ave., Cleveland, OH, 44106, USA
| | - Jochen P Son-Hing
- Division of Pediatric Orthopedics, Rainbow Babies and Children's Hospitals/ University Hospitals Cleveland Medical Center; Case Western Reserve University, 11100 Euclid Ave., Cleveland, OH, 44106, USA
| | - Christina K Hardesty
- Division of Pediatric Orthopedics, Rainbow Babies and Children's Hospitals/ University Hospitals Cleveland Medical Center; Case Western Reserve University, 11100 Euclid Ave., Cleveland, OH, 44106, USA
| | - R Justin Mistovich
- Division of Pediatric Orthopedics, Rainbow Babies and Children's Hospitals/ University Hospitals Cleveland Medical Center; Case Western Reserve University, 11100 Euclid Ave., Cleveland, OH, 44106, USA
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Poe-Kochert C, Shimberg JL, Thompson GH, Son-Hing JP, Hardesty CK, Mistovich RJ. Surgical site infection prevention protocol for pediatric spinal deformity surgery: does it make a difference? Spine Deform 2020; 8:931-938. [PMID: 32356280 DOI: 10.1007/s43390-020-00120-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 04/09/2020] [Indexed: 11/28/2022]
Abstract
STUDY DESIGN Retrospective. OBJECTIVE Can a standardized, hospital-wide care bundle decrease surgical site infection (SSI) rate in pediatric spinal deformity surgery? SSI is a major concern in pediatric spinal deformity surgery. METHODS We performed a retrospective review of our primary scoliosis surgeries between 1999 and 2017. In 2008, we implemented a standardized infection reduction bundle. Interventions included preoperative nares screening for methicillin-resistant staphylococcus aureus or methicillin-sensitive Staphylococcus aureus 2 weeks preoperatively, and treatment with intranasal mupirocin when positive, a bath or shower the night before surgery, a preoperative chlorohexidine scrub, timing of standardized antibiotic administration, standardized intraoperative re-dosing of antibiotics, limiting operating room traffic, and standardized postoperative wound care. In 2011, we added intrawound vancomycin powder at wound closure. Our inclusion criteria were patients 21 years of age or less with idiopathic, neuromuscular, syndromic, or congenital scoliosis who had a primary spinal fusion or a same day anterior and posterior spine fusion with segmental spinal instrumentation of six levels or more. We compared the incidence of early (within 90 days of surgery) and late (> 91 days) SSI during the first postoperative year. RESULTS There were 804 patients who met inclusion criteria: 404 in the non-bundle group (NBG) for cases prior to protocol change and 400 in the bundle group (BG) for cases after the protocol change. Postoperatively, there were 29 infections (7.2% of total cases) in the NBG: 9 early (2.2%) and 20 late (5.0%) while in the BG there were only 10 infection (2.5%): 6 early (1.5%) and 4 late (1.0%). The reduction in overall SSIs was statistically significant (p = 0.01). There was a trend toward decreased early infections in the BG, without reaching statistical significance (p = 0.14). CONCLUSION Standardized care bundles appear effective in reducing the incidence of postoperative pediatric spine SSIs. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Connie Poe-Kochert
- Rainbow Babies and Children's Hospital, University Hospitals Cleveland Medical Center, Cleveland, USA.,Case Western Reserve University School of Medicine, Cleveland, USA
| | - Jilan L Shimberg
- Case Western Reserve University School of Medicine, Cleveland, USA
| | - George H Thompson
- Rainbow Babies and Children's Hospital, University Hospitals Cleveland Medical Center, Cleveland, USA.,Case Western Reserve University School of Medicine, Cleveland, USA
| | - Jochen P Son-Hing
- Rainbow Babies and Children's Hospital, University Hospitals Cleveland Medical Center, Cleveland, USA.,Case Western Reserve University School of Medicine, Cleveland, USA
| | - Christina K Hardesty
- Rainbow Babies and Children's Hospital, University Hospitals Cleveland Medical Center, Cleveland, USA.,Case Western Reserve University School of Medicine, Cleveland, USA
| | - R Justin Mistovich
- Rainbow Babies and Children's Hospital, University Hospitals Cleveland Medical Center, Cleveland, USA. .,Case Western Reserve University School of Medicine, Cleveland, USA.
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Clement RC, Yaszay B, McClung A, Bartley CE, Nabizadeh N, Skaggs DL, Thompson GH, Boachie-Adjei O, Sponseller PD, Shah SA, Sanders JO, Pawelek J, Mundis GM, Akbarnia BA. Growth-preserving instrumentation in early-onset scoliosis patients with multi-level congenital anomalies. Spine Deform 2020; 8:1117-1130. [PMID: 32451975 DOI: 10.1007/s43390-020-00124-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 04/15/2020] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Retrospective. OBJECTIVES To assess final outcomes in patients with early-onset scoliosis (EOS) who underwent growth-preserving instrumentation (GPI). Various types of growth-preserving instrumentation (GPI) are frequently employed, but until recently had not been utilized long enough to assess final outcomes. METHODS GPI "graduates" with multi-level congenital curves were identified. Graduation was defined as a final fusion or 5 years of follow-up without planned future surgeries. Outcomes included radiographic parameters and complications. RESULTS 26 patients were included. 11 had associated diagnoses; eight had fused ribs. 17 were treated with traditional growing rods, seven with vertically expandable prosthetic ribs, and two with Shilla procedures. The mean GPI spanned 12.3 levels including 10.7 motion segments, age at index surgery was 5.5 years, treatment spanned 7.5 years, and follow-up was 9.2 years. 24 patients underwent final fusion. Mean major curve decreased from 73° to 49° with index surgery (p < 0.01) and remained unchanged through a final follow-up. Final major curve was < 40° in 9 patients (35%), 40°-60° in 11 patients (42%), and > 60° in 6 patients (23%). None worsened throughout treatment. Mean T1-T12 height increased 2.4 cm with index surgery (p = 0.02) and 5.4 cm total (p < 0.01). T1-T12 height increased in all patients and was ultimately < 18 cm in 10 patients (38%), 18-22 cm in 10 patients (38%), and > 22 cm in 6 patients (23%). On average, there were 2.6 complications per patient, including 1.7 implant failures. 12 patients (46%) experienced ≥ 3 complications; four patients (15%) experienced none. CONCLUSION We observed successful prevention of deformity progression but substantial residual deformity among GPI graduates with multi-level congenital EOS. Most coronal curve correction was attained during GPI implantation; thoracic height improved throughout treatment. While some favorable results were found, treatment strategies allowing improved deformity correction would be valuable for this challenging population. LEVEL OF EVIDENCE Therapeutic-III.
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Affiliation(s)
- R Carter Clement
- Department of Pediatric Orthopedic Surgery, Children's Hospital of New Orleans, Orleans, LA, USA
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, New Orleans, USA
| | - Burt Yaszay
- Department of Orthopedics, Rady Children's Hospital, 3030 Children's Way, San Diego, CA, MC506292123, USA.
| | | | - Carrie E Bartley
- Department of Orthopedics, Rady Children's Hospital, 3030 Children's Way, San Diego, CA, MC506292123, USA
| | - Naveed Nabizadeh
- Department of Orthopedic Surgery, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Islamic Republic of Iran
| | - David L Skaggs
- Children's Orthopedic Center, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - George H Thompson
- Rainbow Babies & Childrens Hospital, Case Western Reserve University, Cleveland, OH, USA
| | | | - Paul D Sponseller
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Suken A Shah
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - James O Sanders
- Department of Orthopaedics, University of Rochester, Rochester, NY, USA
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Ina J, Poe-Kochert C, Hardesty CK, Son-Hing JP, Tripi P, Thompson GH. Intrathecal Morphine in the Presence of a Syrinx in Pediatric Spinal Deformity Surgery. J Pediatr Orthop 2020; 40:e272-e276. [PMID: 31876701 DOI: 10.1097/bpo.0000000000001495] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Intrathecal morphine (IM) is a popular adjunct for pain relief during pediatric spinal deformity surgery. There is no literature regarding its usefulness and safety in the presence of a spinal cord syrinx for patients undergoing spinal instrumentation. Anesthesiologists have previously been reluctant to use IM in the presence of any syrinx. METHODS We retrospectively reviewed all patients with a preoperatively diagnosed spinal cord syrinx undergoing spinal deformity surgery who received IM and did not receive IM (non-IM). We recorded location of the syrinx, surgical time, length of stay, unexpected pediatric intensive care unit (PICU) admission, IM related complications (neurological, respiratory depression, or pruritus, nausea/vomiting), and reason for no IM administration. Patients with a syrinx and myelodysplasia (8), tethered spinal cord (4), paraplegia (1), holocord (1), neuroblastoma (1), and spinal cord glioma (1) were not given IM. Other reasons included a failed attempt (1), expectedly short surgical time (1), and anesthesiologist declined (2). RESULTS There were 42 patients who met the inclusion criteria. Twenty-two patients received IM, while 20 patients did not. Patients receiving IM had 4 cervical, 5 cervicothoracic, 12 thoracic syrinxes, and 1 holocord syrinx. The non-IM group had 8 cervicothoracic, 6 thoracic, 4 holocord syrinxes, and 2 had unclassified locations. There were no neurological complications in the IM group, and 1 patient experienced respiratory depression following a shorter than expected surgery and was observed overnight in the PICU. One patient in the non-IM group with a holocord syrinx had temporary lower extremity weakness postoperatively that completely resolved and 4 patients were unexpectedly admitted to the PICU. Pruritus and nausea/vomiting was mild and similar in both groups. CONCLUSIONS Our study demonstrates that with careful preoperative evaluation, most patients with a spinal cord syrinx can safely be given IM. Certain patients, such as those with a spinal holocord syrinx may have anatomic reasons to avoid IM, but those who are deemed appropriate for IM can receive it safely. LEVEL OF EVIDENCE Level III-therapeutic study; retrospective comparative study.
