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Study Design: Retrospective chart review.Objectives: To evaluate the efficacy of the Rosenberger thoracic lumbar sacral orthosis in preventing curve progression in adolescent idiopathic scoliosis.Summary Of Background Data: Radiographic outcomes of patients using the Rosenberger thoracic lumbar sacral orthosis have never been reported in the literature, but reports of other thoracic lumbar sacral orthoses conflict concerning the ability braces to improve on the natural history of adolescent idiopathic scoliosis.Methods: Seventy-one patients with progressive adolescent idiopathic scoliosis treated with the Rosenberger were evaluated at an average of 2.3 years following brace discontinuation. Initial curves averaged 29 degrees. Braces were prescribed for 16 to 20 hours per day and worn for an average of 3.2 years. Patients were between 9 and 16 years of age, and all were skeletally immature at the time of bracing.Results: Twenty-one patients (30%) underwent instrumentation and arthrodesis despite bracing. Forty (56%) had more than 5 degrees of progression. Overall, 43 (61%) had surgery and/or progressed by the time of follow-up. The average curve correction was 33% in patients who did not have surgery and 21% in those patients who did (P < 0.04). Other significant factors associated with brace failure included absence of menarche before treatment, younger age at presentation and initial bracing, increased apical rotation of the primary curve at presentation, and a thoracic curve pattern.Conclusions: The Rosenberger brace demonstrated an overall failure rate similar to untreated rates from published natural history studies, although subgroups of patients had lower failure rates. These findings suggest the need for further refinement of the indications for the Rosenberger brace. [ABSTRACT FROM AUTHOR]

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 degrees and 45 degrees ). 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. [ABSTRACT FROM AUTHOR]

Study Design: Prospective multicenter study data were used for model derivation and externally validated using retrospective cohort data., Objective: Derive and validate a prognostic model of benefit from bracing for adolescent idiopathic scoliosis (AIS)., Summary of Background Data: The Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST) demonstrated the superiority of bracing over observation to prevent curve progression to the surgical threshold; 42% of untreated subjects had a good outcome, and 28% progressed to the surgical threshold despite bracing, likely due to poor adherence. To avoid over-treatment and to promote patient goal setting and adherence, bracing decisions (who and how much) should be based on physician and patient discussions informed by individual-level data from high-quality predictive models., Materials and Methods: Logistic regression was used to predict curve progression to <45° at skeletal maturity (good prognosis) in 269 BrAIST subjects who were observed or braced. Predictors included age, sex, body mass index, Risser stage, Cobb angle, curve pattern, and treatment characteristics (hours of brace wear and in-brace correction). Internal and external validity were evaluated using jackknifed samples of the BrAIST data set and an independent cohort (n=299) through estimates of discrimination and calibration., Results: The final model included age, sex, body mass index, Risser stage, Cobb angle, and hours of brace wear per day. The model demonstrated strong discrimination ( c -statistics 0.83-0.87) and calibration in all data sets. Classifying patients as low risk (high probability of a good prognosis) at the probability cut point of 70% resulted in a specificity of 92% and a positive predictive value of 89%., Conclusion: This externally validated model can be used by clinicians and families to make informed, individualized decisions about when and how much to brace to avoid progression to surgery. If widely adopted, this model could decrease overbracing of AIS, improve adherence, and, most importantly, decrease the likelihood of spinal fusion in this population., Competing Interests: M.L.S.: consultant to Stryker, Orthofix, and OrthoPediatrics. The remaining authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The institutional standard follow-up schedule for patients undergoing spinal instrumentation and fusion for adolescent idiopathic scoliosis (AIS) is return to clinic at 6-weeks and 3 months post-procedure for radiographs. COVID-19 prompted a change in this practice and most routine post-op visits were performed virtually during that time. The purpose of this study is to estimate the cost and benefit of in-person visits to inform the relative value of in-person follow-up using data from the year prior to COVID changes., Methods: This was a retrospective study including all patients with AIS who underwent spinal instrumentation and fusion in 2019 by a single surgeon at a tertiary medical center. The cost of radiographs, travel, and parental lost wages associated with follow-up visits at 6-weeks and 3-months were estimated. Transportation costs were estimated by multiplying the distance between home and clinic by the standard IRS travel reimbursement rate ($0.58/mile). Parental lost wages were estimated using the average 2019 US census income for men and women. Each patient's electronic medical record was reviewed to see whether radiographs and physical assessment resulted in any changes in orthopaedic management at each visit., Results: The sample included 63 patients (75% female, 94% Caucasian) with an average age of 15.22 years. The average round-trip distance traveled was 94.4 miles (range 3.2-476), resulting in an average travel cost of $109.47. The total time spent for a visit (travel, wayfinding and the clinic visit itself) averaged 330 minutes, resulting in an estimated lost parental wage of $125.47. Estimated cost of radiographs at each visit was $693. This combined cost burden totaled $927.94 for each visit, and no changes in management were prompted by clinical or radiographic findings at any of the 126 visits., Conclusion: COVID-19 presented many new challenges to healthcare, including a necessary increase in virtual healthcare delivery. This study estimated the cost of in-person follow-up visits the year prior to COVID-19. Patients and their families traveled hundreds of miles and spent hundreds of dollars to attend these visits. No changes in clinical management were prompted by findings at these in-person follow-up visits, and implementation of virtual post-operative visits could potentially lead to cost savings for families in these instances. Level of Evidence: III ., Competing Interests: Disclosures: The authors report no potential conflicts of interest related to this study., (Copyright © The Iowa Orthopaedic Journal 2024.)

