James T. Bennett

Epidemiological perspective on prophylactic pinning in patients with unilateral slipped capital femoral epiphysis.

The purpose of this review was to determine whether the literature supports in situ prophylactic pinning of the hip contralateral to a hip with a slipped capital femoral epiphysis (SCFE). Three hundred twenty-five articles on SCFE between 1931 and 1998 were reviewed. Two hundred six studies were used to establish normative data. Patients with a unilateral SCFE were 2,335 times more likely to develop a SCFE in the contralateral hip when compared to children in the general population experiencing an initial SCFE. Because a majority of these sequential SCFEs were detected and treated early, we concluded that close follow-up and not prophylactic pinning was most supported by the literature.

Lumbar spine and femoral neck bone mineral density in idiopathic scoliosis: a follow-up study.

A follow-up study of the bone mineral densities (BMD) of 22 female subjects with idiopathic scoliosis was performed using dual-photon absorptiometry at an average follow-up period of 30.8 months. Compared to the initial scans, statistically significant increases in lumbar spine and femoral neck BMD were observed. When compared to normal subjects, approximately half of the scoliotic subjects were markedly osteoporotic, having BMD measurements at least two standard deviations below the expected value. Scoliotic curvature data could not be correlated with the BMD data. The observed osteoporosis is not transient and appears characteristic of idiopathic scoliosis.

Femoral neck and Lumbar spine bone mineral densities in a normal population 3−20 years of age

Dual-photon absorptiometry (DPA) with a 153gadolinium radionuclide source was used to measure bone mineral in the lumbar spine of 109 subjects and the femoral neck of 100 subjects 3–20 years of age. From the scan data collected, multiple linear regression models were developed to predict the measured bone mineral density values as a function of age, height, and weight; male and female data were evaluated separately. From the table of predicted values, a particular subjects bone mineral measurements can be readily compared with that of normal subjects in the same way “growth charts” are commonly used to assess development.

Current management of idiopathic clubfoot questionnaire: A multicentric study

A survey was mailed to 541 members of the Pediatric Society of North America to define currently accepted treatment options in the management of talipes equinovarus. Four hundred sixteen (77%) responses were received, representing a total of 6125 years in practice (average of 17.4 years per physician) and 8595 clubfeet treated in the past year (average of 26 feet treated per physician). While specific trends were reported and great variability exists, certain principles are universal: initial nonoperative management followed by surgery for persisting deformities. A renewed interest in Ponsetis techniques of casting and surgery to address specific persisting deformities was reflected in this survey.

Lower cervical spondylosis and myelopathy in adults with Down's syndrome

Abnormalities in the upper cervical spine resulting in cervical myelopathy in patients with Downs syndrome have been well-documented. However, two adult Downs syndrome patients recently presented with cervical myelopathy secondary to abnormalities of the lower cervical spine. Because of this, 105 Downs syndrome patients with normal upper cervical spines were evaluated clinically and radiographically. They were found to have an increased prevalence of lower cervical spondylosis that significantly correlated with physical findings consistent with cervical myelopathy. Therefore, physicians dealing with Downs patients should closely monitor neurological function and obtain flexion/extension laterals of the cervical spine to evaluate C1-C2 instability and degenerative changes in the lower cervical spine if a change in neurologic status is noted.

The posterior pedicle screw construct: 5-year results for thoracolumbar and lumbar curves

OBJECT Several studies of the outcomes of patients with adolescent idiopathic scoliosis (AIS) with thoracolumbar and lumbar curves after treatment with posterior pedicle screws have been reported, but most of these studies reported only 2-year follow-up. The authors analyzed the radiographic and clinical outcomes of patients with thoracolumbar and lumbar curves treated with posterior pedicle screws after 5 years of follow-up. METHODS A multicenter database was retrospectively queried to identify patients with AIS who underwent spinal fusion for Lenke 3C, 5C, and 6C curves. Radiographs from the following times were compared: preoperative, first follow-up visit, 1-year follow-up visit, 2-year follow-up visit, and 5-year follow-up visit. Chart review included scoliometer measurements, Scoliosis Research Society (SRS)-22 questionnaires, and complications requiring return to the operating room. RESULTS Among 26 patients with Lenke 3C, 5C, and 6C curves, the mean (± SD) age was 14.6 ± 2.1 years. From the time of the preoperative radiographs to the 5-year follow-up radiographs, there was a statistically significant improvement in the mean coronal lumbar Cobb angles (p < 0.0001), and from the time of the first postoperative radiographs to the 5-year follow-up radiographs, the lumbar curve remained stable (p = 0.14). From the time of the preoperative radiographs to the 5-year follow-up radiographs, there was a statistically significant improvement in the mean coronal thoracic Cobb angles (p < 0.0001), and from the time of the first postoperative radiographs to the 5-year follow-up radiographs, the thoracic curve remained stable (p = 0.10). From the first postoperative visit to the 5-year follow-up visit, the thoracic kyphosis (T5-12) remained stable (p = 0.10), and from the time of the preoperative radiographs to the 5-year follow-up radiographs, the lumbar lordosis (T-12 to top of sacrum) remained stable (p = 0.44). From the preoperative visit to the 5-year follow-up visit, the coronal balance improved significantly (p < 0.05) and remained stable from the first postoperative visit to the 5-year follow-up visit (p = 0.20). The SRS-22 total scores improved significantly from before surgery to 5 years after surgery (p < 0.0001). No patients required reoperation because of complications. CONCLUSIONS Correction of the coronal, sagittal, and axial planes in this cohort of patients was maintained from the first follow-up measurements to 5 years after surgery. In addition, at 5 years after surgery total SRS-22 scores and inclinometer readings were improved from preoperative scores and measurements.

