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Classification of high-grade spondylolistheses based on pelvic version and spine balance: possible rationale for reduction.

Study Design. Retrospective review of a radiographic database of high-grade spondylolisthesis patients in comparison with asymptomatic controls. Objective. To analyze the sagittal spinopelvic alignment in high-grade spondylolisthesis patients and identify subgroups that may require reduction to restore sagittal balance. Summary of Background Data. High-grade spondylolisthesis is associated with an abnormally high pelvic incidence (PI); however, the spatial orientation of the pelvis, determined by sacral slope (SS) and pelvic tilt (PT), is not known. We hypothesized that sagittal spinal alignment would vary with the pelvic orientation. Methods. Digitized sagittal radiographs of 133 high-grade spondylolisthesis patients (mean age, 17 years) were measured to determined sagittal alignment. K-means cluster analysis identified 2 groups based on the PT and SS, which were compared by paired t test. Comparisons were made to asymptomatic controls matched for PI. Results. High-grade spondylolisthesis patients had a mean PI of 78.9° ± 12.1°. Cluster analysis identified a retroverted, unbalanced pelvis group with high PT (36.5° ± 8.0°)/low SS (40.3° ± 9.0°) and a balanced pelvic group with low PT (mean 21.3° ± 8.2°)/high SS (59.9° ± 11.2°). The retroverted pelvis group had significantly greater L5 incidence and lumbosacral angle with less thoracic kyphosis than the balanced pelvic group. A total of 83% of controls had a “balanced pelvis” based on the categorization by SS and PT. Conclusion. Analysis of sagittal alignment of high-grade spondylolisthesis patients revealed distinct groups termed “balanced” and “unbalanced” pelvis. The PT and SS were similar in controls and balanced pelvis patients. Unbalanced pelvis patients had a sagittal spinal alignment that differed from the balanced pelvis and control groups. Treatment strategies for high-grade spondylolisthesis should reflect the different mechanical strain on the spinopelvic junction in each group; reduction techniques might be considered in patients with an unbalanced pelvis high-grade spondylolisthesis.

Hip disease in adults with Down syndrome

The life expectancy of patients with Down syndrome has increased significantly in recent years. Hip abnormalities occur in children with this syndrome but little is known about their natural history in later life. In 65 adults with Down syndrome we found hip abnormalities in 28%, and this was statistically correlated with walking ability. A subgroup of 18 patients was followed by serial examination; this showed that hip instability occurred in adulthood and became worse with time. In some patients, hip instability started after skeletal maturity.

Femur fractures in children : Treatment with early sitting spica casting

The purpose of this article is to review our experience with early spica casting and determine risk factors for loss of reduction and skin complications. The radiographic and clinical charts of 114 children were retrospectively reviewed. At the time of fracture union, excessive shortening and angular malunion were not significant problems. Loss of reduction and skin complications occurred in 20 and 14% of patients, respectively. In addition to previously described risk factors, we identified spica knee flexion angle < 50 degrees as predictive of eventual loss of reduction and found that > 2 cm of initial shortening was not a contraindication to early spica casting. Factors associated with skin problems included younger age and abuse as a mechanism of injury. In our opinion, early spica casting is the treatment of choice for all isolated, closed femur fractures in otherwise healthy children aged 6 years or younger, regardless of the degree of initial deformity.

