Lori A. Dolan

Adolescent idiopathic scoliosis

Adolescent idiopathic scoliosis (AIS) affects 1-3% of children in the at-risk population of those aged 10-16 years. The aetiopathogensis of this disorder remains unknown, with misinformation about its natural history. Non-surgical treatments are aimed to reduce the number of operations by preventing curve progression. Although bracing and physiotherapy are common treatments in much of the world, their effectiveness has never been rigorously assessed. Technological advances have much improved the ability of surgeons to safely correct the deformity while maintaining sagittal and coronal balance. However, we do not have long-term results of these changing surgical treatments. Much has yet to be learned about the general health, quality of life, and self-image of both treated and untreated patients with AIS.

Effects of Bracing in Adolescents with Idiopathic Scoliosis

BACKGROUND The role of bracing in patients with adolescent idiopathic scoliosis who are at risk for curve progression and eventual surgery is controversial. METHODS We conducted a multicenter study that included patients with typical indications for bracing due to their age, skeletal immaturity, and degree of scoliosis. Both a randomized cohort and a preference cohort were enrolled. Of 242 patients included in the analysis, 116 were randomly assigned to bracing or observation, and 126 chose between bracing and observation. Patients in the bracing group were instructed to wear the brace at least 18 hours per day. The primary outcomes were curve progression to 50 degrees or more (treatment failure) and skeletal maturity without this degree of curve progression (treatment success). RESULTS The trial was stopped early owing to the efficacy of bracing. In an analysis that included both the randomized and preference cohorts, the rate of treatment success was 72% after bracing, as compared with 48% after observation (propensity-score-adjusted odds ratio for treatment success, 1.93; 95% confidence interval [CI], 1.08 to 3.46). In the intention-to-treat analysis, the rate of treatment success was 75% among patients randomly assigned to bracing, as compared with 42% among those randomly assigned to observation (odds ratio, 4.11; 95% CI, 1.85 to 9.16). There was a significant positive association between hours of brace wear and rate of treatment success (P<0.001). CONCLUSIONS Bracing significantly decreased the progression of high-risk curves to the threshold for surgery in patients with adolescent idiopathic scoliosis. The benefit increased with longer hours of brace wear. (Funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases and others; BRAIST ClinicalTrials.gov number, NCT00448448.).

Surgical rates after observation and bracing for adolescent idiopathic scoliosis: an evidence-based review.

Study Design. Systematic review of clinical studies. Objectives. To develop a pooled estimate of the prevalence of surgery after observation and after brace treatment in patients with adolescent idiopathic scoliosis (AIS). Summary of Background Data. Critical analysis of the studies evaluating bracing in AIS yields limited evidence concerning the effect of TLSOs on curve progression, rate of surgery, and the burden of suffering associated with AIS. Many patients choose bracing without an evidence-based estimate of their risk of surgery relative to no treatment. Therefore, such an estimate is needed to promote informed decision-making. Methods. Multiple electronic databases were searched using the key words “adolescent idiopathic scoliosis,” “observation,” “orthotics,” “surgery,” and “bracing.” The search was limited to the English language. Studies were included if observation or a TLSO was evaluated and if the sample closely matched the current indications for bracing (skeletal immaturity, age <15 years, Cobb angle between 20° and 45°). One reviewer (L.A.D) selected the articles and abstracted the data, including research design, type of brace, minimum follow-up, and surgical rate. Additional data concerning inclusion criteria and risk factors for surgery included gender, Risser, age and Cobb angle at brace initiation, curve type, and dose (hours of recommended brace wear). Results. Eighteen studies were included (observation = 3, bracing = 15). All were Level III or IV clinical series. Despite some uniformity in surgical indications, the surgical rates were extremely variable, ranging from 1 surgery of 72 patients (1%) to 51 of 120 patients (43%) after bracing, and from 2 surgeries of 15 patients (13%) to 18 of 47 patients (28%) after observation. When pooled, the bracing surgical rate was 23% compared with 22% in the observation group. Pooled estimates for surgical rate by type of brace, curve type, Cobb angle, Risser sign, and dose were also calculated. Conclusion. Comparing the pooled rates for these two interventions shows no clear advantage of either approach. Based on the evidence presented here, one cannot recommend one approach over the other to prevent the need for surgery in AIS. This recommendation carries a grade of D, indicating that the use of bracing relative to observation is supported by “troublingly inconsistent or inconclusive studies of any level.” The decision to brace for AIS is often difficult for clinicians and families. An evidence-based estimate of the risk of surgery will provide additional information to use as they weigh the costs and benefits of bracing.

Use of the Milwaukee brace for progressive idiopathic scoliosis.

