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Hardesty CK. What's New in Pediatric Orthopaedics. J Bone Joint Surg Am 2024; 106:269-275. [PMID: 38113304 DOI: 10.2106/jbjs.23.01141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Affiliation(s)
- Christina K Hardesty
- Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, Ohio
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Furdock RJ, Sun KJ, Ren B, Folkman M, Glotzbecker MP, Son-Hing JP, Gilmore A, Hardesty CK, Mistovich RJ, Liu RW. The Reliability of the Modified Fels Knee Skeletal Maturity System. J Pediatr Orthop 2024; 44:e192-e196. [PMID: 37899511 DOI: 10.1097/bpo.0000000000002553] [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: 10/31/2023]
Abstract
BACKGROUND The recently described Modified Fels knee skeletal maturity system (mFels) has proven utility in prediction of ultimate lower extremity length in modern pediatric patients. mFels users evaluate chronological age, sex, and 7 anteroposterior knee radiographic parameters to produce a skeletal age estimate. We developed a free mobile application to minimize the learning curve of mFels radiographic parameter evaluation. We sought to identify the reliability of mFels for new users. METHODS Five pediatric orthopaedic surgeons, 5 orthopaedic surgery residents, 3 pediatric orthopaedic nurse practitioners, and 5 medical students completely naïve to mFels each evaluated a set of 20 pediatric anteroposterior knee radiographs with the assistance of the (What's the Skeletal Maturity?) mobile application. They were not provided any guidance beyond the instructions and examples embedded in the app. The results of their radiographic evaluations and skeletal age estimates were compared with those of the mFels app developers. RESULTS Averaging across participant groups, inter-rater reliability for each mFels parameter ranged from 0.73 to 0.91. Inter-rater reliability of skeletal age estimates was 0.98. Regardless of group, steady proficiency was reached by the seventh radiograph measured. CONCLUSIONS mFels is a reliable means of skeletal maturity evaluation. No special instruction is necessary for first time users at any level to utilize the (What's the Skeletal Maturity?) mobile application, and proficiency in skeletal age estimation is obtained by the seventh radiograph. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Ryan J Furdock
- Department of Orthopaedics, University Hospitals Cleveland Medical Center
| | - Kristie J Sun
- Case Western Reserve University School of Medicine, Cleveland
| | - Bryan Ren
- Department of Orthopaedics, University of Michigan Medical School, Ann Arbor, MI
| | - Matthew Folkman
- University of Toledo College of Medicine and Life Sciences, Toledo, OH
| | - Michael P Glotzbecker
- Division of Pediatric Orthopaedics, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine
| | - Jochen P Son-Hing
- Division of Pediatric Orthopaedics, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine
| | - Allison Gilmore
- Division of Pediatric Orthopaedics, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine
| | - Christina K Hardesty
- Division of Pediatric Orthopaedics, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine
| | - R Justin Mistovich
- Division of Pediatric Orthopaedics, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine
| | - Raymond W Liu
- Division of Pediatric Orthopaedics, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine
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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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Hardesty CK. Waiting for Change: Pulmonary Function Improves in a Delayed Fashion Following Dual Growing-Rod Surgery for Early-Onset Scoliosis: Commentary on an article by Yunsheng Wang, MD, et al.: "Long-Term Radiographic and Pulmonary Function Outcomes After Dual Growing-Rod Treatment for Severe Early-Onset Scoliosis". J Bone Joint Surg Am 2023; 105:e31. [PMID: 37341693 DOI: 10.2106/jbjs.23.00411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Affiliation(s)
- Christina K Hardesty