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Affiliation(s)
| | | | | | | | - Paul Tripi
- Division of Pediatric Anesthesiology, Rainbow Babies and Children's Hospital at University Hospitals Cleveland Medical Center, Cleveland, OH
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Helenius IJ, Saarinen AJ, White KK, McClung A, Yazici M, Garg S, Thompson GH, Johnston CE, Pahys JM, Vitale MG, Akbarnia BA, Sponseller PD. Results of growth-friendly management of early-onset scoliosis in children with and without skeletal dysplasias. Bone Joint J 2019; 101-B:1563-1569. [DOI: 10.1302/0301-620x.101b12.bjj-2019-0735.r1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims The aim of this study was to compare the surgical and quality-of-life outcomes of children with skeletal dysplasia to those in children with idiopathic early-onset scoliosis (EOS) undergoing growth-friendly management. Patients and Methods A retrospective review of two prospective multicentre EOS databases identified 33 children with skeletal dysplasia and EOS (major curve ≥ 30°) who were treated with growth-friendly instrumentation at younger than ten years of age, had a minimum two years of postoperative follow-up, and had undergone three or more lengthening procedures. From the same registries, 33 matched controls with idiopathic EOS were identified. A total of 20 children in both groups were treated with growing rods and 13 children were treated with vertical expandable prosthetic titanium rib (VEPTR) instrumentation. Results Mean preoperative major curves were 76° (34° to 115°) in the skeletal dysplasia group and 75° (51° to 113°) in the idiopathic group (p = 0.55), which were corrected at final follow-up to 49° (13° to 113°) and 46° (12° to 112°; p = 0.68), respectively. T1-S1 height increased by a mean of 36 mm (0 to 105) in the skeletal dysplasia group and 38 mm (7 to 104) in the idiopathic group at the index surgery (p = 0.40), and by 21 mm (1 to 68) and 46 mm (7 to 157), respectively, during the distraction period (p = 0.0085). The skeletal dysplasia group had significantly worse scores in the physical function, daily living, financial impact, and parent satisfaction preoperatively, as well as on financial impact and child satisfaction at final follow-up, than the idiopathic group (all p < 0.05). The domains of the 24-Item Early-Onset Scoliosis Questionnaire (EOSQ24) remained at the same level from preoperative to final follow-up in the skeletal dysplasia group (all p > 0.10). Conclusion Children with skeletal dysplasia gained significantly less spinal growth during growth-friendly management of their EOS and their health-related quality of life was significantly lower both preoperatively and at final follow-up than in children with idiopathic EOS. Cite this article: Bone Joint J 2019;101-B:1563–1569
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Affiliation(s)
- Ilkka J. Helenius
- Department of Paediatric Orthopaedic Surgery, University of Turku and Turku University Hospital, Turku, Finland
| | - Antti J. Saarinen
- Department of Paediatric Orthopaedic Surgery, University of Turku and Turku University Hospital, Turku, Finland
| | - Klane K. White
- Department of Orthopaedics and Sports Medicine, Seattle Children’s Hospital, Seattle, Washington, USA
| | - Anna McClung
- Pediatric Spine Study Group, Children’s Spine Foundation, Valley Forge, Pennsylvania, USA
| | - Muharrem Yazici
- Department of Orthopaedics, Faculty of Medicine, Hacettepe University, Sihhiye, Ankara, Turkey
| | - Sumeet Garg
- Department of Pediatric Orthopaedics and Spine Surgery, Children’s Hospital Colorado, Aurora, Colorado, USA
| | - George H. Thompson
- Division of Pediatric Orthopaedic Surgery, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, Ohio, USA
| | | | - Joshua M. Pahys
- Department of Orthopaedic Surgery, Shiners Hospitals for Children, Philadelphia, Pennsylvania, USA
| | | | - Behrooz A. Akbarnia
- Department of Orthopaedic Surgery, University of California-San Diego, La Jolla, San Diego, California, USA
| | - Paul D. Sponseller
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland, USA
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Moyer K, Thompson GH, Poe-Kochert C, Splawski J. Superior Mesenteric Artery Syndrome Complicated by Gastric Mucosal Necrosis Following Congenital Scoliosis Surgery: A Case Report. JBJS Case Connect 2019; 9:e0380. [PMID: 31584907 DOI: 10.2106/jbjs.cc.18.00380] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
CASE This is a report of severe superior mesenteric artery (SMA) syndrome in an 11-year-old girl with congenital scoliosis following posterior spinal fusion and segmental spinal instrumentation. This was complicated by gastric mucosal necrosis but resolved satisfactory with prolonged nasogastric suction, intravenous fluids, and total parental nutrition. CONCLUSIONS All pediatric spine surgeons should be aware of SMA syndrome following spine surgery. This case demonstrates that although rare, significant complications such as gastric mucosal necrosis can occur. When present, it can be treated successfully with prolonged conservative management. Comanagement with pediatric gastroenterology and pediatric general surgery is recommended.
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Affiliation(s)
- Kathleen Moyer
- Department of Pediatrics, Division of Pediatric Gastroenterology, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia
| | - George H Thompson
- Department of Orthopaedic Surgery, Division of Pediatric Orthopaedic Surgery, Cleveland Medical Center University Hospitals, Rainbow Babies & Children's Hospital, Cleveland, Ohio
| | - Constance Poe-Kochert
- Department of Orthopaedic Surgery, Division of Pediatric Orthopaedic Surgery, Cleveland Medical Center University Hospitals, Rainbow Babies & Children's Hospital, Cleveland, Ohio
| | - Judy Splawski
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Cleveland Medical Center University Hospitals, Rainbow Babies & Children's Hospital, Cleveland, Ohio
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Du JY, Poe-Kochert C, Thompson GH, Son-Hing JP, Hardesty CK, Mistovich RJ. Risk Factors for Early Infection in Pediatric Spinal Deformity Surgery: A Multivariate Analysis. Spine Deform 2019; 7:410-416. [PMID: 31053311 DOI: 10.1016/j.jspd.2018.09.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 09/11/2018] [Accepted: 09/15/2018] [Indexed: 11/17/2022]
Abstract
STUDY DESIGN Retrospective case-control study. OBJECTIVES To identify risk factors for early deep surgical site infections (SSIs; within three months of index procedure) following pediatric spinal deformity surgery. BACKGROUND Deep surgical site infections (SSIs) following pediatric spinal deformity surgery are a source of significant morbidity. We sought to identify independent risk factors for early infection following primary, definitive single-stage pediatric posterior spinal fusion and instrumentation (PSFI). METHODS A total of 616 consecutive patients (2001-2016) from an institutional prospectively maintained Pediatric Orthopaedic Spine database were identified that met inclusion criteria of definitive single-stage PSFI. Early deep SSI was defined as infection within three months of index procedure requiring surgical intervention. A multivariate analysis of demographics, comorbidities, and perioperative factors was performed and independent risk factors were identified. RESULTS Eleven patients (1.6%) developed an early deep SSI. Independent risk factors for SSI identified were nonidiopathic (neuromuscular, syndromic, and congenital) etiologies of scoliosis (adjusted odds ratio [aOR]: 8.384, 95% confidence interval [CI]: 1.784-39.386, p = .007) and amount of intraoperative crystalloids (aOR: 1.547 per additional liter of fluid, 95% CI: 1.057-2.263, p = .025). Mean crystalloid administered in the SSI group was 3.3 ± 1.2 L versus 2.4 ± 1.0 L in the noninfected group (p = .019). On univariate analysis, there was no significant difference in weight of patients between cohorts (p = .869) or surgery time (p = .089). There was also no significant difference in infection rates from redosing of antibiotics intraoperatively after 3 hours of surgery (p = .231). CONCLUSIONS Nonidiopathic scoliosis and amount of intraoperative crystalloids were independently associated with early postoperative SSI. Further investigation into intraoperative fluid management may identify modifiable risk factors for early postoperative SSI in primary pediatric spinal deformity posterior spinal fusion patients. LEVEL OF EVIDENCE Level III, case-control study.