Surgical treatment of congenital kyphosis

Study Design. In this study, 26 cases of congenital kyphosis and kyphoscoliosis treated surgically were retrospectively reviewed. Objective. To assess the clinical outcomes and surgical indications for posterior only versus anteroposterior surgery in the child. Summary of Background Data. Congenital kyphosis usually is progressive without surgical intervention. Current recommended treatment includes posterior arthrodesis for deformities of less than 50° to 60°, and anterior release or decompression, anterior fusion, and posterior instrumented arthrodesis for large deformities and cord compression. Methods. Cases involving myelodysplasia, spinal dysgenesis, and skeletal dysplasia were excluded from the study. Kyphoscoliosis was included if the kyphotic deformity was greater than the scoliotic deformity. Patients were grouped by age and surgical technique. The patients in group P1 underwent posterior arthrodesis at an age younger than 3 years, and those in group P2 underwent the procedure at an age older than 3 years. The patients in group AP1 underwent anterior and posterior procedures at an age younger than 3 years, and those in group AP2 underwent the procedures at an age older than 3 years. The preoperative deformity, complications, and postoperative deformity correction were analyzed. There were nine Type 1 (failure of formation), nine Type 2 (failure of segmentation), and eight Type 3 (mixed) deformities. Four patients had associated spinal dysraphism. Three patients with Type 1 deformities had clinical or radiographic evidence of cord compression. Results. In Group P1, five patients at an average age of 16 months underwent posterior arthrodesis alone for an average kyphotic deformity of 49°. The immediate postoperative correction improved over a period of 6 years and 9 months by an additional 10°, resulting in a final deformity of 26°. Pseudarthrosis developed in two patients, requiring fusion mass augmentation or anterior arthrodesis. Neither patient was instrumented. In Group P2, five patients at an average age of 13 years and 7 months underwent posterior arthrodesis with instrumentation for kyphotic deformity of 59°. Approximately 30° of intraoperative correction was achieved safely using compression instrumentation and positioning. No further correction occurred with growth. The final residual kyphotic deformity was 29° after a follow-up period of 4 years and 5 months. In Group AP1, seven patients underwent anterior release or vertebra resection for deformity correction and posterior arthrodesis for an average kyphotic deformity of 48° at the age of 16 months. There were no iatrogenic neurologic injuries. The final residual kyphotic deformity was 22° after a follow-up period of 6 years and 3 months. In Group AP2, nine patients underwent anterior release or decompression with posterior arthrodesis for kyphotic deformity of 77° at the age of 11 years and 6 months. The deformity was corrected to 37°, with no significant loss over a follow-up period of 5 years and 2 months. There were two postoperative neurologic complications. Conclusions. After reviewing their experience, the authors made the following observations: 1) The pseudarthrosis rate was low even without routine augmentation of fusion mass if instrumentation was used; 2) gradual correction of kyphosis may occur with growth in patients younger than 3 years with Types 2 and 3 deformities after posterior fusion, but appears to be unpredictable; 3) the risk of neurologic injury with anterior and posterior fusion for kyphotic deformity was associated with greater age, more severe deformity, and preexisting spinal cord compromise.

Physeal arrest about the knee associated with non-physeal fractures in the lower extremity.

The cases of seven patients who had a physeal arrest about the knee in association with nonphyseal fractures in the lower extremity were reviewed. The patients were between ten and twelve and one-half years old at the time of injury, and the physeal arrest involved either the posterolateral part of the distal femoral physis or the anterior part of the proximal tibial physis. There was no evidence of iatrogenic trauma to the physis. Recognition of the physeal injury was delayed for an average of one year and ten months until a gross angular deformity appeared. Adolescents who have fractures of the lower extremities that do not appear to involve a physeal plate should nevertheless be evaluated and followed for possible physeal injury about the knee that can be detected only after additional growth has taken place.

Intertrochanteric versus subcapital osteotomy in slipped capital femoral epiphysis.

We reviewed 15 flexion intertrochanteric osteotomies and 11 subcapital osteotomies done for chronic, severe, stable slipped capital femoral epiphysis at one institution with a minimum 2 years followup. The goal was to determine which procedure achieved better deformity correction and which procedure was safer. Radiographically, the two groups were equivalent in compensating for epiphyseal slip. Flexion intertrochanteric osteotomy was more effective in restoring proximal femoral anatomy, as determined by articulotrochanteric distance and trochanter-center of head distance. The incidence of complications, including osteonecrosis and chondrolysis, was low for both groups, but the reoperation rate was greater in the subcapital osteotomy group than in the flexion intertrochanteric group. Flexion intertrochanteric osteotomy seems to be an effective, safe, and reproducible realignment osteotomy for treatment of chronic, severe, stable slipped capital femoral epiphysis.

