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Purpose: To radiographically evaluate if vertebral body tethering (VBT) can maintain differential peri-apical vertebral growth at medium-term follow-up of 4 years., Methods: A prospective, international, multicenter database was queried to identify idiopathic scoliosis patients treated with thoracic VBT. Concave vs. convex vertebral body height, vertebral wedging, and disc wedging of the 3 peri-apical vertebrae were measured by two independent observers at 5 timepoints (pre-operative to 4-year follow-up)., Results: 65 skeletally immature patients (60 female, mean 12.8 years old, 21 with open triradiate cartilages) met inclusion criteria. Mean pre-operative maximum scoliosis of 50 ± 8° decreased significantly post-operatively to 27 ± 9° (p < 0.001), which remained stable at 4-year follow-up 30 ± 17° (p = 0.38 vs. post-operative). Mean instrumented scoliosis was 21 ± 14° at 4-year follow-up, which was significantly different than 4-year maximum scoliosis (p < 0.001). Mean pre-operative kyphosis of 30 ± 12° did not significantly change post-operatively (p = 1.0) and remained stable at 4-year follow-up (35 ± 18°; p = 0.05). Mean individual convex vertebral height increased from 17.7 ± 1.9 mm to 19.8 ± 1.5 mm (p < 0.001), while mean individual concave height increased from 14.8 ± 1.9 mm to 17.6 ± 1.6 mm (p < 0.001). Summing the peri-apical heights, the difference in height from pre-operative to 4-year follow-up was greater on the concave (8.3 ± 4.7 mm) than on the convex side (6.2 ± 4.7 mm) (p < 0.001). Mean individual vertebral wedging decreased from 6 ± 2° at pre-operative to 4 ± 2° at 4-year follow-up (p < 0.001). Mean total vertebral and disc wedging started at 29 ± 7° pre-operatively, decreased to 16 ± 6° at post-operative (p < 0.001), then further decreased to 14 ± 8° at 4-year follow-up (p < 0.001). Patients with open triradiate cartilages at the time of surgery had a larger height change over the 4 years compared to those with closed triradiate cartilages (p < 0.001)., Conclusion: Patients with idiopathic scoliosis treated with VBT demonstrated differential vertebral growth which was maintained at minimum 4-year follow-up. This effect was more pronounced in patients whose triradiate cartilages were open at the time of surgery., Level of Evidence: III., (© 2024. The Author(s), under exclusive licence to Scoliosis Research Society.)

Background: Pediatric forearm fractures are common injuries in the pediatric emergency department (PED). Pediatric procedural sedation (PPS) is often required for forearm fracture reductions and pain control for casting. Bier blocks and hematoma blocks are types of regional anesthesia (RA) procedures that can be performed as a potential alternative to PPS., Objective: The objective of this study is to compare the safety of RA with that of PPS. We hypothesized that RA has a safety profile that is equal or superior to PPS as well as a shorter duration of treatment in the PED., Methods: Pediatric emergency department encounters in patients presenting with a diagnosis of radius fracture, ulna fracture, distal "both-bone" fracture, Monteggia fracture, and/or Galeazzi fracture were included. Outcomes of interest included patient adverse events (AEs), sedation medications used, PED duration of treatment (arrival time to disposition time), sedation failures, and reduction failures., Results: Propensity matching was performed resulting in 632 well-matched RA-PPS pairs. The PPS cohort had 13% of encounters with at least 1 AE compared with 0.2% in the RA cohort, P < 0.001. The most common AE in the PPS group was hypoxia (9.8%), and the only AE in the RA group was an intravenous infiltrate (0.16%). Within the matched cohorts, PPS required more medications than RA (100% vs 60%, P < 0.001). Ketamine alone was more commonly used in the PPS group than the RA group (86% vs 0.2%, P < 0.001). Propofol was used only in the PPS group. The average duration of treatment was 205 (SD, 81) minutes in the PPS group and 178 (SD, 75) minutes in the RA group ( P < 0.001). There were no reduction failures in either group., Conclusions: Bier blocks and hematoma blocks are an acceptable alternative to PPS for children requiring forearm reductions. The AE rate is low and the reduction success rate is high. Duration of treatment in the PED is shorter for patients receiving RA compared with PPS., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Morel-Lavallée lesions are serious internal degloving injuries associated with trauma. Its diagnosis and treatment can be challenging. We describe the surgical treatment of a case of a chronic Morel-Lavallée lesion in a pediatric patient who sustained an injury to her left thigh during an all-terrain vehicle accident more than a year ago., Competing Interests: The authors declare that there are no conflicts of interest regarding the publication of this article., (Copyright © 2023 Anthony O. Kamson et al.)

