Ross S. Chafetz

Vertebral body stapling: a fusionless treatment option for a growing child with moderate idiopathic scoliosis.

Study Design. Retrospective review. Objective. To report the results of vertebral body stapling (VBS) with minimum 2-year follow-up in patients with idiopathic scoliosis. Summary of Background Data. While bracing for idiopathic scoliosis is moderately successful, its efficacy has been called into question, and it carries associated psychosocial ramifications. VBS has been shown to be a safe, feasible alternative to bracing for idiopathic scoliosis. Methods. We retrospectively reviewed 28 of 29 patients (96%) with idiopathic scoliosis treated with VBS followed for a minimum of 2 years. Inclusion criteria: Risser sign of 0 or 1 and coronal curve measuring between 20° and 45°. Results. There were 26 thoracic and 15 lumbar curves. Average follow-up was 3.2 years. The procedure was considered a success if curves corrected to within 10° of preoperative measurement or decreased >10°. Thoracic curves measuring <35° had a success rate of 77.7%. Curves which reached ≤20° on first erect radiograph had a success rate of 85.7%. Flexible curves >50% correction on bend film had a success rate of 71.4%. Of the 26 curves, 4 (15%) showed correction >10°. Kyphosis improved in 7 patients with preoperative hypokyphosis (<10° of kyphosis T5–T12). Of the patients, 83.5% had remaining normal thoracic kyphosis of 10° to 40°. Lumbar curves demonstrated a success rate of 86.7%. Four of the 15 lumbar curves (27%) showed correction >10°. Major complications include rupture of a unrecognized congenital diaphragmatic hernia and curve overcorrection in 1 patient. Two minor complications included superior mesenteric artery syndrome and atelectasis due to a mucous plug. There were no instances of staple dislodgement or neurovascular injury. Conclusion. Analysis of patients with idiopathic scoliosis (IS) with high-risk progression treated with vertebral body stapling (VBS) and minimum 2-year follow-up shows a success rate of 87% in all lumbar curves and in 79% of thoracic curves <35°. Thoracic curves >35° were not successful and require alternative treatments.

Arthroscopic treatment of internal rotation contracture and glenohumeral dysplasia in children with brachial plexus birth palsy

BACKGROUND The purpose of the study was to assess the ability of arthroscopic anterior release, +/- tendon transfers to maintain shoulder joint alignment in children with brachial plexus palsy, and to assess their outcome after arthroscopic reduction. METHODS Forty-four patients underwent arthroscopic release, +/- tendon transfers to realign a dysplastic glenohumeral joint in children with brachial plexus palsy. Twenty-eight children underwent isolated release and 16 children underwent concomitant tendon transfers. MRI and clinical measurements were used to assess outcome at 1-year follow-up. RESULTS There was a significant improvement (P < .001) in both retroversion from -34 (+/-15) to -19 (+/-13), and percentage of the humeral head anterior to the middle of the glenoid fossa (PHHA) from 19% (+/-12%) to 33% (+/-12%), at 1 year. Passive external rotation increased from -26 (+/-20) degrees to 47 (+/-17) degrees (P < .001). Active elevation increased from 112 (+/-28) degrees to 130 (+/-38) (P = .008) degrees. Patients that underwent tendon transfers obtained greater active elevation, 147 (+/-9) degrees compared to 119 (+/-6) degrees. Mallet aggregate and domain scores also demonstrated statistically significant improvements. CONCLUSIONS Our results after arthroscopic release +/- tendon transfers are encouraging with improvements in joint alignment and clinical evaluations following surgery. The clinical improvements paralleled the MRI corrections. Importantly, superior outcomes were associated with better preoperative clinical and MRI status. This indicates that early recognition of glenohumeral dysplasia and timely intervention results in better shoulder motion and improved joint alignment. LEVEL OF EVIDENCE 4.

International standards for neurological classification of spinal cord injury: training effect on accurate classification.

