Search

Purpose: Proximal femoral osteotomy (PFO) is a reconstructive surgical option used to improve hip containment or correct internal hip rotation gait in children with cerebral palsy (CP). A few reports describe the risk of surgical complications after PFO. The purpose of this study was to determine the risk factors associated with adverse postoperative surgical outcomes in pediatric patients with CP following PFO and to report the treatment of complications., Methods: Following institutional review board approval, 1085 (1003 primary and 82 secondary) PFO procedures were retrospectively reviewed in 563 children with CP with at least 1 year of follow-up after final surgery over an 18-year follow-up period. Demographic characteristics, motor type, gross motor function classification system (GMFCS) level, medical comorbidities, feeding tube status, seizure history, intervention type, and prevalence of PFO-related surgical complications and associated treatments were evaluated. Multivariate regression analysis was performed to determine risk factors for all surgical complications., Results: During a 5.8-year (± 3.8 years) follow-up, at least 1 surgical complication was identified in 143 (13.1%) hips in 121 (21.5%) patients after PFO in children with CP. Of these complications, the most common was heterotopic ossification (65 [6%] of hips); most of which were asymptomatic and required no treatment. Other complications included 25 (2%) nonunions, 21 (2%) deep or superficial infections, 13 (1%) delayed unions, 12 (1%) peri-implant fractures, and 7 early implant failures (0.64). The rate of revision surgery due to these complications was 13.1% (6.8% of hips), of which 41% (30 revision surgeries) were for the treatment of nonunion. Regarding the development of delayed union or nonunion, dystonia, GMFCS level IV/V, and seizure history were identified as risk factors by multivariate analysis., Conclusions: The prevalence of surgical complications after PFO was 13.1% with 6.8% of hips requiring revision surgery. Dystonia, seizure history, and nonambulatory status were the strongest predictors for the need for revision surgery after PFO. These data can be used to help counsel patients and families regarding the risks associated with PFO for children with CP. Level of proof: IV; retrospective study., Competing Interests: Conflict of interestsDrs. Imerci, Miller, Howard, and Shrader declare that they have no conflicts of interest., (© Indian Orthopaedics Association 2024. Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.)

Purpose: Use of spinal cord monitoring in children with cerebral palsy (CP) and neuromuscular scoliosis is challenging. The previous reports suggest low success rates in the setting of CP, and it is unclear if transcranial electric motor evoked potentials (TcMEP) monitoring is contraindicated in patients with an active seizure disorder. The purpose of this study was to determine (1) are patients with CP able to be appropriately monitored with TcMEP? and (2) does TcMEP cause an increase in seizure activity?, Methods: This was an institutional review board-approved retrospective cohort study observing 304 patients from 2011 to 2020. Inclusion criteria included all patients with CP undergoing posterior spinal fusion during this time. Intraoperative data were examined for the ability to obtain monitoring and any intraoperative events. Patients were followed for 3 months postoperatively to determine any increase in seizure activity that could have been attributed to the TcMEP monitoring., Results: Of the 304 patients who were observed, 21% (20.8%) were unable to be monitored due to lacking baseline signals from the extremities. Seventy-seven percent (77.5%) were successfully monitored with TcMEP. For these patients, no increased seizure activity was documented either intra- or postoperatively., Conclusion: A high percentage of children (77.5%) with CP were able to be successfully monitored with TcMEP during posterior spinal fusion. Furthermore, the concerns about increased seizure activity after TcMEP were not supported by the data from this cohort. Technical details of successful neuromonitoring in these patients are important and included increased stimulation voltage requirements and latency times., Level of Evidence: III retrospective comparative study., (© 2023. The Author(s), under exclusive licence to Scoliosis Research Society.)