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Affiliation(s)
- Jerry Y Du
- Division of Pediatric Orthopaedics, Rainbow Babies & Children's Hospitals/University Hospitals Cleveland Medical Center, Case Western Reserve University, 11100 Euclid Ave., Cleveland, OH 44106, USA.
| | - Connie Poe-Kochert
- Division of Pediatric Orthopaedics, Rainbow Babies & Children's Hospitals/University Hospitals Cleveland Medical Center, Case Western Reserve University, 11100 Euclid Ave., Cleveland, OH 44106, USA
| | - George H Thompson
- Division of Pediatric Orthopaedics, Rainbow Babies & Children's Hospitals/University Hospitals Cleveland Medical Center, Case Western Reserve University, 11100 Euclid Ave., Cleveland, OH 44106, USA
| | - Jochen P Son-Hing
- Division of Pediatric Orthopaedics, Rainbow Babies & Children's Hospitals/University Hospitals Cleveland Medical Center, Case Western Reserve University, 11100 Euclid Ave., Cleveland, OH 44106, USA
| | - Christina K Hardesty
- Division of Pediatric Orthopaedics, Rainbow Babies & Children's Hospitals/University Hospitals Cleveland Medical Center, Case Western Reserve University, 11100 Euclid Ave., Cleveland, OH 44106, USA
| | - R Justin Mistovich
- Division of Pediatric Orthopaedics, Rainbow Babies & Children's Hospitals/University Hospitals Cleveland Medical Center, Case Western Reserve University, 11100 Euclid Ave., Cleveland, OH 44106, USA
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Connell B, Oore JJ, Pahys JM, Thompson GH, St Hilaire T, Flynn T, El-Hawary R. Growth-Friendly Surgery Is Effective at Treating Early-Onset Scoliosis Associated With Goldenhar Syndrome. Spine Deform 2019; 6:327-333. [PMID: 29735145 DOI: 10.1016/j.jspd.2017.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Accepted: 11/12/2017] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate the radiographic results and complications of growth-friendly (GF) surgery in the treatment of early-onset scoliosis (EOS) associated with Goldenhar syndrome. BACKGROUND Goldenhar syndrome has been associated with spinal deformity, which may be progressive. Efficacy and complication rate of GF treatment has not been reported for this population of patients with EOS. METHODS Patients with Goldenhar syndrome and EOS with two years' follow-up were identified from two international multicenter EOS databases. Scoliosis, kyphosis, spine height, and hemithoracic height/width were determined preimplant, immediately postoperative, and at the two-year follow-up. Severity of complications (SV) was recorded (Smith et al. JPO 2015). RESULTS Ten patients met inclusion criteria and had a mean age of 4.6 ± 2.5 years at GF implantation (one spine and nine rib-based). Mean preoperative scoliosis was 64°, postimplant 52°, and at mean follow up of 2.4 ± 0.5 years was 50° (p = .09). Preoperative kyphosis was 36°, postimplant 38°, and final 42° (p = .08). Preoperative T1-S1 height was 23.5 cm, postimplant 23.6 cm, and final 27.3 cm (p = .06). Preoperative convex hemithoracic height was 10.4 cm, postimplant 7.9 cm, and final 12.8 cm (p < .05). Preoperative concave hemithoracic height was 8.4 cm, postimplant 8.8 cm, and final 9.9 cm (p = .30). Preoperative right hemithoracic width was 8.02 cm, postimplant 7.22 cm, and final 7.86 cm (p = .07). Preoperative left hemithoracic width was 7.18 cm, postimplant 7.86 cm, and final 8.60 cm (p = .43). Eight patients had ≥1 complication with SV I (n = 7), SV II (n = 2), and SV IIA (n = 7). These included infection (n = 4), migration (n = 3), pneumonia (n = 2), and instrumentation failure (n = 2). CONCLUSION At minimum two-year follow-up, GF surgical intervention for the treatment of EOS associated with Goldenhar syndrome trended toward improvements in scoliosis and spine height, but had a significant improvement in convex hemithoracic height; however, the majority of patients experienced severity grade I or II complications. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Braydon Connell
- Department of Medicine, Dalhousie University, 6299 South St, Halifax, NS B3H 4R2, Canada; IWK Health Centre, 5980 University Ave, Halifax, NS B3K 6R8, Canada.
| | - Jonathan J Oore
- Department of Medicine, Dalhousie University, 6299 South St, Halifax, NS B3H 4R2, Canada; IWK Health Centre, 5980 University Ave, Halifax, NS B3K 6R8, Canada
| | - Joshua M Pahys
- Shriner's Hospital, 3551 N Broad St, Philadelphia, PA 19140, USA
| | - George H Thompson
- Rainbow Babies and Children's Hospital, 11100 Euclid Ave, Cleveland, OH 44106, USA
| | - Tricia St Hilaire
- Children's Spine Foundation, P.O. Box 397, Valley Forge, PA 19481, USA
| | - Tara Flynn
- Children's Spine Foundation, P.O. Box 397, Valley Forge, PA 19481, USA
| | - Ron El-Hawary
- Department of Medicine, Dalhousie University, 6299 South St, Halifax, NS B3H 4R2, Canada; IWK Health Centre, 5980 University Ave, Halifax, NS B3K 6R8, Canada
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Helenius IJ, Oksanen HM, McClung A, Pawelek JB, Yazici M, Sponseller PD, Emans JB, Sánchez Pérez-Grueso FJ, Thompson GH, Johnston C, Shah SA, Akbarnia BA. Outcomes of growing rod surgery for severe compared with moderate early-onset scoliosis: a matched comparative study. Bone Joint J 2018; 100-B:772-779. [PMID: 29855249 DOI: 10.1302/0301-620x.100b6.bjj-2017-1490.r1] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Aims The aim of this study was to compare the outcomes of surgery using growing rods in patients with severe versus moderate early-onset scoliosis (EOS). Patients and Methods A review of a multicentre EOS database identified 107 children with severe EOS (major curve ≥ 90°) treated with growing rods before the age of ten years with a minimum follow-up of two years and three or more lengthening procedures. From the same database, 107 matched controls with moderate EOS were identified. Results The mean preoperative major curve was 101° (90 to 139) in the severe group and 67° (33° to 88°) in the moderate group (p < 0.001), which was corrected at final follow-up to 57° (10° to 96°) in the severe group and 40° (3° to 85°) in the moderate group (p < 0.001). T1-S1 height increased by a mean of 54 mm (-8 to 131) in the severe group and 27 mm (-4 to 131) in the moderate group at the initial surgery (p < 0.001), and by 50 mm (-17 to 200) and 54 mm (-11 to 212), respectively, during distraction (p = 0.84). The mean number of complications per patient was 2.6 (0 to 14) in the severe group and 1.9 (0 to 10) in the moderate group (p = 0.040). Five patients (4.7%) in the severe group and three (2.8%) in the moderate group developed a neurological deficit postoperatively (p = 0.47). Conclusion Severe EOS can be treated effectively using growing rods, but the risk of complications is high. Cite this article: Bone Joint J 2018;100-B:772-9.