Comparison of Single- and Dual-rod Techniques for Posterior Spinal Instrumentation in the Treatment of Adolescent Idiopathic Scoliosis

Study Design. Two groups of patients undergoing posterior spinal instrumentation and arthrodesis for treatment of adolescent idiopathic scoliosis were reviewed retrospectively. Objective. To compare intraoperative concerns (operative time and blood loss), complications, and outcome in patients undergoing single or double posterior rod instrumentation for treatment of adolescent idiopathic scoliosis. Summary of Background Data. The current treatment of idiopathic scoliosis includes posterior spinal instrumentation and arthrodesis. The standard configuration is a rectangular construct of dual rods connected by cross-links. Use of a single rod with multiple fixation points has been proposed as an alternative method to decrease operative time and blood loss, and to avoid late deep infections. Methods. In this study, 21 patients underwent posterior instrumentation using a standard dual-rod construct, and 25 patients underwent posterior instrumentation using a solitary rod with multiple fixation points. Patients were assessed after a minimum 2-year follow-up period. Results. No significant differences were found in blood loss, operative time, or overall frequency of long-term complications. Although not statistically significant, the trend was toward implant prominence in the double-rod group and implant failure in the single-rod group. Implant failure occurred only in instrumentations extending into the lumbar spine. There was no statistical difference in curve progression. Conclusions. Single-rod instrumentation and dual-rod constructs offered similar curve correction, blood loss, and operative time. However, single-rod instrumentation may be more prone to implant failure when extended into the lumbar spine.

Reliability of the Spinal Deformity Study Group classification of lumbosacral spondylolisthesis.

Study Design. Reliability study of the computer-assisted SDSG (Spinal Deformity Study Group) classification of lumbosacral spondylolisthesis. Objective. To assess the intra- and interobserver reliability of the computer-assisted SDSG classification of lumbosacral spondylolisthesis. Summary of Background Data. The SDSG has proposed a new classification of lumbosacral spondylolisthesis based on slip grade, pelvic incidence (PI), and sacro-pelvic and spinal balance. Three types of low-grade spondylolisthesis are described: low PI (type 1), normal PI (type 2), and high PI (type 3). High-grade spondylolisthesis are defined as type 4 (balanced sacro-pelvis), type 5 (retroverted sacro-pelvis with balanced spine), and type 6 (retroverted sacro-pelvis with unbalanced spine). Methods. Full-length standing lateral radiographs of the spine of 40 subjects with lumbosacral spondylolisthesis were reviewed twice by 7 observers. Custom software was used by the observers to identify 7 anatomical landmarks on each radiograph to determine the SDSG type for all subjects. Percentage of agreement and &kgr; coefficients were used to determine the intra- and interobserver reliability. Results. All 6 types of spondylolisthesis described in the computer-assisted SDSG classification were identified. Overall intra- and interobserver agreements were 80% (&kgr;: 0.74) and 71% (&kgr;: 0.65), respectively. The intra- and interobserver agreements associated with computerized determination of slip grade were 92% (&kgr;: 0.83) and 88% (&kgr;: 0.78), respectively. As for computerized determination of sacro-pelvic and spinal balance, intra- and interobserver agreements were 86% (&kgr;: 0.76) and 75% (&kgr;: 0.63) for low-grade slips, whereas they were 88% (&kgr;: 0.80) and 83% (&kgr;: 0.75) for high-grade slips. Conclusion. Substantial intra- and interobserver reliability was found for the computer-assisted SDSG classification, and all 6 types of lumbosacral spondylolisthesis were identified. Refinement of the computer-assisted classification technique is, however, needed to further increase the reliability of the SDSG classification and facilitate its clinical use.

Incidence of skin complications and associated charges in children treated with hip spica casts for femur fractures.

Background Spica cast immobilization remains the treatment of choice for femur fractures in children aged 6 months to 6 years. The incidence of skin complications and their associated charges have not been well described. This studys purposes were to: (1) determine the rate of skin complications in children treated with spica casts for femur fractures, (2) identify predictors, and (3) calculate the charges associated with skin complications. Methods Health records for all patients treated with immediate spica casting for a femur fracture at a major tertiary-care childrens hospital from 2003 to 2009 were reviewed and relevant data were abstracted. Descriptive statistics and univariate and multiple logistic regression analyses were used to compare children with and without skin complications and to identify predictors of skin complications. The total charges for skin complications leading to a cast change and early bivalving and lining were calculated. Results Of the 300 spica cast applications in 297 patients, 77 subjects (28%) had skin complications. Twenty-four (31%) of these 77 patients underwent a cast change in the operating room, 34 (44%) required early bivalving and lining and 19 (25%) required cast trimming and/or skin care. Predictors of skin complications included: child abuse as mechanism of injury, younger age, and cast time more than 40 days. Sex, weight, fracture location, and total number of clinic visits were not statistically significant predictors of skin complications. The median charge for patients who required cast changes for skin complications was

Reliability and development of a new classification of lumbosacral spondylolisthesis

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