Abstract Objective: To evaluate the accuracy and agreement of International Standards for Neurological Classification of Spinal Cord Injury (ISCSCI) classification and to determine the effectiveness of formal training for pediatric clinicians. Study Population: Participants (N = 28) in a formal 90-minute classification training session. Outcome Measure: Pre/post-training examination of 1 0 case examples of a variety of neurological classifications. Results: Regardless of years of experience with the ISCSCI, a statistically significant improvement (P < 0.05) in classification was achieved after formal training. Before training, 27%(539 of 1,960) of the questions were answered incorrectly. After training, the percentage of incorrect classifications decreased to 11%(198 of 1 ,960) incorrect (P < 0.05). After training, the percentage of incorrect motor level classifications decreased by 23%(42%to 19%incorrect; P < 0.05). Post-training improvements were also demonstrated (P < 0.05) in classifying sensory levels (9%to 3%incorrect), neurological levels (31%to 6%incorrect), and severity of injury (9%to 0%incorrect). After training, reductions in classification errors (P < 0.05) were demonstrated in American Spinal Injury Association (ASIA) Impairment Scale (AIS) A (from 20%to 7%), B (50%to 11%), C (71%to 46%), and D (63%to 16%). Conclusions: This study demonstrated the benefits of formal, standardized training for accurate classification of the ISCSCI. Effective training programs must emphasize the guidelines and decision algorithms used to determine motor level and ASIA AIS designations because these remained problematic after training and are often a concern of patients/parents and are primary endpoints in clinical trials for neurological recovery.

Biceps-to-Triceps Transfer for Elbow Extension in Persons With Tetraplegia

PURPOSE Restoration of elbow extension via tendon transfer is an integral part of upper extremity surgical reconstruction in persons with tetraplegia. The purpose of this investigation was to assess patient satisfaction and elbow extension strength after biceps-to-triceps transfers. METHODS This is a retrospective chart review of biceps-to-triceps transfers in patients with spinal cord injury. Forty-five patients (77 arms) with spinal cord injury underwent biceps-to-triceps transfer. A total of 40 patients (68 arms) were available for follow-up. The average age at surgery was 17.3 years (range, 6.4-21.7 y).The biceps tendon was transferred around the medial aspect of the arm. The preoperative elbow extension strength was 0/5 (54 arms), 1/5 (10 arms), or 2/5 (4 arms). We also used the Canadian Occupational Performance Measure to measure patient-perceived outcome in a subset of 8 subjects. RESULTS Stringent manual muscle testing (MMT) for elbow extension revealed a statistically significant increase in muscle strength after surgery (p < .001). Forty-two arms were able to extend completely against gravity (MMT 3/5 or greater). Nine arms had a mild extension lag against gravity (MMT of 3/5). Therefore, 75% (51/68) of arms were able to function overhead. Seventeen arms had MMT scores less than 3/5. The top 5 goals of the 8 patients with completed preoperative and postoperative Canadian Occupational Performance Measure results were analyzed. After transfer, all 8 patients reported improved performance of and/or satisfaction with at least one goal. Performance and satisfaction were greatly improved (at least 4 points) for activities of living such as dressing, grooming, reaching for objects, recreational activities, wheelchair propulsion, and transfers. CONCLUSIONS Based on these results, we believe the biceps-to-triceps transfer is a reliable technique for restoration of elbow extension in persons with tetraplegia. Overhead function is obtainable in most cases with careful surgical technique and meticulous postoperative therapy. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Interrater Reliability of the International Standards for Neurological Classification of Spinal Cord Injury in Youths With Chronic Spinal Cord Injury

OBJECTIVES To evaluate the interrater reliability of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) in children with chronic spinal cord injury (SCI), and to define the lower age limit at which the examinations have clinical utility. DESIGN Repeated measures, multicenter reliability study. SETTING Two U.S. pediatric specialty hospitals with recognized SCI programs. PARTICIPANTS Children (N=236) with chronic SCI. INTERVENTIONS Subjects underwent 4 examinations by 2 raters: sensory tests (pin prick [PP] and light touch [LT]), a motor test, and a test of anal sensation (AS) and anal contraction (AC). MAIN OUTCOME MEASURES A 2-way general linear model analysis of variance was used for analysis. Intraclass correlation coefficients (ICCs) and 95% confidence intervals were calculated for PP, LT, motor, AS, and AC. RESULTS No child younger than 6 years completed the examination. When examined as a function of age, interrater reliability for motor, PP, LT, AS, and AC was moderate (ICC=.89) to high (ICC=.99). There was poor reliability for AS (ICC=.49) in subjects with complete injuries but moderate reliability for all other variables. There was moderate to high reliability for classification of type (tetraplegia/paraplegia) and severity (complete/incomplete) of injury across age groups. CONCLUSIONS The ISNCSCI does not have utility for children younger than 6 years. For children older than 6 years, interrater reliability of PP, LT, and motor examinations is high.