- Division of Pediatric Orthopaedic Surgery, 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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Guzek RH, Murphy R, Hardesty CK, Emans JB, Garg S, Smith JT, Roye BD, Glotzbecker MP, Sturm PF, Snyder BD, Poon SC, Poe-Kochert C, Anari JB. Mortality in Early-Onset Scoliosis During the Growth-friendly Surgery Era. J Pediatr Orthop 2022; 42:131-137. [PMID: 35138296 DOI: 10.1097/bpo.0000000000001983] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Early-onset scoliosis (EOS) is a spinal deformity that occurs in patients 9 years of age or younger. Severe deformity may result in thoracic insufficiency, respiratory failure, and premature death. The purpose of this study is to describe the modern-day natural history of mortality in patients with EOS. METHODS The multicenter Pediatric Spine Study Group database was queried for all patients with EOS who are deceased, without exclusion. Demographics, underlying diagnoses, EOS etiology, operative and nonoperative treatments or observation, complications, and date of death were retrieved. Descriptive statistics and survival analysis with Kaplan-Meier curves were performed. RESULTS There were 130/8009 patients identified as deceased for a registry mortality rate of 16 per 1000 patients. The mean age at death was 10.6 years (range: 1.0 to 30.2 y) and the most common EOS etiology was neuromuscular (73/130, 56.2%; P<0.001). Deceased patients were more likely be treated operatively than nonoperatively or observed (P<0.001). The mean age of death for patients treated operatively (12.3 y) was older than those treated nonoperatively (7.0 y) or observed (6.3 y) (P<0.001) despite a larger deformity and similar index visit body mass index and ventilation requirements. Kaplan-Meier analysis confirmed an increased survival time in patients with a history of any spine operation compared with patients without a history of spine operation (P<0.0001). Operatively treated patients experienced a median of 3.0 complications from diagnosis to death. Overall, cardiopulmonary related complications were the most common (129/271, 47.6%; P<0.001), followed by implant-related (57/271, 21.0%) and wound-related (26/271, 9.6%). The primary cause of death was identified for 78/130 (60.0%) patients, of which 57/78 (73.1%) were cardiopulmonary related. CONCLUSIONS This study represents the largest collection of EOS mortality to date, providing surgeons with a modern-day examination of the effects of surgical intervention to better council patients and families. Both fatal and nonfatal complications in children with EOS are most likely to involve the cardiopulmonary system. LEVEL OF EVIDENCE Level IV-therapeutic.
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Affiliation(s)
- Ryan H Guzek
- Children's Hospital of Philadelphia, Philadelphia, PA
| | - Robert Murphy
- Medical University of South Carolina, Charleston, SC
| | | | | | | | | | | | | | - Peter F Sturm
- Cincinnati Children's Hospital and Medical Center, Cincinnati, OH
| | | | | | | | - Jason B Anari
- Children's Hospital of Philadelphia, Philadelphia, PA
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Hardesty CK, Murphy RF, Pawelek JB, Glotzbecker MP, Hosseini P, Johnston CE, Emans J, Akbarnia BA. An initial effort to define an early onset scoliosis "graduate"-The Pediatric Spine Study Group experience. Spine Deform 2021; 9:679-683. [PMID: 33258069 DOI: 10.1007/s43390-020-00255-6] [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: 05/29/2020] [Accepted: 11/08/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE Increasingly, patients with early onset scoliosis (EOS) are completing a growth friendly surgical program followed by observation, removal of implants or a definitive spinal fusion. These patients are colloquially referred to as "graduates". A standardized definition of a graduate is needed for research and comparing the outcomes, family counseling, and a better understanding of the population. METHODS A 15-question electronic survey was completed by 39 experienced pediatric spine surgeons to identify factors salient to the definition of a graduate of EOS surgical programs. A Delphi/Nominal group technique session with nine questions was then performed face-to-face with 21 members of the Pediatric Spine Study Group to discuss and refine the definition. A follow-up electronic survey was then distributed to these same 21 members to gain consensus on the final definition. RESULTS From the initial survey, it was identified that a graduate did not require definitive spinal fusion after a growing program. From the Delphi session, it was determined that skeletal maturity was the most important factor in defining a graduate. A strictly defined minimum length of follow-up was not felt to be a prerequisite for qualification of graduation. After the final electronic version was distributed, > 80% of respondents agreed upon the final definition, thereby achieving consensus. CONCLUSION The Pediatric Spine Study Group recommends adoption of the following definition: a "graduate" is a patient who has undergone any surgical program to treat early onset scoliosis, and has reached skeletal maturity and does not have a planned surgical intervention for EOS in the future. LEVEL OF EVIDENCE V.