One hundred and two (92 per cent) of 111 immature patients in whom idiopathic scoliosis had been treated with a Milwaukee brace were followed to determine the effectiveness of the brace in preventing progression of the scoliosis. The average time from cessation of bracing until the latest radiographs were made for the patients who were managed non-operatively was six years and four months. The average progression of the curve, from the time of initial bracing until use of the brace was stopped, in the eighty-eight patients who were included in the statistical analysis was 4 degrees. The curve continued to progress an average of 5 degrees after use of the brace was stopped in the patients who did not have an arthrodesis. Forty-two patients (48 per cent) had more than 5 degrees of progression at the time that use of the brace was stopped. Thirty-seven patients (42 per cent) had an operation or a curve of sufficient magnitude to warrant operative intervention. The maximum correction of the Cobb angle in the brace had prognostic importance for progression of the curve. The patients in whom the curve did not progress or who did not need operative intervention had had an average correction of 20 per cent, while the patients who had a failure had had an average correction of 8 per cent. The patients who eventually had the indications for an arthrodesis were, on the average, one year younger (eleven years and nine months) and had a curve of a larger magnitude at the time of bracing than the patients who did not need an arthrodesis. The findings of this study do not agree with previously reported favorable results with bracing and raise questions about whether the natural history of progressive idiopathic scoliosis is truly altered by use of the Milwaukee brace.

Long-term psychosocial characteristics of patients treated for idiopathic scoliosis.

Psychosocial characteristics of 95 female patients treated with Milwaukee bracing for idiopathic scoliosis were examined using a battery of five psychosocial scales. Sixty-five patients treated with bracing alone and 30 patients who also underwent arthrodesis for curve progression were compared with 49 age-matched female controls. At an average follow-up of 7 years, no differences in depression or health locus of control existed. Significant perceptions of discrimination and a lower satisfaction of overall appearance was recalled during the treatment phase. By final follow-up, there was no longer any difference between the patients and controls in these areas. Significantly, differences in body-image scores persisted at follow-up. Operative patients had a more negative body image of the axial skeleton in comparison with the braced and control groups. We conclude that transient psychological effects are often present during treatment, and a lower body image may persist for several years in surgical patients.

Acetabular dysplasia after treatment for developmental dysplasia of the hip. Implications for secondary procedures.

Untreated acetabular dysplasia following treatment for developmental dysplasia of the hip (DDH) leads to early degenerative joint disease. Clinicians must accurately and reliably recognise dysplasia in order to intervene appropriately with secondary acetabular or femoral procedures. This study sought early predictors of residual dysplasia in order to establish empirically-based indications for treatment. DDH treated by closed or open reduction alone was reviewed. Residual hip dysplasia was defined according to the Severin classification at skeletal maturity. Future hip replacement in a subset of these patients was compared with the Severin classification. Serial measurements of acetabular development and subluxation of the femoral head were collected, as were the age at reduction, type of reduction, and Tonnis grade prior to reduction. These variables were used to predict the Severin classification. The mean age at reduction in 72 hips was 16 months (1 to 46). On the final radiograph, 47 hips (65%) were classified as Severin I/II, and 25 as Severin III/IV (35%). At 40 years after reduction, five of 43 hips (21%) had had a total hip replacement (THR). The Severin grade was predictive for THR. Early measurements of the acetabular index (AI) were predictive for Severin grade. For example, an AI of 35 degrees or more at two years after reduction was associated with an 80% probability of becoming a Severin grade III/IV hip. This study links early acetabular remodelling, residual dysplasia at skeletal maturity and the long-term risk of THR. It presents evidence describing the diagnostic value of early predictors of residual dysplasia, and therefore, of the long-term risk of degenerative change.

Long-Term Outcome after Open Reduction through an Anteromedial Approach for Congenital Dislocation of the Hip*

We reviewed the long-term outcome of open reduction of ninety-three congenitally dislocated hips (in seventy-six children) through an anteromedial approach. The average age of the patients was fourteen months (range, two to fifty months) at the time of the reduction and eleven years (range, four to twenty-three years) at the time of the most recent follow-up evaluation. At the most recent follow-up evaluation, sixty-six hips (71 per cent) had an excellent or good result, twenty-four (26 per cent) had a fair result, and three (3 per cent) had a poor result, according to the Severin classification system. An inverted neolimbus at the time of the operation and postoperative growth disturbance of the femoral head were associated with a poor roentgenographic result. According to the classification of Bucholz and Ogden, twenty-two hips (24 per cent) had type-II avascular necrosis, thirteen hips (14 per cent) had type-III, three (3 per cent) had type-IV, two (2 per cent) had non-classifiable lesions, and fifty-three (57 per cent) did not have avascular necrosis. A high hip dislocation and an operation after the age of twenty-four months were associated with a higher rate of growth disturbances of the femoral head. With the numbers available for study, we did not find any association between short-term preoperative traction, ligation of the medial circumflex vessel, or the type of neolimbus and the prevalence of growth disturbances. Two hips redislocated postoperatively, and seven had transient stiffness. We consider the anteromedial approach to be useful in the management of patients with congenital dislocation of the hip who are twenty-four months old or less. The advantages of this approach include direct access to the obstacles to reduction, avoidance of damage of the iliac apophysis and the abductor muscles, minimum blood loss, the need for only a single operative session for treatment of both hips, and a cosmetically acceptable scar. The prevalence of type-II growth disturbances of the femoral head was higher than had been expected, emphasizing the need for additional investigation.