Purpose: Prior studies have suggested that distraction-based treatment for early onset scoliosis (EOS) may impede the natural development of the sagittal spinal alignment and pelvic parameters. However, to date no study has investigated the effect of distal fixation on pelvic development., Methods: Ambulatory children with EOS undergoing index distraction-based treatment with distal fixation below T11 were retrospectively reviewed. Patients with distal fixation to the pelvis were identified and compared to children with Spine-based fixation at T12-L5. Radiographic measurements were performed for coronal and sagittal alignment in addition to pelvic parameters (pelvic incidence (PI), pelvic tilt (PT), and sacral slope (SS) and compared at initial presentation, first erect radiograph, and at 2 years following instrumentation., Results: 33 ambulatory children were identified with a minimum of 2-year follow-up (25 female, average 6.59 ± 2.6 years), with 33% (N = 11) instrumented to the pelvis (54.4% female, average 4.42 ± 2.2 years, initial Cobb 76.1°). Children in the pelvis cohort were significantly younger at treatment initiation (P < 0.001). There was no significant difference in PI at the study time periods, however, there was a significant change in PI between presentation and 2-year follow-up with the pelvic fixation demonstrating a mean 12.3° decrease in PI vs a 3.8° increase in the spine-based cohort (P = 0.027)., Discussion: Distal fixation to the pelvis in ambulatory children with EOS treated with growth-friendly instrumentation was associated with a mean decrease in PI of 12.3° that developed over the 2-year treatment duration. Further research is needed to investigate the long-term implications of these findings on pelvic and spinal development., (© 2022. The Author(s), under exclusive licence to Scoliosis Research Society.)

Purpose: To assess the reliability of vertebral height and angular measurements for anterior vertebral body tethering (AVBT)., Methods: Eight observers measured PA radiographs of 15 idiopathic scoliosis patients treated with AVBT, pre-operative and 4-year follow-up. Vertebral wedging, disc wedging, convex vertebral body heights, and concave vertebral body heights of the 3 apical vertebrae were measured. For each observer, there were a total of 90 measurements for vertebral body height and 75 measurements for all wedging types At least 14 days elapsed between first and second round measurements., Results: From the pre-operative to the 4-year follow-up time-point, the total wedging angle over the 3 peri-apical levels fell from 30 ± 7° to 16 ± 6° (p < 0.001) and the difference between the convex and concave vertebral heights decreased from 9 ± 4 to 6 ± 3 mm (p < 0.001). Interobserver agreement for pre-operative vertebral body heights was good [ICC = 0.80; 95% CI (0.74-0.85)]. At 4-year follow-up there was a moderate agreement [ICC = 0.67 (0.59-0.74)]. There was a poor interobserver agreement for pre-operative wedging angle measurements [ICC = 0.41 (0.32-0.52)] and 4-year follow-up [ICC = 0.45 (0.36-0.56)]. The Limits of Agreement with the Mean (LOAM) for pre-op heights was ± 2.4 mm, similar to the follow-up ± 2.6 mm. When raters are averaged in random groups of two the agreement limits decrease to ± 1.8 mm pre-op and ± 1.6 mm at follow-up. Similarly for wedging angles, LOAM values among the 8 observers of ± 4.6° pre-op and ± 4.2° dropped to ± 2.7° for both pre-op and follow-up when random groups of two raters were averaged together. Intraobserver agreement ranged from good to excellent per individual (ICC = 0.84-0.94) for pre-operative vertebral body heights, but this decreased at 4-year follow-up (ICC = 0.52-0.88). Intraobserver agreement was low overall for wedging (pre-operative ICC = 0.41-0.71; 4-year follow-up ICC = 0.41-0.76)., Conclusion: Based on 8 individual observers, interobserver agreement ranged from good (pre-operative vertebral body heights) to moderate (4-year follow-up vertebral body heights) to poor (all wedging angles). To improve the reliability of the measurement of wedging angles, we recommend averaging the measurements of at least two observers., (© 2022. The Author(s), under exclusive licence to Scoliosis Research Society.)