Relationship of the Anterior Humeral Line to the Capitellar Ossific Nucleus: Variability with Age

BACKGROUND The anterior humeral line is used to assess displacement and the adequacy of reduction of supracondylar humeral fractures in children. It is said to pass through the middle third of the capitellum in the elbow of a normal child. Few reports in the published literature have discussed this measurement, and the intra-rater and inter-rater reliability of the measurement is not known. The purposes of the present study were to define the position of the anterior humeral line in normal, skeletally immature elbows and to determine the intra-rater and inter-rater reliability of this parameter. METHODS On two occasions, three observers (a pediatric orthopaedic surgeon, a senior orthopaedic resident, and a senior medical student) recorded the location of the anterior humeral line as it passed through the capitellum as seen on the lateral radiographs of thirty normal elbows in children ranging in age from four months to three years and eleven months and thirty normal elbows in children ranging in age from four to nine years. For these measurements, the capitellum was divided into three regions: the anterior third, the middle third, and the posterior third. All observers received written instructions, and identical rulers were used to make the measurements. RESULTS Each observer made 120 measurements. Overall, the anterior humeral line passed through the anterior third of the capitellum in 31% of the elbows, the middle third in 52%, and the posterior third in 18%. In children younger than four years of age, the line passed nearly equally through either the anterior or middle third of the capitellum. In older children, the anterior humeral line passed through the middle third in 62% of the elbows. Overall, intra-rater reliability and inter-rater reliability were moderate to substantial. CONCLUSIONS The anterior humeral line passes through the middle third of the capitellum in the majority of normal children. In children younger than four years of age, it passes nearly equally through the anterior or middle third of the capitellum, whereas in older children it more consistently passes through the middle third of the capitellum. The surgeon must be aware of the variability of the location of the anterior humeral line with age when utilizing it to assess radiographs of the elbow in children after an injury or after the reduction of a displaced supracondylar fracture.

Magnetic resonance imaging and clinical findings before and after tendon transfers about the shoulder in children with residual brachial plexus birth palsy: a 3-year follow-up study.

Background Incomplete recovery after brachial plexus birth palsy often results in decreased movement and muscle imbalance about the shoulder, as rotator cuff and deltoid innervation are incomplete. Tendon transfers redistribute the forces about the joint and were thought to promote glenohumeral joint remodeling. Early reports, however, indicate limited ability to affect joint configuration. Our previous report and conclusions to this regard were based upon short follow-up. The purpose of this study was to assess the magnetic resonance imaging and clinical outcome after tendon transfers about the shoulder in children with residual brachial plexus birth palsy. Methods This was a retrospective chart review of 24 children who underwent transfer of the latissimus dorsi and teres major to the posterior rotator cuff with or without concomitant musculotendinous lengthenings. Follow-up magnetic resonance imaging data were available for all subjects at 1-year postsurgery and 19 subjects at 3-year follow-up. Results Preoperative average glenoid version was −25±13 degrees (range, −51-−11 degrees). Compared with preoperative version, there was no statistical difference at 1 year (−25±14 degrees; range, −56-−7 degrees; P=1.00) or at 3 years (−22±11 degrees; range, −54-−8 degrees; P=1.00). Preoperative average percent of humeral head anterior was 29%±15% (range, 0%-44%). Compared with preoperative percent of humeral head anterior, there was no statistical difference at 1 year (28%±16%; range, 0%-52%; P=1.00) or at 3 years (35%±13%; range, 0%-51%; P=0.32). Clinical evaluation showed significant improvements (P<0.05) in preoperative (−3±21) to 1-year (18±32) external rotation Significant improvements in abduction were found from 116±39 degrees before surgery to 151±30 degrees and 161±20 degrees at 1 and 3 years after surgery, respectively. Conclusions These results demonstrate that tendon transfers improve overall shoulder motion, but do not reduce humeral head subluxation or improve glenohumeral joint realignment. Level of Evidence Level IV.