Purpose: The Morbidity and Mortality (M&M) report of the Scoliosis Research Society (SRS) has been collected since 1965 and since 1968 submission of complications has been required of all members. Since 2009, the SRS has collected information on death, blindness, and neurological deficit, with acute infection being added in 2012 and unintentional return to the operating room (OR) being added in 2017. In this report, we use the most recent data submitted to the SRS M&M database to determine the rate of neurological deficit, blindness, acute infection, unintentional return to the OR, and death, while also comparing this information to previous reports., Methods: The SRS M&M database was queried for all cases from 2013 to 2020. The rates of death, vision loss, neurological deficit, acute infection, and unintentional return to the OR were then calculated and analyzed. The rates were compared to previously published data if available. Differences in complication rates between years were analyzed with Poisson regression with significance set at α = 0.05., Results: The total number of cases submitted per year varied with a maximum of 49,615 in 2018 and a minimum of 40,464 in 2020. The overall reported complication rate from 2013 to 2020 was 2.86%. The overall mortality rate ranged from 0.09% in 2018 to 0.14% in 2015. The number of patients with visual impairment ranged from 4 to 13 between 2013 and 2015 (no data on visual impairment were collected after 2015). The overall infection rate varied from 0.95 in 2020 to 1.30% in 2015. When the infection rate was analyzed based on spinal deformity group, the neuromuscular scoliosis group consistently had the highest infection rate ranging from 3.24 to 3.94%. The overall neurological deficit rate ranged from 0.74 to 0.94%, with the congenital kyphosis and dysplastic spondylolisthesis groups having the highest rates. The rates of unintentional return to the OR ranged from 1.60 to 1.79%. Multiple groups showed a statistically significant decreasing trend for infection, return to the operating room, neurologic deficit, and death., Conclusions: Neuromuscular scoliosis had the highest infection rate among all spinal deformity groups. Congenital kyphosis and dysplastic spondylolisthesis had the highest rate of neurological deficit postoperatively. This is similar to previously published data. Contrary to previous reports, neuromuscular scoliosis did not have the highest annual death rate. Multiple groups showed a statistically significant decreasing trend in complication rates during the reporting period, with only mortality in degenerative spondylolisthesis significantly trending upwards., Level of Evidence: Level III., (© 2022. The Author(s).)

Outcomes of a pilot study of spine growth modulation (GM) were compared to those of untreated and braced patients from a concurrent bracing effectiveness trial (BrAIST). The purpose of this study was to determine probabilities of progression (PP) to fusion indications (≥45°) in a cohort of subjects who underwent GM surgery, and to compare GM outcomes to those of matched BrAIST subjects. Secondary analyses were conducted comparing two prospective longitudinal studies. In one, a vertebral GM system was implanted in 6 highly skeletally immature AIS patients. The control group provided by BrAIST was comprised of a subset of untreated or braced subjects that fit the eligibility criteria of the GM study. GM outcomes were compared to predictions from two prognostic logistic regression models derived from BrAIST to estimate risk of curve progression to ≥45°. If the GM patients were untreated, PPs ranged from 68-98%. If braced for 18 hours/day, progression was expected in two of six, one with a PP of 71%. This latter patient not only did not progress, his curve decreased >20°. In the matched cohort, two were untreated and quickly progressed, whereas two were braced and did not progress. Therefore, the bracing models and matched cohort confirmed the initial assumption that all GM patients were at high risk if untreated. They also supported the probable benefit of the GM system, as 3 of 6 benefited from GM relative to predictions for untreated patients, and one of 6 benefited compared to predictions for highly compliant braced patients.