Results of an accelerated Ponseti protocol for clubfoot.

The Ponseti method has demonstrated excellent results when performed at weekly intervals, but it is not known whether correction can be accomplished in a shorter amount of time. This study evaluated the success in correction in relation to time between casts (5 or 7 days). The authors retrospectively reviewed 230 patients (319 clubfeet). One hundred sixty-five patients (72%) had undergone previous nonsurgical treatment elsewhere. Patients were assigned to 5 or 7 days based solely on geography. Ninety percent of patients required five or fewer casts for correction, and there was no difference between groups (P = 0.85). Average time from first cast to Achilles tenotomy was 16 days for the 5-day group and 24 days for the 7-day group (P = 0.001). Three patients (1.3%) required corrective surgery and there were 36 relapses (P = 0.4). In conclusion, the Ponseti method is very effective and the deformity can be corrected in a relatively short time.

Long-Term Results of Reconstruction for Treatment of a Flexible Cavovarus Foot in Charcot-Marie-Tooth Disease

BACKGROUND Cavovarus foot deformity is common in patients with Charcot-Marie-Tooth disease. Multiple surgical reconstructive procedures have been described, but few authors have reported long-term results. The purpose of this study was to evaluate the long-term results of an algorithmic approach to reconstruction for the treatment of a cavovarus foot in these patients. METHODS We evaluated twenty-five consecutive patients with Charcot-Marie-Tooth disease and cavovarus foot deformity (forty-one feet) who had undergone, between 1970 and 1994, a reconstruction consisting of dorsiflexion osteotomy of the first metatarsal, transfer of the peroneus longus to the peroneus brevis, plantar fascia release, transfer of the extensor hallucis longus to the neck of the first metatarsal, and in selected cases transfer of the tibialis anterior tendon to the lateral cuneiform. Each patient completed standardized outcome questionnaires (the Short Form-36 [SF-36] and Foot Function Index [FFI]). Radiographs were evaluated to assess alignment and degenerative arthritis, and gait analysis was performed. The mean age at the time of follow-up was 41.5 years, and the mean duration of follow-up was 26.1 years. RESULTS Correction of the cavus deformity was well maintained, although most patients had some recurrence of hindfoot varus as seen on radiographic examination. The patients had a lower mean SF-36 physical component score than age-matched norms, and the women had a lower mean SF-36 physical component score than the men, although this difference was not significant. Smokers had lower mean SF-36 scores and significantly higher mean FFI pain, disability, and activity limitation subscores (p < 0.0001). Seven patients (eight feet) underwent a total of eleven subsequent foot or ankle operations, but no patient required a triple arthrodesis. Moderate-to-severe osteoarthritis was observed in eleven feet. With the numbers studied, the age at surgery, age at the time of follow-up, and body mass index were not noted to have a significant correlation with the SF-36 or FFI scores. CONCLUSIONS Use of the described soft-tissue procedures and first metatarsal osteotomy to correct cavovarus foot deformity results in lower rates of degenerative changes and reoperations as compared with those reported at the time of long-term follow-up of patients treated with triple arthrodesis.

Stulberg Classification System for Evaluation of Legg-Calvé-Perthes Disease: Intra-Rater and Inter-Rater Reliability*

BACKGROUND Researchers and clinicians commonly use the classification system of Stulberg et al. as a basis for treatment decisions during the active phase of Legg-Calvé-Perthes disease because of its putative utility as a predictor of long-term outcome. It is generally assumed that this system has an acceptable degree of reliability. This assumption, however, is not convincingly supported by the literature. METHODS The purpose of the present study was to assess the inter-rater and intra-rater reliability of the classification system of Stulberg et al. with use of a pre-test, post-test design. During the pre-test phase, nine raters independently used the system to evaluate the radiographs of skeletally mature patients who had been managed for Legg-Calvé-Perthes disease. The intervention between the pre-test and post-test phases consisted of a consensus-building session during which all raters jointly arrived at standardized definitions of the various joint structures that are assessed with use of the classification system. The effect of these definitions on reliability then was assessed by reevaluating the radiographs during the post-test phase. RESULTS The pre-test intra-rater reliability coefficients ranged from 0.709 to 0.915, and the post-test coefficients ranged from 0.568 to 0.874. The pre-test inter-rater reliability coefficients ranged from 0.603 to 0.732, and the post-test coefficients ranged from 0.648 to 0.744. Contributing to the variance was a lack of agreement concerning the assessment of joint structures and the way in which the raters translated these evaluations into a classification according to the system of Stulberg et al. CONCLUSIONS Although intra-rater reliability was marginally acceptable, the degree of variability between the classifications assigned by different raters even after the intervention - calls into question the reliability of the system of Stulberg et al.; consequently, the validity of any treatment decisions, outcome evaluations, or epidemiological studies based on this system is also in question.