Background: Given reduced rates of both pulmonary function decline and scoliosis progression with steroid treatment in Duchenne muscular dystrophy (DMD), the role of early scoliosis surgery has been questioned. The purpose of this study was to compare the postoperative complication rates of early versus late scoliosis correction in DMD., Methods: This study was a retrospective cohort, conducted at an academic tertiary level children's hospital. Patients with DMD who underwent posterior scoliosis correction, with preoperative pulmonary function testing [forced vital capacity (FVC)] were included and divided into two groups by preoperative curve angles: ≤ 45° and > 45°. The primary outcome variable was postoperative complications by Clavien-Dindo classification grading. Secondary outcome variables included postoperative complications occurring after the first 90 days, age at surgery, duration of wheelchair dependency preoperatively, pulmonary function, steroid utilization, shortening fraction by echocardiogram, surgery duration, intensive care unit/hospital length of stay, days intubated, infection, and percent curve correction. Two-tailed t-test and Chi-square testing were used for analysis of patient factors and Clavien-Dindo complication grade, respectively., Results: Thirty-one patients were included with a total follow-up of 8.3 ± 3.2 years, 4.8 ± 2.2 years post-spinal fusion. Steroid treatment (prednisone, deflazacort) was utilized for 21 (67.7%) patients. Primary curve correction was not different between groups (65.0% vs 71.4% [p = 0.37]). There were no significant differences in Clavien-Dindo classification grades between groups (p > 0.05). For the entire cohort, the overall complication rate was higher for patients with steroid treatment (61.9% vs 10.0% [p = 0.008]). Neither forced vital capacity nor fractional shortening on echocardiogram was different between groups at final follow-up (p = 0.6 and p = 0.4, respectively)., Conclusion: The comparable risk of perioperative complications for early and late scoliosis correction supports a "watchful waiting" approach, whereby curves less than 45° can be carefully followed while cardiopulmonary function is maintained. Patients undergoing steroid treatment should be counseled regarding the higher risk of postoperative blood transfusion and deep wound infection., Level of Evidence: III Retrospective cohort., (© 2022. The Author(s), under exclusive licence to Scoliosis Research Society.)

Purpose: Intrathecal baclofen (ITB) is a well-known treatment option for cerebral palsy (CP) spasticity. The combination of soft-tissue release and ITB for spasticity is common. This study compared patients who had soft-tissue release before ITB (PRE-ITB), soft-tissue release at the same time as ITB (ST-ITB), and no ITB (NON-ITB) but had soft-tissue release at a similar age as PRE-ITB., Methods: Inclusion criteria were a spastic or mixed nonambulatory CP diagnosis, prior hip adductor surgery, no prior reconstructive surgery, and at least a five-year post-operative follow-up. Thirty hips were identified as PRE-ITB, 20 hips as ST-ITB, and 43 hips as NON-ITB. The primary outcome variables were the subsequent hip surgery during the study period and/or a migration percentage ≥ 50% at the final follow-up defined as "unsuccessful hip.", Results: The mean follow-up duration was 9.0 years (SD 2.4) for PRE-ITB, 9.4 (SD 3.6) for ST-ITB, and 9.3 (SD 3) for NON-ITB. The odds of unsuccessful outcomes were not different between NON-ITB and PRE-ITB but were lower for the ST-ITB group. The need for subsequent osteotomies or revision adductor surgery was significantly higher in ST-ITB compared with PRE-ITB ( p  = 0.02) or NON-ITB ( p  = 0.015). The incidence of surgical site infection over the whole follow-up period was higher in ST-ITB (40%) compared with PRE-ITB (13.3%, p  = 0.035) and NON-ITB (0, p  < 0.001)., Conclusion: The addition of tone management with ITB did not reduce the need for later hip surgery but did increase the risk for surgical site infection., Competing Interests: Conflict of interestAli Asma, Armagan Can Ulusaloglu, Jason J. Howard, Kenneth J. Rogers, Freeman Miller, and Michael Wade Shrader declare that they have no conflict of interest., (© Indian Orthopaedics Association 2022, Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.)

Background: Posterior spinal fusion (PSF) in children with cerebral palsy (CP) carries a high risk of complications and morbidity. The purpose of this study is to investigate the impact of using two attending surgeons on blood loss, operative time, and complications in this fragile population., Methods: This was a prospective, matched cohort analysis of patients with CP who underwent PSF with two attending surgeons. These were matched with a control group that had a single-surgeon team, assisted by a senior resident or PA. The groups were compared using paired Student t tests and chi-square tests., Results: 50 patients were included in the study (25 study and 25 matched controls), determined by our power analysis. There was no statistical difference in the mean age, preoperative major curve angle, major curve angle correction, or use of antifibrinolytics. The two-surgeon group decreased surgical time from 5.25 to 3.3 hours (p = .000002), and estimated blood loss from 1,238 to 865 mL (p = .009). The complication rate decreased from 33% to 8% (p=.034). Length of stay was also decreased from 6.5 days to 5.35 (p = .02)., Conclusions: Although confounding variables were present, this study demonstrates that the use of a two-surgeon team during spinal surgery for patients with cerebral palsy could have a role in reducing operative time, blood loss, complication rates, and hospital length of stay. Overall, these factors and any improved operating room efficiencies may lead to lasting improved patient outcomes., Level of Evidence: Level III, retrospective, comparative study., (Copyright © 2018 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