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Affiliation(s)
- I J Helenius
- University of Turku, Turku University Hospital, Turku, Finland and Consultant Orthopaedic Spine Surgeon, Spine Unit, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - H M Oksanen
- University of Turku and Turku University Hospital, Turku, Finland
| | - A McClung
- Growing Spine Foundation, Milwaukee, Wisconsin, USA
| | - J B Pawelek
- Growing Spine Foundation, San Diego, California, USA
| | - M Yazici
- Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | | | - J B Emans
- Children's Hospital Boston, Boston, Massachusetts, USA
| | | | - G H Thompson
- Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, Ohio, USA
| | - C Johnston
- Texas Scottish Rite Hospital, Dallas, Texas, USA
| | - S A Shah
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware, USA
| | - B A Akbarnia
- University of California San Diego, California, USA
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Thompson GH, Poe-Kochert C, Hardesty CK, Son-Hing J, Mistovich RJ. Does Vancomycin Powder Decrease Surgical Site Infections in Growing Spine Surgery?: A Preliminary Study. J Bone Joint Surg Am 2018; 100:466-471. [PMID: 29557862 DOI: 10.2106/jbjs.17.00459] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Vancomycin powder has been demonstrated to be safe in children, and yet there are no data on its use to reduce surgical site infections (SSIs) in surgery for early-onset scoliosis. METHODS We performed a retrospective study of our patients treated for early-onset scoliosis in the period of 2010 to 2016. In 2010, we updated our standardized perioperative growing spine care path. The only later change was the gradual introduction of intrawound vancomycin powder. Procedures were categorized into either the control group (without vancomycin powder) or the experimental group (with vancomycin powder), with otherwise identical perioperative management. Initial insertion, revision, and lengthening procedures and final fusions were included. We compared the rate of postoperative SSIs per procedure between the groups. RESULTS Thirty-six patients who underwent 191 procedures met the inclusion criteria. The clinical and radiographic data were essentially the same between the groups. During the study period, 14 (39%) of the 36 patients developed ≥1 deep SSI. Only 2 patients had multiple acute infections. There were 87 procedures with 12 infections in the control group (SSI rate of 13.8% per procedure), while there were 104 procedures with 5 infections in the vancomycin group (4.8% per procedure). The difference in the SSI rate per procedure was significant (p = 0.038). The number of individual procedures needed to be performed using vancomycin to prevent an SSI was 10.9. CONCLUSIONS The use of vancomycin powder in growing spine surgery for early-onset scoliosis is associated with a significant decreased risk of SSI. It appears to be effective even when previous surgeries have been performed without its use. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- George H Thompson
- Division of Pediatric Orthopaedic Surgery, Rainbow Babies and Children's Hospital, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Connie Poe-Kochert
- Division of Pediatric Orthopaedic Surgery, Rainbow Babies and Children's Hospital, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Christina K Hardesty
- Division of Pediatric Orthopaedic Surgery, Rainbow Babies and Children's Hospital, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Jochen Son-Hing
- Division of Pediatric Orthopaedic Surgery, Rainbow Babies and Children's Hospital, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - R Justin Mistovich
- Division of Pediatric Orthopaedic Surgery, Rainbow Babies and Children's Hospital, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
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Luhmann SJ, Smith JC, McClung A, McCullough FL, McCarthy RE, Thompson GH. Radiographic Outcomes of Shilla Growth Guidance System and Traditional Growing Rods Through Definitive Treatment. Spine Deform 2017. [PMID: 28622904 DOI: 10.1016/j.jspd.2017.01.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
STUDY DESIGN Retrospective review of a multicenter database. OBJECTIVES To compare the radiographic outcomes of patients who had undergone the Shilla Growth Guidance System (SGGS) and traditional growing rod (GR) treatment for management of early-onset scoliosis (EOS) through definitive treatment. SUMMARY OF BACKGROUND DATA The efficacy of surgical treatment of EOS can only be determined after definitive treatment has been completed. We wanted to review our experience with the SGGS and GR for management of EOS through definitive treatment. METHODS Patients who had surgical treatment with SGGS or GR and had undergone definitive treatment were included. The patients were matched by age, preoperative curve magnitude, and diagnosis. The study population consisted of 36 patients (18 in each group) whose mean age at initial surgery was as follows: SGGS, 7.9 years; and GR, 7.7 years (not significant [NS]). Length of follow-up after initial surgery was 6.1 years for SGGS and 7.4 years for GR (NS). Definitive treatment was posterior spinal fusion (15 SGGS, 17 GR), implant removal (3 SGGS), or completion of lengthenings (1 GR). RESULTS The preoperative curve was 61 degrees for SGGS and 65 degrees for GR (NS). After index surgery, the major curve decreased to 24 degrees (-37 degrees) for SGGS and 38 (-27 degrees) for GR (p < .05). At last follow-up, the major curve was 34 degrees (44%) for SGGS and 36 degrees (45%) for GR (NS). The initial T1-T12 length for SGGS was 188 mm and for GR, 181 mm; at last follow-up, SGGS was 234 mm (46 mm increase) and GR was 233 mm (52 mm increase) (NS). CONCLUSION Our analysis shows the final radiographic outcomes (and changes) and complications (implant-related and infection) between the SGGS and GR groups were not statistically different. The main difference between the two groups was the threefold difference in overall surgeries.
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Affiliation(s)
- Scott J Luhmann
- St Louis Shriners Hospital, 4400 Clayton Ave, St Louis, MO 63110, USA; St Louis Childrens Hospital, One Childrens Place, St Louis, MO 63110, USA.
| | - June C Smith
- Wash U Ortho Surgery, 660 S. Euclid Ave, Campus Box 8233, St Louis, MO 63110, USA
| | - Ann McClung
- Growing Spine Study Group, Growing Spine Foundation, 555 East Wells St., Suite 1100, Milwaukee, WI 53202, USA
| | | | | | - George H Thompson
- Rainbow Babies & Childrens Hospital, 11100 Euclid Ave, Cleveland, OH 44106, USA
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Poe-Kochert C, Shannon C, Pawelek JB, Thompson GH, Hardesty CK, Marks DS, Akbarnia BA, McCarthy RE, Emans JB. Final Fusion After Growing-Rod Treatment for Early Onset Scoliosis: Is It Really Final? J Bone Joint Surg Am 2016; 98:1913-1917. [PMID: 27852908 DOI: 10.2106/jbjs.15.01334] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Connie Poe-Kochert
- Rainbow Babies and Children's Hospital, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Claire Shannon
- Rainbow Babies and Children's Hospital, University Hospitals Case Medical Center, Cleveland, Ohio
| | | | - George H Thompson
- Rainbow Babies and Children's Hospital, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Christina K Hardesty
- Rainbow Babies and Children's Hospital, University Hospitals Case Medical Center, Cleveland, Ohio
| | - David S Marks
- Royal Orthopaedic Hospital, Birmingham, United Kingdom
| | | | | | - John B Emans
- Boston Children's Hospital, Boston, Massachusetts
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Hosseini P, Pawelek JB, Nguyen S, Thompson GH, Shah SA, Flynn JM, Dormans JP, Akbarnia BA, Group GSS. Rod fracture and lengthening intervals in traditional growing rods: is there a relationship? Eur Spine J 2016; 26:1690-1695. [DOI: 10.1007/s00586-016-4786-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 08/10/2016] [Accepted: 09/18/2016] [Indexed: 12/01/2022]
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Upasani VV, Parvaresh KC, Pawelek JB, Miller PE, Thompson GH, Skaggs DL, Emans JB, Glotzbecker MP. Age at Initiation and Deformity Magnitude Influence Complication Rates of Surgical Treatment With Traditional Growing Rods in Early-Onset Scoliosis. Spine Deform 2016; 4:344-350. [PMID: 27927491 DOI: 10.1016/j.jspd.2016.04.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 02/26/2016] [Accepted: 04/03/2016] [Indexed: 12/15/2022]
Abstract
STUDY DESIGN Multi-center retrospective review. OBJECTIVE The purpose of this study was to identify preoperative variables associated with postoperative complications in early-onset scoliosis (EOS) patients treated with traditional growing rods (TGR); and to develop a model to predict the incidence of postoperative complications based on preoperative variables. SUMMARY OF BACKGROUND DATA TGRs are commonly used to treat progressive EOS. Prior research has demonstrated a high rate of postoperative complications using this technique; however, few studies have identified preoperative factors that contribute to such complications. METHODS A total of 110 patients who initiated TGR treatment before 10 years of age and completed final treatment were identified from a multi-center database. Overall treatment effect was calculated for major curve size, thoracic kyphosis, thoracic height, and total spine height. Univariable and multivariable logistic regression identified preoperative predictors of complications. An algorithm was developed and validated to calculate the probability of complications based on preoperative data. RESULTS All patients completed TGR treatment (average follow-up 8.1 years). The overall treatment effect was a significant decrease in major curve magnitude, increase in thoracic height, increase in spine height, and no significant change in thoracic kyphosis. There were 263 total complications in 87 patients (79%) resulting in 84 unplanned surgeries. The most common complications were implant-related (49%), surgical site infection (23%), medical (19%), alignment (6%), and neurologic (3%). The significant independent preoperative predictors of complications were age at implantation and preoperative thoracic kyphosis. Multivariable regression showed that age less than 7.6 years, thoracic kyphosis greater than 38 degrees, or major curve magnitude greater than 84 degrees significantly increased the probability of complications. CONCLUSIONS Earlier age at implantation, greater thoracic kyphosis, and larger major curves increased the probability of complications following TGR instrumentation. These findings provide a valuable tool for predicting complications that may aid in surgical planning and shared decision making with patients and their families. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Vidyadhar V Upasani
- Department of Orthopedic Surgery, Rady Children's Hospital San Diego, University of California San Diego, 3030 Children's Way, Suite 410, San Diego, CA 92123, USA.