Development and pilot test of the shriners pediatric instrument for neuromuscular scoliosis (SPNS): A quality of life questionnaire for children with spinal cord injuries

Abstract Background/Objective: The purpose of this study is to report the results of rater agreement for the International Standards for Neurological Classification of Spinal Cord Injury (ISCSCI) motor and sensory scores before and after training in the testing technique. Methods: Six raters performed sequential motor and sensory examinations on 5 adolescents with SCI according to the ISCSCI manual. After completion of the first examinations, all raters were provided with a half-day formal training session on testing techniques, after which the raters repeated the examinations. lntraclass correlation coefficients (ICCs) and 95% confidence intervals (Cis) were calculated to provide parameters for ICC interpretation: > 0.90 = high agreement; 0.75 to 0.90 = moderate agreement; < 0.75 = poor agreement. Results: After training, there was improvement in rater agreement of summed motor scores (MS) from ICC = 0.809 to 0.862 and discrimination scores from ICC = 0.786 to 0.892. There was moderate rater agreement for light touch scores (LTS) before and after training. After training, there was improvement in 95% Cis except for ICCs for LTS, but for all ICCs, the lower 95% Cl value remained less than 0.75. Conclusions: Training improved rater agreement on MS and discrimination, but 95% Cis remained unacceptably wide. The positive effect of training in motor and sensory testing techniques is supported by the study data. Unlike previous studies that have suggested the ISCSCI has acceptable reliability for clinical trials, the results of this study do not fully support the use of the ISCSCI for clinical trials without better standardization to establish a lower 95% Cl value of at least 0.75.

Validity and Reliability of Physical Functioning Computer-adaptive Tests for Children With Cerebral Palsy

Background The purpose of this study was to assess the concurrent validity and reliability of scores from 4 new parent-report computer-adapted testing (CAT) programs developed to measure the physical functioning of children with cerebral palsy (CP). The Shriners Hospitals for Children CP-CAT battery includes upper-extremity skills, lower-extremity and mobility skills, activity, and global physical health. Methods This was a prospective study of 91 children with CP who were tested cross-sectionally and 27 children with CP who were administered the CP-CAT programs twice within approximately a 1-month interval. We examined the concurrent validity of the 4 Shriners Hospitals for Children CP-CAT programs by Pearson correlations with comparative parent-report instruments. The scale reliability was tested by developing estimates of marginal reliability; test-retest reliability was assessed by intraclass correlations. Results Pearson correlations were moderate to high in matching content domains of the CATs with the comparison measures. Marginal reliability estimates were always better for the CAT program than the comparative instruments. Average test-retest reliability using Intraclass correlations across the 4 CATs was ICC3,1=0.91 with a range of 0.88 to 0.94. Conclusions We found the CAT scores to be related to expected domains from external instruments, to have good scale reliability, and to have stable scores as determined by test-retest reliability. These results support the use of parent-report CATs in the assessment of physical functioning in children with CP. Level of Evidence This is a level 2 prospective study designed to establish the validity and reliability of CAT as an evaluation method.

Ossification of the proximal humerus in children with residual brachial plexus birth palsy: a magnetic resonance imaging study.

Background Children with residual brachial plexus birth palsy may develop deformities of the humeral head and the glenoid. Surgical treatment has been described to maximize function and to lessen deformity by means of glenohumeral remodeling. The timing and technique of surgical intervention have not been resolved. The timing of the appearance on magnetic resonance imaging of the ossific nuclei in patients with brachial plexus birth palsy has not been described. We examined the timing of ossification about the proximal humerus. Our hypothesis was that the timing of ossification of the proximal humerus differs between the side involved in brachial plexus palsy and the uninvolved side. Methods A retrospective study was performed of 117 children with residual brachial plexus birth palsy (aged 5 mo to 10 y) who had magnetic resonance imaging scans of the bilateral shoulders performed at our institution between 2000 and 2007. All axial slices were reviewed by a single observer for evidence of ossification of the humeral head epiphysis, the greater tuberosity, and the lesser tuberosity, as well as for evidence that the 3 were coalesced. Statistical analysis was performed to compare the involved and uninvolved sides. Results The appearance of the greater tuberosity ossific nucleus on the involved side was significantly delayed. There was a trend towards delay in the appearance of the lesser tuberosity ossific nucleus and the coalescence of the 3 ossific nuclei on the involved side. The duration during which ossification of the involved brachial plexus side occurred was generally shorter compared with the uninvolved side. Conclusion There is delay in the ossification of the involved side in brachial plexus birth palsy, and a shorter duration of ossification. Level of Evidence Diagnostic Study, Level II.