A 10-year-old male with a past medical history of premature pubarche, mild persistent asthma, and eczema presented to the emergency department with progressive dyspnea and chest pain. On examination, he was found to be tachycardic and tachypneic. Chest radiograph demonstrated cardiomegaly, bilateral pleural effusions, and scattered atelectasis. Echocardiogram revealed a large pericardial effusion with right atrial collapse. The patient was admitted to the pediatric ICU for pericardiocentesis and drain placement. As he later became hypertensive and febrile, we will discuss how our patient's hospital course guided our differential diagnosis and how we arrived at a definitive diagnosis using a multidisciplinary approach., (Copyright © 2023 by the American Academy of Pediatrics.)

Purpose: To compare the outcomes of anterior Vertebral Body Tethering (AVBT) surgery between overweight and non-overweight patients., Methods: AIS/JIS patients with AVBT with 2-year follow-up from a multi-center pediatric spine database were evaluated pre-operatively, 1st post-operative erect, and 2 years post-operatively. ANOVA was used to compare 3 categories of BMI with significance as per Tukey-Kramer HSD post hoc test. Risk of scoliosis progression was analysed with Mid-P exact test., Results: 121 patients (51 underweight, 58 normal, 12 overweight; mean age 12.5 ± 1.6 yr; BMI 18.8 ± 4.6 kg/m 2 ) were identified. Comparing underweight, normal, and overweight groups: mean pre-operative age (13 yr, 13 yr, 12 yr), scoliosis (52°, 50°, 52°), pre-operative kyphosis (29°, 28°, 33°), peri-operative scoliosis correction (44%, 42%, 46%), and complications by 2-year follow-up (23%, 24%, 17%) were similar between groups. There was one broken tether in each of the underweight and normal weight groups. Change in percent scoliosis correction from 1st erect to 2-year post-operative (i.e., growth modulation phase) was not significantly different between groups; however, the risk ratio for scoliosis progression during this period was 4.74 (1.02-22.02; p = 0.04) for overweight patients., Conclusion: Our findings demonstrate that, as compared to normal weight and underweight patients, overweight patients did not have a statistically significant difference in intra-operative scoliosis correction or in risk of experiencing complication; however, overweight patients had a risk ratio of 4.74 for progression of scoliosis during the growth modulation phase of treatment from first erect radiographs to minimum 2-year follow-up., Level of Evidence: III., (© 2021. The Author(s), under exclusive licence to Scoliosis Research Society.)

Background: Patent Ductus Arteriosus (PDA) in premature neonates has been associated with comorbidities including chronic lung disease (CLD), and death. However, the treatment of PDA remains controversial. There have been several echocardiographic variables previously used to determine the hemodynamic significance of PDA but their utility in early prediction of clinical outcomes is not well studied. Objective: The objective of our study was to evaluate the use of a severity scoring system incorporating markers of systemic under perfusion, pulmonary over perfusion and left ventricular (LV) function in predicting clinical outcomes in premature neonates. Methods: It is a single center prospective observational study involving newborns < 32 weeks’ gestation. An echocardiogram was done within seven days of life to measure variables previously known to predict severity of shunting in PDA including pulmonary perfusion index (PPI). Predictors of CLD/death were identified using multivariate logistic regression. A severity score was derived and its ability to predict clinical outcomes was tested using a receiver operating characteristic curve. Results: We studied 98 infants with a mean (SD) gestation of 28.9 ± 1.91 weeks and birth weight of 1228.06 ± 318.94 g, respectively. We identified five echocardiographic variables along with gestational age that was independently associated with the outcome variable (PPI, LV output, Superior Mesenteric Artery [SMA] Velocity Time Integral [VTI], Peak diastolic flow velocity in Pulmonary Vein [PV Vd], and reversal of flow in diastole in descending aorta [DFR]). The range of severity score was 0 (low risk) to 12 (high risk). A higher score was associated with the primary outcome variable of CLD/death (7.5 [1.2] vs. 3.6 [1.5], p < 0.001). Our severity score had an area under the curve of 0.97 (95% CI 0.93−0.99, p < 0.001) for predicting CLD/death. Conclusion: Our new PDA severity score of 5.5 has a sensitivity and specificity of 94% and 93%, and positive and negative predictive values of 94% and 93%, respectively.