| | - Kevin C Parvaresh
- Department of Orthopedic Surgery, Rady Children's Hospital San Diego, University of California San Diego, 3030 Children's Way, Suite 410, San Diego, CA 92123, USA
| | - Jeff B Pawelek
- Department of Orthopedic Surgery, Rady Children's Hospital San Diego, University of California San Diego, 3030 Children's Way, Suite 410, San Diego, CA 92123, USA
| | - Patricia E Miller
- Department of Orthopedic Surgery, Rady Children's Hospital San Diego, University of California San Diego, 3030 Children's Way, Suite 410, San Diego, CA 92123, USA
| | - George H Thompson
- Department of Orthopedic Surgery, Rady Children's Hospital San Diego, University of California San Diego, 3030 Children's Way, Suite 410, San Diego, CA 92123, USA
| | - David L Skaggs
- Department of Orthopedic Surgery, Rady Children's Hospital San Diego, University of California San Diego, 3030 Children's Way, Suite 410, San Diego, CA 92123, USA
| | - John B Emans
- Department of Orthopedic Surgery, Rady Children's Hospital San Diego, University of California San Diego, 3030 Children's Way, Suite 410, San Diego, CA 92123, USA
| | - Michael P Glotzbecker
- Department of Orthopedic Surgery, Rady Children's Hospital San Diego, University of California San Diego, 3030 Children's Way, Suite 410, San Diego, CA 92123, USA
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- Department of Orthopedic Surgery, Rady Children's Hospital San Diego, University of California San Diego, 3030 Children's Way, Suite 410, San Diego, CA 92123, USA
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Jain A, Sponseller PD, Flynn JM, Shah SA, Thompson GH, Emans JB, Pawelek JB, Akbarnia BA. Avoidance of "Final" Surgical Fusion After Growing-Rod Treatment for Early-Onset Scoliosis. J Bone Joint Surg Am 2016; 98:1073-8. [PMID: 27385680 DOI: 10.2106/jbjs.15.01241] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Amit Jain
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Paul D Sponseller
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - John M Flynn
- Division of Orthopaedic Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Suken A Shah
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - George H Thompson
- Division of Pediatric Orthopaedic Surgery, Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, Ohio
| | - John B Emans
- Department of Orthopaedic Surgery, Children's Hospital Boston, Boston, Massachusetts
| | - Jeff B Pawelek
- San Diego Center for Spinal Disorders, La Jolla, California
| | - Behrooz A Akbarnia
- Department of Orthopaedic Surgery, University of California-San Diego, San Diego, California San Diego Center for Spinal Disorders, San Diego, California
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Brooks JT, Jain A, Sanchez-Perez-Grueso F, Skaggs DL, Thompson GH, Akbarnia BA, Sponseller PD. Outcomes of Pelvic Fixation in Growing Rod Constructs: An Analysis of Patients With a Minimum of 4 Years of Follow-up. Spine Deform 2016; 4:211-216. [PMID: 27927505 DOI: 10.1016/j.jspd.2015.11.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Revised: 10/16/2015] [Accepted: 11/24/2015] [Indexed: 10/21/2022]
Abstract
STUDY DESIGN Retrospective review. OBJECTIVE To evaluate which distal anchors in growing rod (GR) constructs optimally correct major curve, pelvic obliquity, sagittal alignment, T1-S1 length, thoracic kyphosis, and lumbar lordosis with the fewest complications at 4 or more years' postoperative follow-up. SUMMARY OF BACKGROUND DATA Pelvic fixation to the ilium and/or sacrum in GR constructs is used to treat patients with early-onset scoliosis. No studies have evaluated radiographical outcomes and complications in these patients at 4 or more years' follow-up. METHODS Included were 38 patients from a multicenter early-onset-scoliosis database with dual GRs anchored to the pelvis. Radiographic data included major curve, T1-S1 length, T5-T12 kyphosis, lordosis, sagittal alignment, and pelvic obliquity at preoperative and latest follow-up time points. Complications were evaluated for all anchor subtypes. RESULTS Mean follow-up time was 5.3 ± 0.1 years. GRs with distal anchors to the ilium significantly improved major curve (49%, p = .013) and pelvic obliquity (78%, p = .035) compared with constructs anchored to the sacrum only. Constructs with iliac fixation with S1 screws provided greater correction of lumbar kyphosis than constructs with iliac fixation and no S1 screws (p = .023). Constructs with a single caudal crosslink had a greater T1-S1 length at latest follow-up than constructs with combined cephalad and caudal crosslinks (p = .027). There were no significant differences in the rates of infection or instrumentation failure between iliac and sacral fixation groups. GR constructs with distal anchors that used a posterior superior iliac spine start point had a higher infection rate (60%) than those inserted via a sacral-alar-iliac technique (7%) (p = .002). CONCLUSIONS GR constructs anchored to the ilium provide significant improvements in the major curve and pelvic obliquity at a minimum of 4 years of follow-up versus constructs anchored to the sacrum alone. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Jaysson T Brooks
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N Caroline St, Baltimore, MD 21231, USA
| | - Amit Jain
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N Caroline St, Baltimore, MD 21231, USA
| | | | - David L Skaggs
- Children's Orthopedic Center, Children's Hospital Los Angeles, 4650 Sunset Blvd, MS #69, Los Angeles, CA 90027, USA
| | - George H Thompson
- Division of Pediatric Orthopaedic Surgery, Rainbow Babies & Children's Hospital, Case Western Reserve University, 11100 Euclid Ave, Cleveland, OH 44106, USA
| | - Behrooz A Akbarnia
- Department of Orthopaedic Surgery, University of California-San Diego, 200 West Arbor Dr, San Diego, CA 92103, USA; San Diego Center for Spinal Disorders, 6190 Cornerstone Ct, Ste 212, San Diego, CA 92121, USA
| | - Paul D Sponseller
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N Caroline St, Baltimore, MD 21231, USA.
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Tripi PA, Kuestner ME, Poe-Kochert CS, Rubin K, Son-Hing JP, Thompson GH, Tobias JD. Intrathecal morphine attenuates acute opioid tolerance secondary to remifentanil infusions during spinal surgery in adolescents. J Pain Res 2015; 8:637-40. [PMID: 26445559 PMCID: PMC4590583 DOI: 10.2147/jpr.s88687] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Introduction The unique pharmacokinetic properties of remifentanil with a context-sensitive half-life unaffected by length of infusion contribute to its frequent use during anesthetic management during posterior spinal fusion in children and adolescents. However, its intraoperative administration can lead to increased postoperative analgesic requirements, which is postulated to be the result of acute opioid tolerance with enhancement of spinal N-methyl-D-aspartate receptor function. Although strategies to prevent or reduce tolerance have included the coadministration of longer acting opioids or ketamine, the majority of these studies have demonstrated little to no benefit. The current study retrospectively evaluates the efficacy of intrathecal morphine (ITM) in preventing hyperalgesia following a remifentanil infusion. Methods We retrospectively analyzed 54 patients undergoing posterior spinal fusion with segmental spinal instrumentation, to evaluate the effects of ITM on hyperalgesia from remifentanil. Patients were divided into two groups based on whether they did or did not receive remifentanil during the surgery: no remifentanil (control group) (n=27) and remifentanil (study group) (n=27). Data included demographics, remifentanil dose and duration, Wong–Baker visual analog scale postoperative pain scores, and postoperative intravenous morphine consumption in the first 48 postoperative hours. Results The demographics of the two study groups were similar. There were no differences in the Wong–Baker visual analog scale pain scores in the postanesthesia care unit and on postoperative days 1 and 3. Pain scores were higher in the remifentanil group on postoperative day 2 (2.9 vs 3.8). Postoperative morphine requirements were similar between the two groups (0.029 vs 0.017 mg/kg/48 h for the control group and the study group, respectively). Conclusion In patients receiving preincisional ITM during spinal surgery, intraoperative remifentanil does not increase postoperative analgesic requirements.