Study Design: Retrospective, chart review., Objectives: The identification and management of pelvic obliquity in neuromuscular scoliosis can be difficult; therefore, appropriate evaluation of this pathology is important. Variations in presentation have resulted in various methods of measurement, without a consensus or gold standard measurement. This study is the evaluation of reliability of five methods commonly used to determine pelvic obliquity in the frontal plane., Summary of Background Data: Previous studies have used five different methods (ie, the Maloney method, the O'Brien method, the Osebold method, the Allen and Ferguson method, and the Lindseth method) to determine pelvic obliquity in the frontal plane., Methods: Radiographic images of 50 patients with neuromuscular scoliosis involving the pelvic girdle were identified and evaluated by a team of 5 raters. Each rater was instructed to apply five commonly used methods of measuring pelvic obliquity. The same raters were asked to rate the same radiographs again after a minimum of one month. The interobserver reliability was assessed using the intraclass correlation coefficient (ICC) and the intraobserver analysis was assessed using the Pearson correlation. A rating greater than 0.8 was considered excellent reliability., Results: The Maloney method showing the highest interobserver reliability of ICC of 0.965 and 0.964. The Lindseth method had the lowest ICC, but all the methods were considered highly reliable by the rating classification system. The Maloney method also showed the highest intraobserver reliability, ranging from 0.845 to 0.962. The Allen and Ferguson method had the lowest intraobserver reliability., Conclusions: Many of the methods tested had excellent reliability in this study, but our data suggest the Maloney method is the most reliable method of measuring pelvic obliquity on a frontal view radiograph., Level of Evidence: Level III, retrospective, comparative study., (Copyright © 2017 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

Background: Hypotensive events (HEs) following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) can lead to delayed neurologic postoperative deficits (DNPD). This study aimed to determine the incidence of HEs (mean arterial pressure [MAP] <60 mmHg) after PSF for AIS and identify predictors for HEs., Methods: Medical records of 99 consecutive patients who had PSF for AIS were retrospectively reviewed (2011-2013). Perioperative data were collected. Patients were divided into two groups based on MAP readings by an arterial line in the pediatric intensive care unit immediately postoperatively into postoperative day one: Group 1 (MAP ≥60 mmHg) and Group 2 (multiple occurrences of MAPs <60 mmHg). Mean values were compared using the independent t test. Multiple logistic regression was used to estimate the association of preoperative and intraoperative parameters with multiple HEs., Results: Group 1 had 68 patients (68.7%) and Group 2 had 31 patients (31.3%). None of the compared parameters were associated significantly with multiple HE. However, patients who did not exhibit HEs within the first four hours postoperatively remained stable throughout the rest of the postoperative period. Only those with HEs in the first four hours experienced subsequent HEs in the first 24 hours. There were no DNPD or other major complications., Conclusion: Results showed that the incidence of HEs after PSF in AIS can be as high as 31.3%. We did not find any significant risk factors. Although DNPD after PSF is a rare complication and we had none in this series, we suggest that these patients with multiple HEs may be at risk for DNPD as a result of hypotension and potential for cord ischemia. Therefore, all patients after PSF should be monitored in a pediatric intensive care unit-type environment or postanesthesia recovery room initially. If stable for, at least, the initial four hours, then patients should be good candidates for a less intensive environment., Level of Evidence: Level 3., (Copyright © 2017 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