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Affiliation(s)
- Christina K Hardesty
- Division of Pediatric Orthopaedic Surgery, Rainbow Babies and Children's Hospital, 11100 Euclid Avenue, RBC 6081, Cleveland, OH, 44106, USA.
| | - Robert F Murphy
- Department of Orthopaedics and Physical Medicine, Medical University of South Carolina, Charleston, SC, USA
| | | | - Michael P Glotzbecker
- Division of Pediatric Orthopaedic Surgery, Rainbow Babies and Children's Hospital, 11100 Euclid Avenue, RBC 6081, Cleveland, OH, 44106, USA
| | - Pooria Hosseini
- Department of Orthopaedic Surgery, St. Louis University, St. Louis, MO, USA
| | - Charles E Johnston
- Department of Orthopaedic Surgery, Texas Scottish Rite Hospital for Children, Dallas, TX, USA
| | - John Emans
- Department of Orthopaedic Surgery, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - Behrooz A Akbarnia
- San Diego Spine Foundation, San Diego, CA, USA.,Department of Orthopaedic Surgery, University of California, San Diego, San Diego, CA, USA
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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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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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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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Thomas SP, Hardesty CK, Buxton KA, Collins AB, Pruente J, Pham KLD, Sheriko J, McClanahan ME, Inanoglu D, Srinivasan R, Ridnour L, Cooper R, Khurana S, Network TPI. Pediatric intrathecal baclofen management during the COVID-19 pandemic in the US and Canada. J Pediatr Rehabil Med 2020; 13:379-384. [PMID: 33164962 DOI: 10.3233/prm-200755] [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] [Indexed: 11/15/2022] Open
Abstract
The COVID-19 pandemic has been a challenge to healthcare systems around the world. Within pediatric rehabilitation medicine, management of intrathecal baclofen has been particularly challenging. This editorial reviews how programs in the US and Canada coped with the quickly changing healthcare environment and how we can learn from this pandemic to be prepared for future crises.
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Affiliation(s)
- Sruthi P Thomas
- Departments of Physical Medicine and Rehabilitation and Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Christina K Hardesty
- Departments of Orthopedic Surgery and Pediatrics, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Kristin A Buxton
- Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrew B Collins
- Department of Pediatrics, University of Cincinnati College of Medicin, Divisions of Pediatric Rehabilitation Medicine and Pain Management, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jessica Pruente
- Department of Physical Medicine and Rehabilitation, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Kelly L D Pham
- Rehabilitation Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Jordan Sheriko
- Departments of Pediatrics, Medicine, Dalhousie University, Rehabilitation Services, IWK Health, Halifax, Nova Scotia, Canada
| | - M Elise McClanahan
- Pediatric Rehabilitation Medicine, Department of Neurosurgery, Division of Physical Medicine and Rehabilitation, University of Louisville School of Medicine, Louisville, KY, USA
| | - Didem Inanoglu
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Rajashree Srinivasan
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Laura Ridnour
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Robert Cooper
- Physical Medicine and Rehabilitation, Mary Bridge Children's, Tacoma, WA, USA
| | - Seema Khurana
- Physical Medicine and Rehabilitation, University of Miami Miller School of Medicine, Miami, FL, USA
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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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Hardesty CK, Huang RP, El-Hawary R, Samdani A, Hermida PB, Bas T, Balioğlu MB, Gurd D, Pawelek J, McCarthy R, Zhu F, Luhmann S. Early-Onset Scoliosis: Updated Treatment Techniques and Results. Spine Deform 2019; 6:467-472. [PMID: 29886921 DOI: 10.1016/j.jspd.2017.12.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [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: 08/09/2017] [Revised: 12/22/2017] [Accepted: 12/25/2017] [Indexed: 02/08/2023]
Abstract
STUDY DESIGN This is a review of the current literature on early-onset scoliosis (EOS) techniques and treatment written by the Growing Spine Committee of the Scoliosis Research Society. OBJECTIVES The Growing Spine Committee of the Scoliosis Research Society sought to update the information available on the definition and treatment of EOS, including new information about existing techniques. SUMMARY OF BACKGROUND DATA EOS represents a diverse, heterogeneous, and clinically challenging group of spinal disorders occurring in children under the age of 10. Our understanding of EOS has changed dramatically in the last 15 years, and management of EOS has changed even more rapidly in the last five years. METHODS The Growing Spine Committee of the Scoliosis Research Society has embarked upon a review of the most current literature on EOS techniques and treatment. RESULTS This white paper provides recent updates on current techniques, including a summary of new modalities, indications, contraindications, and clinical results. CONCLUSIONS Although treatment of EOS is still challenging and complicated, the evolution of options and knowledge presents hope for better understanding and management in the future. LEVEL OF EVIDENCE Level V.