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Affiliation(s)
- Paul A Tripi
- Division of Pediatric Anesthesiology, Case Western Reserve University, Cleveland, OH, USA
| | - Matthew E Kuestner
- Division of Pediatric Anesthesiology, Case Western Reserve University, Cleveland, OH, USA
| | - Connie S Poe-Kochert
- Division of Pediatric Orthopaedic Surgery, Rainbow Babies and Children's Hospital, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Kasia Rubin
- Division of Pediatric Anesthesiology, Case Western Reserve University, Cleveland, OH, USA
| | - Jochen P Son-Hing
- Division of Pediatric Orthopaedic Surgery, Rainbow Babies and Children's Hospital, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - George H Thompson
- Division of Pediatric Orthopaedic Surgery, Rainbow Babies and Children's Hospital, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
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Paloski MD, Sponseller PD, Akbarnia BA, Thompson GH, Skaggs DL, Pawelek JB, Nguyen PT, Odum SM. Is There an Optimal Time to Distract Dual Growing Rods? Spine Deform 2014; 2:467-470. [PMID: 27927407 DOI: 10.1016/j.jspd.2014.08.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Revised: 08/04/2014] [Accepted: 08/05/2014] [Indexed: 11/16/2022]
Abstract
STUDY DESIGN Retrospective multicenter observational cohort study. OBJECTIVES To determine whether there is a significant difference in final spinal height achieved, instrumented height, or Cobb angle related to the mean time interval between distractions of dual growing rods. SUMMARY OF BACKGROUND DATA Patients were prospectively enrolled in "The Treatment of Progressive Early Onset Spinal Deformities: A Multi-Center Study." Additional data were collected via a retrospective review of medical records. METHODS Using data from a multicenter database, the authors identified 46 patients (23 boys and 23 girls) with early-onset scoliosis who were treated with dual growing rods and who had surgical treatment spanning more than 4 years. The patients were divided into 2 groups: those who had less than 9 months (16 patients) and those who had 9 months or more (30 patients) between distractions. Standard univariate statistics were calculated. The researchers performed 2-tailed t tests. Significance was set at p = .05. RESULTS The differences in primary Cobb angle, T1-S1 height, and instrumented segment length at the last distraction or final arthrodesis, compared with the post-index procedure values, were not significantly different (p = .52, .58, and .60, respectively) between groups with the available data. The normalized instrumented height gains, in millimeters per year, were not significantly different (p = .22). CONCLUSIONS Patients with longer times between growing-rod distractions (9 or more months) had no significant differences in primary Cobb angle, T1-S1 length, or instrumented length gain compared with patients with shorter times (less than 9 months) between distractions.
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Affiliation(s)
| | - Paul D Sponseller
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, 601 N Caroline Street, Baltimore, MD 21287, USA.
| | - Behrooz A Akbarnia
- Department of Orthopaedic Surgery, University of California-San Diego, 200 West Arbor Drive, San Diego, CA 92103, USA; San Diego Center for Spinal Disorders, 4130 La Jolla Village Drive, La Jolla, CA 92037, USA
| | - George H Thompson
- Division of Pediatric Orthopaedic Surgery, Rainbow Babies and Children's Hospital, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - David L Skaggs
- Children's Orthopedic Center, 4650 Sunset Boulevard, Los Angeles, CA 90027, USA
| | - Jeff B Pawelek
- San Diego Center for Spinal Disorders, 4130 La Jolla Village Drive, La Jolla, CA 92037, USA
| | - Phuong T Nguyen
- OrthoCarolina Research Institute, 2001 Vail Avenue, Suite 300, Charlotte, NC 28207, USA
| | - Susan M Odum
- OrthoCarolina Research Institute, 2001 Vail Avenue, Suite 300, Charlotte, NC 28207, USA
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Akbarnia BA, Pawelek JB, Cheung KMC, Demirkiran G, Elsebaie H, Emans JB, Johnston CE, Mundis GM, Noordeen H, Skaggs DL, Sponseller PD, Thompson GH, Yaszay B, Yazici M. Traditional Growing Rods Versus Magnetically Controlled Growing Rods for the Surgical Treatment of Early-Onset Scoliosis: A Case-Matched 2-Year Study. Spine Deform 2014; 2:493-497. [PMID: 27927412 DOI: 10.1016/j.jspd.2014.09.050] [Citation(s) in RCA: 114] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2014] [Revised: 09/03/2014] [Accepted: 09/16/2014] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Behrooz A Akbarnia
- San Diego Center for Spinal Disorders, 4130 La Jolla Village Drive #300, San Diego, CA 92037, USA.
| | - Jeff B Pawelek
- San Diego Center for Spinal Disorders, 4130 La Jolla Village Drive #300, San Diego, CA 92037, USA
| | | | | | - Hazem Elsebaie
- University of Cairo, 22 Degla Street, Mohandessine, Cairo, Giza 12411, Egypt
| | - John B Emans
- Department of Orthopaedic Surgery, 300 Longwood Avenue, Boston, MA 02115-5724, USA
| | - Charles E Johnston
- Texas Scottish Rite Hospital, 2222 Welborn Street, Dallas, TX 75219-3993, USA
| | - Gregory M Mundis
- San Diego Center for Spinal Disorders, 4130 La Jolla Village Drive #300, San Diego, CA 92037, USA
| | - Hilali Noordeen
- The Royal National Orthopaedic Hospital, 42 Addison Road, London W14 8JH, United Kingdom
| | - David L Skaggs
- Children's Hospital Los Angeles, 4650 W. Sunset Boulevard Orthopaedics, #69 Los Angeles, CA 90027, USA
| | - Paul D Sponseller
- Bloomberg Children's Center, Suite 7359 A, 1800 Orleans Street, Baltimore, MD 21287-0882, USA
| | - George H Thompson
- Rainbow Babies & Children's Hospital, 11100 Euclid Avenue, Cleveland, OH 44106-5043, USA
| | - Burt Yaszay
- Rady Children's Hospital San Diego, 3030 Children's Way, Suite 410, San Diego, CA 92123, USA
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- Growing Spine Foudation, 555 East Wells Street, Suite 1100, Milwaukee, WI 53202, USA
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Arandi NR, Pawelek JB, Kabirian N, Thompson GH, Emans JB, Flynn JM, Dormans JP, Akbarnia BA. Do Thoracolumbar/lumbar Curves Respond Differently to Growing Rod Surgery Compared With Thoracic Curves? Spine Deform 2014; 2:475-480. [PMID: 27927409 DOI: 10.1016/j.jspd.2014.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Revised: 03/31/2014] [Accepted: 04/03/2014] [Indexed: 02/08/2023]
Abstract
STUDY DESIGN Retrospective study. OBJECTIVES To compare radiographic outcomes between primary thoracic and primary thoracolumbar/lumbar curves in patients with early-onset scoliosis (EOS) after growing rod (GR) surgery. SUMMARY OF BACKGROUND DATA Previous studies have shown the efficacy of GR surgery for progressive EOS. However, there is no information on the behavior of different curve patterns in EOS after GR surgery. METHODS A multicenter international EOS database query identified 175 patients who met the following inclusion criteria: non-congenital etiology, GR surgery, ≤ 10 years of age at index surgery, minimum 2-year follow-up, and at least 3 lengthenings. Patients were categorized into 2 groups based on the Scoliosis Research Society definition of the anatomical location of primary curves: group 1 included thoracic apices (T2 to T11/12 disc) and group 2 included thoracolumbar (T12 to L1) and lumbar (L1/2 disc to L4) apices. Radiographic measurements were performed before and after index surgery and at latest follow-up. RESULTS A total of 139 patients (79%) had primary thoracic (group 1) and 36 (21%) had primary thoracolumbar or lumbar curves (group 2). Mean number of levels instrumented was statistically greater in group 2 (15.0) versus group 1 (13.6) (p < .05). Group 2 had statistically better mean curve correction than group 1 after the index GR surgery (51% and 44%, respectively; p < .05). However, there was no significant difference in mean percent curve correction at latest follow-up (46% and 39%, respectively; p > .05). Implant complication rate was 45% and 47% for groups 1 and 2, respectively. Preoperative curve flexibility was greater in group 2 (45%) compared with group 1 (40%) (p > .05). CONCLUSIONS Overall, thoracolumbar/lumbar and thoracic curves achieve similar major curve correction and have a similar complication profile.