Study Design: Retrospective, chart review., Objectives: The objective of this study is to investigate the impact of using two surgeons for posterior spinal fusion (PSF) in patients with AIS with large-magnitude curves (greater than 70°)., Summary of Background Data: Previous studies have shown that intraoperative risk factors can be reduced by having two surgeons operate simultaneously., Methods: A retrospective chart review identified 47 patients between January 1, 2009, and December 31, 2014, who underwent a posterior spinal fusion (PSF) with AIS with large-magnitude curves (greater than 70°). Patients with large-magnitude curves due to neuromuscular diseases or any defined pathology other than idiopathic scoliosis were excluded, as well as patients with kyphotic or kyphoscoliotic curves., Results: There was no statistical difference between the total operative time, anesthesia time, estimated blood loss (EBL), %EBL, and blood transfusion units. Total operative time for the two-surgeon group and single-surgeon group was 212.11 and 238.07 minutes, respectively (p = .078). The two-surgeon group averaged 0.26 blood transfusion units versus 0.39 units for the single-surgeon group (p = .50). Average hospital length of stay was decreased in the two-surgeon group (5.16 vs. 6.82 days, p = .002)., Conclusions: The use of two surgeons for PSF for AIS has previously been shown to decrease operative time and blood loss, factors that are correlated with prolonged hospital stay and increased risk of both neurologic and nonneurologic complications. However, in this study, the technique of having two experienced orthopedic spine surgeons work simultaneously to perform pedicle screw-only posterior spinal fusion on large-magnitude AIS curves greater than 70° did not improve blood loss or operative time. Further study needs to continue to identify ways to minimize complications for patients who undergo spinal fusion., Level of Evidence: Level III, retrospective, comparative study., (Copyright © 2017 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

Study Design: Retrospective, matched study of patients with adolescent idiopathic scoliosis (AIS) and patients with cerebral palsy (CP) undergoing (PSF)., Objectives: To compare pain management, through measurement of the amount of narcotic used and pain scores, for patients with neuromuscular (NM) scoliosis undergoing PSF to a cohort of patients with AIS., Summary of Background Data: Posterior spinal fusion for children with severe NM scoliosis carries a high risk of complications. Appropriate assessment of pain is crucial; undertreatment of pain leads to anxiety whereas overtreatment can lead to respiratory depression and additional complications., Methods: A series of patients with NM scoliosis was matched for age, gender, and weight with a group of patients with AIS. Data collection included age, curve type and magnitude, and instrumentation type and levels fused. The total opioid used (TOU) was determined by summing all narcotics given during the hospital stay and converting them to morphine equivalent units. The data were then analyzed to determine differences in TOU., Results: A total of 25 patients with NM scoliosis were included in the study. This group was matched with 25 patients with AIS scoliosis. The TOU for the NM group was 1.2 mg morphine/kg (range, 0.28-4.21 mg morphine/kg) whereas the TOU for the AIS group was 3.52 mg morphine/kg (range, 0.71-15.51 mg morphine/kg) (p < .0000001)., Conclusions: In this case-control analysis, patients with AIS undergoing PSF received more than twice the amount of narcotic compared with a matched group of patients with NM scoliosis. These data suggest that NM patients' pain may be undertreated compared with AIS patients. More study is indicated to investigate pain assessment and pain control in this vulnerable patient population to improve care., (Copyright © 2014 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

Study Design: This was a retrospective review of neuromuscular scoliosis radiographs evaluating interobserver and intra-observer error for a novel method of transverse plane pelvic obliquity., Objectives: To evaluate the utility of a previously described method by Lucas et al. of determining transverse plane pelvic obliquity using standard radiographs in patients with cerebral palsy and neuromuscular scoliosis., Summary of Background Data: Evaluation of pelvic obliquity in the transverse plane has not been thoroughly studied. The pelvis has been noted to function as intercalary vertebra in neuromuscular scoliosis, resulting in marked obliquity in all 3 planes., Methods: Forty radiographs were chosen from 10 patients with cerebral palsy and neuromuscular scoliosis who had had a posterior spine arthrodesis and Galveston spino-pelvic fixation. Four observers independently examined the radiographs at different levels of training on 2 dates 1 week apart. Measurements recorded by each observer were described by Lucas et al.: E (the distance measured on lateral radiographs between the ilium at the inferior part of the sacro-iliac joint and the lateral edge of the anterior superior iliac spine), F R and F L (the coronal plane linear distance between the same 2 landmarks, measured from a posteroanterior radiograph, where F was measured for both the left (F L ) and right (F R ) sides of the pelvis, respectively), and β (the transverse plane rotation of the pelvis). Reproducibility of the measurements were analyzed using the concordance correlation coefficient (CCC). A CCC of 0.80 or higher was considered excellent agreement., Results: The CCC between the first and second sets of measurements was lowest for E and highest for the calculated β, although none of the CCC calculations was statistically significant, demonstrating poor agreement., Conclusions: The ability to reliably measure and calculate the degree of transverse plane rotation by radiographs in cerebral palsy patients with spino-pelvic deformity by the method described by Lucas et al. is poor, likely because of difficulty in consistently identify pelvic landmarks., (Copyright © 2014 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)