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Affiliation(s)
- Christina K Hardesty
- Rainbow Babies and Children's Hospital, Case Western Reserve University, 11100 Euclid Avenue, RBC 6081, Cleveland, OH 44106, USA.
| | - Robert P Huang
- Studer Family Children's Hospital Scoliosis and Pediatric Orthopaedic Surgery, 4541 N. Davis Highway, Suite A, Pensacola, FL 32503, USA
| | - Ron El-Hawary
- IWK Heath Centre, 5980 University Ave, Halifax, NS B3K 6R8, Canada
| | - Amer Samdani
- Shriners Hospitals for Children, 3551 N Broad St, Philadelphia, PA 19140, USA
| | - Paloma Bas Hermida
- Hospital Universitario y Politecnico La Fe, Avinguda de Fernando Abril Martorell, 106, 46026, Valencia, Spain
| | - Teresa Bas
- Hospital Universitario y Politecnico La Fe, Avinguda de Fernando Abril Martorell, 106, 46026, Valencia, Spain
| | - Mehmet Bülent Balioğlu
- Department of Orthopaedics, Istinye University Liv Hospital, Asik Veysel mah. Suleyman Demirel Cad. No:1 34510, Esenyurt, Istanbul, Turkey
| | - David Gurd
- San Diego Diego Spine Foundation, 6190 Cornerstone Ct East, Ste 212, San Diego, CA 92121, USA
| | - Jeff Pawelek
- Cleveland Clinic Children's Hospital, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Richard McCarthy
- Arkansas Children's Hospital, 1 Children's Way, Little Rock, AR 72202, USA
| | - Feng Zhu
- Chinese University of Hong Kong, Sino Building, Chung Chi Rd, Sha Tin, Hong Kong, China
| | - Scott Luhmann
- Washington University School of Medicine, 660 S Euclid Ave, St. Louis, MO 63110, 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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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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Abstract
BACKGROUND Are obese patients with idiopathic scoliosis undergoing spinal surgery at higher risk for perioperative complications? This is not clearly understood. One previous study showed a greater preoperative thoracic kyphosis but no increase in perioperative complications. QUESTIONS/PURPOSES We asked whether obese adolescents with idiopathic scoliosis have more perioperative complications and decreased curve correction. METHODS We retrospectively reviewed 478 patients with idiopathic scoliosis operated on from 1998 to 2010. There were 236 (187 females, 49 males) with a mean age of 14 years (range, 11-22 years) who met the inclusion criteria. Demographic data, radiographic measurements, perioperative data, and major and minor complications were recorded. The BMI percentile (BMI%) defined two patient groups: healthy weight (BMI%<85) (n=181) and obese (BMI%≥85) (n=55). The preoperative curves were similar in the two groups. Minimum followup was 2 years (mean, 6 years; range, 2-14 years). RESULTS Postoperatively, the mean major curve was smaller for healthy-weight patients (20°; range, 8°-36°) than for obese patients (23.2°; range, 12°-56°), as was the mean kyphosis (31.1° [range, 10°-56°]) versus 36° [range, 15°-33°], respectively). The postoperative lordosis was similar in both groups. Increased BMI% correlated with increased operative time, intraoperative blood loss, amount of intraoperative crystalloids, and difficulty with administration of spinal anesthesia. CONCLUSIONS Obese patients are at higher risk for perioperative complications when undergoing spinal deformity surgery. Counseling should be done with the patient and family and weight loss recommended before surgery. LEVEL OF EVIDENCE Level IV, prognostic study. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Christina K. Hardesty
- Division of Pediatric Orthopaedics, Rainbow Babies and Children’s Hospital, University Hospitals Case Medical Center, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106 USA
| | - Connie Poe-Kochert
- Division of Pediatric Orthopaedics, Rainbow Babies and Children’s Hospital, University Hospitals Case Medical Center, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106 USA
| | - Jochen P. Son-Hing
- Division of Pediatric Orthopaedics, Rainbow Babies and Children’s Hospital, University Hospitals Case Medical Center, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106 USA
| | - George H. Thompson
- Division of Pediatric Orthopaedics, Rainbow Babies and Children’s Hospital, University Hospitals Case Medical Center, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106 USA
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