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Affiliation(s)
- Navid R Arandi
- San Diego Center for Spinal Disorders, 4130 La Jolla Village Drive, Suite 300, La Jolla, CA 92037, USA
| | - Jeff B Pawelek
- San Diego Center for Spinal Disorders, 4130 La Jolla Village Drive, Suite 300, La Jolla, CA 92037, USA
| | - Nima Kabirian
- San Diego Center for Spinal Disorders, 4130 La Jolla Village Drive, Suite 300, La Jolla, CA 92037, USA
| | - George H Thompson
- Department of Orthopaedics, University Hospitals, Rainbow Babies and Children's Hospital, 11100 Euclid Ave, Cleveland, OH, 44106 USA
| | - John B Emans
- Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115 USA
| | - John M Flynn
- Children's Hospital of Philadelphia, 3400 Civic Center Blvd, Philadelphia, PA, 19104 USA
| | - John P Dormans
- Children's Hospital of Philadelphia, 3400 Civic Center Blvd, Philadelphia, PA, 19104 USA
| | - Behrooz A Akbarnia
- San Diego Center for Spinal Disorders, 4130 La Jolla Village Drive, Suite 300, La Jolla, CA 92037, USA; Department of Orthopedic Surgery, University of California, San Diego, CA, USA.
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Williams BA, Matsumoto H, McCalla DJ, Akbarnia BA, Blakemore LC, Betz RR, Flynn JM, Johnston CE, McCarthy RE, Roye DP, Skaggs DL, Smith JT, Snyder BD, Sponseller PD, Sturm PF, Thompson GH, Yazici M, Vitale MG. Development and initial validation of the Classification of Early-Onset Scoliosis (C-EOS). J Bone Joint Surg Am 2014; 96:1359-67. [PMID: 25143496 DOI: 10.2106/jbjs.m.00253] [Citation(s) in RCA: 181] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Brendan A Williams
- Department of Orthopaedic Surgery (B.A.W., D.J.M., D.P.R., and M.G.V.), and Division of Pediatric Orthopaedic Surgery (H.M.), Columbia University Medical Center, 3959 Broadway, 8 North, New York, NY 10032. E-mail address for M.G. Vitale:
| | - Hiroko Matsumoto
- Department of Orthopaedic Surgery (B.A.W., D.J.M., D.P.R., and M.G.V.), and Division of Pediatric Orthopaedic Surgery (H.M.), Columbia University Medical Center, 3959 Broadway, 8 North, New York, NY 10032. E-mail address for M.G. Vitale:
| | - Daren J McCalla
- Department of Orthopaedic Surgery (B.A.W., D.J.M., D.P.R., and M.G.V.), and Division of Pediatric Orthopaedic Surgery (H.M.), Columbia University Medical Center, 3959 Broadway, 8 North, New York, NY 10032. E-mail address for M.G. Vitale:
| | - Behrooz A Akbarnia
- San Diego Center for Spinal Disorders, 4130 La Jolla Village Drive, Suite 300, San Diego, La Jolla, CA 92037
| | - Laurel C Blakemore
- Department of Orthopaedic Surgery and Sports Medicine, Children's National Medical Center, 111 Michigan Avenue, N.W., Washington, DC 20010
| | - Randal R Betz
- Department of Orthopaedic Surgery, Shriner's Hospital for Children, 3551 North Broad Street, Philadelphia, PA 19140
| | - John M Flynn
- Division of Orthopaedics, Children's Hospital of Philadelphia, 324 South 34th Street, Philadelphia, PA 19104
| | - Charles E Johnston
- Department of Orthopedic Surgery, Texas Scottish Rite Hospital for Children, 2222 Welborn Street, Dallas, TX 75219
| | - Richard E McCarthy
- Departments of Orthopaedics and Pediatrics, University of Arkansas for Medical Sciences, 1 Children's Way, Little Rock, AR 72202
| | - David P Roye
- Department of Orthopaedic Surgery (B.A.W., D.J.M., D.P.R., and M.G.V.), and Division of Pediatric Orthopaedic Surgery (H.M.), Columbia University Medical Center, 3959 Broadway, 8 North, New York, NY 10032. E-mail address for M.G. Vitale:
| | - David L Skaggs
- Children's Orthopaedic Center, Children's Hospital Los Angeles, 4650 Sunset Boulevard, Mailstop #69, Los Angeles, CA 90027
| | - John T Smith
- Department of Orthopaedics and Pediatrics, The University of Utah School of Medicine, Primary Children's Medical Center, 100 Mario Capecchi Drive, Salt Lake City, UT 84113
| | - Brian D Snyder
- Department of Orthopaedic Surgery, Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115
| | - Paul D Sponseller
- Department of Orthopaedic Surgery, The Johns Hopkins University, 1800 Orleans Street, 7359A, Baltimore, MD 21287
| | - Peter F Sturm
- Division of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45267
| | - George H Thompson
- Division of Pediatric Orthopaedic Surgery, Rainbow Babies and Children's Hospital, University Hospitals Case Medical Center, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106
| | - Muharrem Yazici
- Department of Orthopaedics and Traumatology, Hacettepe University, 06100 Sihhiye, Ankara, Turkey
| | - Michael G Vitale
- Department of Orthopaedic Surgery (B.A.W., D.J.M., D.P.R., and M.G.V.), and Division of Pediatric Orthopaedic Surgery (H.M.), Columbia University Medical Center, 3959 Broadway, 8 North, New York, NY 10032. E-mail address for M.G. Vitale:
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Kabirian N, Akbarnia BA, Pawelek JB, Alam M, Mundis GM, Acacio R, Thompson GH, Marks DS, Gardner A, Sponseller PD, Skaggs DL. Deep Surgical Site Infection Following 2344 Growing-Rod Procedures for Early-Onset Scoliosis: Risk Factors and Clinical Consequences. J Bone Joint Surg Am 2014; 96:e128. [PMID: 25100781 DOI: 10.2106/jbjs.m.00618] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Nima Kabirian
- San Diego Center for Spinal Disorders, 4130 La Jolla Village Drive, Suite 300, San Diego, CA 92037. E-mail address for B.A. Akbarnia:
| | - Behrooz A Akbarnia
- San Diego Center for Spinal Disorders, 4130 La Jolla Village Drive, Suite 300, San Diego, CA 92037. E-mail address for B.A. Akbarnia:
| | - Jeff B Pawelek
- San Diego Center for Spinal Disorders, 4130 La Jolla Village Drive, Suite 300, San Diego, CA 92037. E-mail address for B.A. Akbarnia:
| | - Milad Alam
- San Diego Center for Spinal Disorders, 4130 La Jolla Village Drive, Suite 300, San Diego, CA 92037. E-mail address for B.A. Akbarnia:
| | - Gregory M Mundis
- San Diego Center for Spinal Disorders, 4130 La Jolla Village Drive, Suite 300, San Diego, CA 92037. E-mail address for B.A. Akbarnia:
| | - Ricardo Acacio
- San Diego Center for Spinal Disorders, 4130 La Jolla Village Drive, Suite 300, San Diego, CA 92037. E-mail address for B.A. Akbarnia:
| | - George H Thompson
- Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106. E-mail address:
| | - David S Marks
- The Royal Orthopaedic Hospital, Bristol Road, Northfield, Birmingham B31 2AP, United Kingdom. E-mail address for D.S. Marks: . E-mail address for A. Gardner:
| | - Adrian Gardner
- The Royal Orthopaedic Hospital, Bristol Road, Northfield, Birmingham B31 2AP, United Kingdom. E-mail address for D.S. Marks: . E-mail address for A. Gardner:
| | - Paul D Sponseller
- Johns Hopkins Bloomberg Children's Center, 1800 Orleans Street, Room 7359, Baltimore, MD 21287. E-mail address:
| | - David L Skaggs
- Department of Orthopaedic Surgery, Children's Hospital Los Angeles, 4650 Sunset Boulevard, M/S 69, Los Angeles, CA 90027. E-mail address:
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Myung KS, Skaggs DL, Thompson GH, Emans JB, Akbarnia BA. Nutritional improvement following growing rod surgery in children with early onset scoliosis. J Child Orthop 2014; 8:251-6. [PMID: 24760379 PMCID: PMC4142888 DOI: 10.1007/s11832-014-0586-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Accepted: 04/07/2014] [Indexed: 02/03/2023] Open
Abstract
PURPOSE We aimed to evaluate the nutritional status of children with early onset scoliosis (EOS) and to determine if treatment with growing rod instrumentation improves weight percentile. METHODS Data was retrospectively collected on 88 EOS patients treated with growing rods at six institutions. Mean age at surgery was 5.8 years, and mean Cobb angle was 75°. All patients were followed for at least 2 years (mean 4 years). Weights were converted to normative percentiles based on the patients' age and gender. RESULTS Preoperatively, 47 % (41/88) of patients were <5 percentile for weight, thus failing to thrive. There was a significant increase in mean postoperative weight percentiles at latest follow-up (p = 0.004). 49 % of patients gained weight, with a mean of 18 percentile. A significant relationship exists between age at initial surgery and percentile weight gain (p < 0.005), with children <4 years old not demonstrating postoperative improvement. This relationship was not confounded by preoperative weight, preoperative Cobb angle, or years of follow-up (p > 0.05). Children with neuromuscular and syndromic diagnoses do not appear to improve their mean nutritional status after surgery when compared to patients with idiopathic or congenital/structural scoliosis (p = 0.006). CONCLUSION Following growing rod treatment, there was significant improvement in nutritional status in approximately 50 % of patients, similar to that reported with VEPTR. Neuromuscular and syndromic patients did not experience nutritional improvement post-operatively. These findings support the theory that growing rods improve the clinical status of EOS patients, as nutritional improvement is one outcome of improved clinical status. The relationship between age at initial surgery and nutritional improvement is intriguing.