Arthrographic findings in Legg-Calvé-Perthes disease.

Plain radiographs and arthrograms on 46 patients with Legg-Calvé-Perthes were evaluated. Measurements of containment including epiphyseal extrusion, caput index, femoral subluxation, percentage acetabular coverage, were determined. Only with arthrography are measurements of acetabular coverage, subluxation and epiphyseal extrusion consistent and reliable. The concept of eccentricity was developed to assist in the understanding of femoral containment.

Unplanned return to the operating room in patients with adolescent idiopathic scoliosis: are we doing better with pedicle screws?

Study Design. Prospective, longitudinal cohort. Objective. To evaluate the incidence, timing, and risk factors for reoperation in patients with adolescent idiopathic scoliosis (AIS) treated with pedicle screws (PSs) compared with hybrid (Hb) constructs. Summary of Background Data. Rates of return to the operating room (OR) after definitive fusion for AIS vary, with a paucity of data on PS constructs. Methods. A prospective multicenter database was retrospectively queried to identify consecutive patients with AIS who underwent posterior spinal fusion with either PS or Hb constructs with a minimum 2-year follow-up. All reoperations were stratified into an early group (<60 d) or a late group (>60 d). Univariate and multivariate logistical analyses were performed to identify potential risk factors related to reoperation. Results. A total of 627 patients met the inclusion criteria (PS = 540, Hb = 87). There was a statistically significant difference in the rate of reoperations between the PS (3.5%) and Hb groups (12.6%), P < 0.001. Early return to the OR occurred in 2.0% of the patients with PS compared with 3.4% in the Hb group, P = 0.43. Late returns to the OR occurred in 1.5% of PS group versus 9.2% of the Hb group, P < 0.001. Multivariate analysis revealed longer operating time as an independent risk factor for an unplanned return to the OR in patients treated with PSs (P < 0.05). Conclusion. Our results suggest that patients with AIS treated with PS have decreased rates of unplanned return to the OR when compared with patients with Hb constructs. The majority of returns to the OR were early (<60 d) for the PS group compared with late (>60 d) for the Hb group. Longer operative times increased the risk of unplanned reoperation for the PS group. Level of Evidence: 3

Results of selective thoracic versus nonselective fusion in Lenke type 3 curves.

Study Design. A retrospective analysis of a prospectively collected multicenter database. Objective. To identify the radiographical and clinical outcomes in Lenke 3 curves fused selectively (S) versus nonselectively (NS). Summary of Background Data. Surgical treatment options for Lenke 3 curves include fusion of both curves (NS) or selective thoracic curve fusion (S). Selective fusion of the thoracic curve spares lumbar motion segments; however, it may result in marked residual deformity. Methods. A prospectively collected multicenter database was retrospectively reviewed for adolescent idiopathic scoliosis Lenke 3 curves treated with posterior spinal fusion with a minimum of 2 years of follow-up. Patients were divided into 2 groups: NS (nonselective fusion) and S (selective thoracic fusion). Radiographical and clinical data were compared between the groups using the unpaired Student t test and analysis of variance. Results. A total of 74 patients met our inclusion criteria, with 49 (66.2%) in the NS group and 25 (33.8%) in the S group. Overall, both groups were similar preoperatively except for lumbar Cobb (NS = 56.3°, S = 47.2°, P < 0.001), lumbar lordosis (NS = 56.9°, S = 67.2°, P = 0.001), lumbar rotational prominence (NS = 11.2°, S = 8.2°, P < 0.05), and lumbar apical translation (NS = 3.2 cm, S = 1.9 cm, P < 0.05). Postoperatively, NS fusion demonstrated significantly less coronal imbalance of 2 cm or less (NS = 10.2%, S = 56.0%, P < 0.001), better lumbar curve correction (NS = 68.2%, S = 51.9%, P < 0.001), better lumbar apical translation correction (NS = 1.2 cm, S = 2.1 cm, P < 0.01), and better percent correction of the lumbar prominence (NS = 66.5%, S = 40.4%, P < 0.05). Scoliosis Research Society Questionnaire 22 scores at 2 years were similar between the groups. Conclusion. Despite preoperatively smaller lumbar curves with less apical translation and lumbar prominence, most patients with selective fusions were out of balance postoperatively and had inferior radiographical outcomes as compared with their nonselective comparison cohort with similar patient-reported outcomes. Long-term follow-up is required to determine whether the trade-off of sparing motion segments at the expense of somewhat lessened radiographical outcomes is worthwhile. Level of Evidence: 2

Adolescent Scoliosis Classification and Treatment

Adolescent idiopathic scoliosis (AIS) affects up to 3% of the population. It can be stratified by curve type according to the Lenke classification. This classification system incorporates curve magnitude, flexibility, the lumbar modifier, and the sagittal plane. The Lenke classification serves as a guide for selection of levels for surgical treatment of AIS. Surgical treatment of AIS includes anterior and posterior approaches; most AIS is treated through a posterior approach. Surgical goals include maximizing correction in the coronal, sagittal, and axial planes.