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Affiliation(s)
- Karen S. Myung
- Children’s Hospital Los Angeles, 4650 Sunset Blvd., MS #69, Los Angeles, CA 90027 USA
| | - David L. Skaggs
- Children’s Hospital Los Angeles, 4650 Sunset Blvd., MS #69, Los Angeles, CA 90027 USA
| | - George H. Thompson
- Rainbow Babies and Children’s Hospital, Case Western Reserve University, Cleveland, OH USA
| | - John B. Emans
- Department of Orthopaedic Surgery, Children’s Hospital and Harvard Medical School, Boston, MA USA
| | - Behrooz A. Akbarnia
- San Diego Center for Spinal Disorders, La Jolla, CA USA ,Department of Orthopedic Surgery, University of California-San Diego, San Diego, CA USA
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Flynn JM, Tomlinson LA, Pawelek J, Thompson GH, McCarthy R, Akbarnia BA. Growing-rod graduates: lessons learned from ninety-nine patients who completed lengthening. J Bone Joint Surg Am 2013; 95:1745-50. [PMID: 24088966 DOI: 10.2106/jbjs.l.01386] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- John M Flynn
- Division of Orthopaedic Surgery, The Children's Hospital of Philadelphia, 3400 Civic Center Boulevard, 2nd Floor, Wood Building, Philadelphia, PA 19104. E-mail address for J.M. Flynn:
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Johnston CE, McClung AM, Thompson GH, Poe-Kochert C, Sanders JO. Comparison of Growing Rod Instrumentation Versus Serial Cast Treatment for Early-Onset Scoliosis. Spine Deform 2013; 1:339-342. [PMID: 27927389 DOI: 10.1016/j.jspd.2013.05.006] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Revised: 05/10/2013] [Accepted: 05/14/2013] [Indexed: 01/13/2023]
Abstract
STUDY DESIGN A comparison of 2 methods of early-onset scoliosis treatment using radiographic measures and complication rates. OBJECTIVES To determine whether a delaying tactic (serial casting) has comparable efficacy to a surgical method (insertion of growing rod instrumentation [GRI]) in the initial phase of early-onset deformity management. SUMMARY OF BACKGROUND DATA Serial casts are used in experienced centers to delay operative management of curves of surgical magnitude (greater than 50°) in children up to age 6 years. METHODS A total of 27 casted patients from 3 institutions were matched with 27 patients from a multicenter database according to age (within 6 months of each other), curve magnitude (within 10° of each other), and diagnosis. Outcomes were compared according to major curve magnitude, spine length (T1-S1), duration and number of treatment encounters, and complications. RESULTS There was no difference in age (5.5 years) or initial curve magnitude (65°) between groups, which reflects the accuracy of the matching process. Six pairs of patients had neuromuscular diagnoses, 11 had idiopathic deformities, and 10 had syndromic scoliosis. Growing rod instrumentation patients had smaller curves (45.9° vs. 64.9°; p = .002) at follow-up, but there was no difference in absolute spine length (GRI = 32.0 cm; cast = 30.6 cm; p = .26), even though GRI patients had been under treatment for a longer duration (4.5 vs. 2.4 years; p < .0001) and had undergone a mean of 5.5 lengthenings compared with 4.0 casts. Growing rod instrumentation patients had a 44% complication rate, compared with 1 cast complication. Of 27 casted patients, 15 eventually had operative treatment after a mean delay of 1.7 years after casting. CONCLUSIONS Cast treatment is a valuable delaying tactic for younger children with early-onset scoliosis. Spine deformity is adequately controlled, spine length is not compromised, and surgical complications associated with early GRI treatment are avoided.
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Affiliation(s)
- Charles E Johnston
- Texas Scottish Rite Hospital, 2222 Welborn Street, Dallas, TX 75219, USA.
| | - Anna M McClung
- Texas Scottish Rite Hospital, 2222 Welborn Street, Dallas, TX 75219, USA
| | - George H Thompson
- Rainbow Babies and Children's Hospital, 11100 Euclid Ave., Cleveland, OH 44106, USA
| | - Connie Poe-Kochert
- Rainbow Babies and Children's Hospital, 11100 Euclid Ave., Cleveland, OH 44106, USA
| | - James O Sanders
- University of Rochester, Rochester, 601 Elmwood Ave., Box 665, Rochester, NY 14642, USA
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- Growing Spine Foundation, Milwaukee, 555 E. Wells Street, Suite 1100, Milwaukee, WI 53202, USA
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Thompson GH, Lea ES, Chin K, Liu RW, Son-Hing JP, Gilmore A. Closed bone graft epiphysiodesis for avascular necrosis of the capital femoral epiphysis. Clin Orthop Relat Res 2013; 471:2199-205. [PMID: 23389802 PMCID: PMC3676614 DOI: 10.1007/s11999-013-2819-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Avascular necrosis (AVN) of the capital femoral epiphysis (CFE) after an unstable slipped capital femoral epiphysis (SCFE), femoral neck fracture or traumatic hip dislocation can result in severe morbidity. Treatment options for immature patients with AVN are limited, including a closed bone graft epiphysiodesis (CBGE). However, it is unclear whether this procedure prevents AVN progression. QUESTIONS/PURPOSES We investigated whether early MRI screening and CBGE prevented the development of advanced AVN changes in the CFE and the rates of complications with this approach. METHODS We prospectively followed all 13 patients (seven boys, six girls) with unstable SCFEs (six patients), femoral neck fractures (five patients), and traumatic hip dislocations (two patients) and evidence of early AVN treated between 1984 and 2012. Mean age at initial injury was 12 years (range, 10-16 years). Nine of the 13 patients had followup of at least 2 years or until conversion to THA (mean, 4.5 years; range, 0.8-8.5 years), including two with unstable SCFEs, the five with femoral neck fractures, and the two with traumatic hip dislocations. All patients had technetium scans and/or MRI within 1 to 2 months of their initial injury (before CBGE) and all had evidence of early (Ficat 0) AVN. Patients were followed clinically and radiographically for AVN progression. RESULTS Six of the nine hips did not develop typical clinical or radiographic evidence of AVN. These six patients have been followed 6.3 years (range, 4.3-9.1 years) from initial injury and 5.9 years (range, 3.8-8.5 years) from CBGE. The remaining three patients were diagnosed with AVN at periods ranging from 3 to 6 months after CBGE. CONCLUSIONS Early recognition and treatment of AVN with a CBGE may alter the natural history of this complication. LEVEL OF EVIDENCE Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- George H. Thompson
- Division of Pediatric Orthopaedics, Rainbow Babies and Children’s Hospital, Case Medical Center, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106-5043 USA
| | - Ethan S. Lea
- Division of Pediatric Orthopaedics, Rainbow Babies and Children’s Hospital, Case Medical Center, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106-5043 USA
| | - Kenneth Chin
- Division of Pediatric Orthopaedics, Rainbow Babies and Children’s Hospital, Case Medical Center, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106-5043 USA
| | - Raymond W. Liu
- Division of Pediatric Orthopaedics, Rainbow Babies and Children’s Hospital, Case Medical Center, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106-5043 USA
| | - Jochen P. Son-Hing
- Division of Pediatric Orthopaedics, Rainbow Babies and Children’s Hospital, Case Medical Center, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106-5043 USA
| | - Allison Gilmore
- Division of Pediatric Orthopaedics, Rainbow Babies and Children’s Hospital, Case Medical Center, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106-5043 USA
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