Purpose: While the Scoliosis Research Society (SRS) has established criteria for brace initiation in adolescent idiopathic scoliosis (AIS), there are no recommendations concerning other management issues. As the BrAIST study reinforced the utility of bracing, the SRS Non-Operative Management Committee decided to evaluate the consensus or discord in AIS brace management., Methods: 1200 SRS members were sent an online survey in 2017, which included 21 items concerning demographics, bracing indications, management, and monitoring. Free-text responses were analyzed and collated into common themes. Data were analyzed using Microsoft Excel 2013., Results: Of 218 respondents; 207 regularly evaluate and manage patients with AIS, and 205 currently prescribe bracing. 99% of respondents use bracing for AIS and the majority (89%) use the published SRS criteria, or a modified version, to initiate bracing. 85% do not use brace monitoring and 66% use both %-Cobb correction and fit criteria to evaluate brace adequacy. In contrast, other aspects of brace management demonstrated a high degree of practice variability. This was seen with a radiographic assessment of maturity level, hours prescribed, timing and frequency of radiographic evaluation, the use of nighttime bracing only, and the method and timing of brace discontinuation., Conclusion: Although there is consensus in brace management amongst SRS members with respect to brace initiation and evaluation of adequacy, there is striking variability in how bracing for AIS is used. This variability may impact the overall efficacy of brace treatment and may be decreased with more robust guidelines from the SRS., Level of Evidence: III.

Study Design: Retrospective., Objectives: Utilize three-dimensional (3D) measurements to assess the relationship between thoracic scoliosis severity and thoracic kyphosis in a large, multicenter cohort, and determine impact of 3D measurements on adolescent idiopathic scoliosis (AIS) curve classification. Research has demonstrated differences in two-dimensional (2D) and 3D assessment of the sagittal plane deformity in AIS. A prior smaller, single-institution study demonstrated an association between scoliosis severity and loss of 3D thoracic kyphosis., Methods: Data included retrospective compilation of prospectively enrolled bracing candidates and prospectively enrolled surgical candidates with thoracic AIS. Analysis included two groups based on thoracic curve magnitude: moderate (20-45°) and severe (> 45°). Imaging was performed using 2D radiographs. 3D thoracic kyphosis was calculated using a 2D to 3D conversion formula. Kyphosis was categorized according to the Lenke classification sagittal plane modifier., Results: Analysis included 3032 patients. 2D kyphosis was significantly less in the moderate group (21 ± 12 vs 23 ± 14, p = 0.028). However, estimated 3D kyphosis was significantly greater in the moderate group (13 ± 10 vs 5 ± 12, p < 0.001). In the moderate group, the rate of normokyphosis was 78% with 2D measures and 61% with 3D measures of T5-T12 kyphosis. In the severe group, this rate changed from 72 to 32% with use of 2D and 3D measures, respectively. In the moderate group, 16% of patients were classified as hypokyphotic using 2D measures while this rate increased 38% with 3D measures (p < 0.001). In the severe group, this rate changed from 18 to 68% using 2D and 3D measures, respectively (p < 0.001)., Conclusions: Increased coronal curve severity was associated with decreased thoracic kyphosis. Hypokyphosis was more pronounced in 3D. 2D radiographs increasingly underestimate kyphosis with increasing coronal severity. Assessment of sagittal alignment from 2D radiographs can be improved with a 2D-3D conversion formula. Findings indicate potential for classification system improvement with use of 3D sagittal plane measurements., Level of Evidence: IV.

The recently developed magnetically controlled growing rod (MCGR) system has gained popularity because it limits additional surgical lengthening procedures and promises reduction of the complication rate previously reported for the traditional growing rods. A retrospective single-center study was performed. Demographic and complications data were recorded. A statistical analysis was conducted to quantify the effect of MCGR placement and of subsequent lengthening on the Cobb angle, T1-T12 kyphosis, and the distances from T1-T12 and T1-S1. Twenty-four patients met the inclusion criteria. Six had idiopathic scoliosis and 18 patients had nonidiopathic scoliosis (neuromuscular and syndromic scoliosis). Nine patients underwent primary MCGR placement, and 15 had the traditional growing rods removed and replaced with MCGRs. The mean age at surgery and at last follow-up was 6.3 years and 8.8 years, respectively. The mean follow-up was 29.2 months. The MCGR placement significantly reduced the Cobb angle and kyphosis by an average of 21.33° and 10.79°, respectively. The T1-T12 and the T1-S1 distances increased an average of 1.19 and 1.89 cm/year, respectively, during the follow-up period. The average percentage of achieved-to-intended distraction was 65% on the concave side and 68% on the convex side at last follow-up. There were 9 postoperative complications in 8 (33%) patients, 6 of whom had nonidiopathic scoliosis. The MCGR system is reliable and effective in the treatment of patients affected by early-onset scoliosis. [Orthopedics. 2020;43(6):e601-e608.]., (Copyright 2020, SLACK Incorporated.)

Study Design: Comparative effectiveness study OBJECTIVE.: To evaluate factors leading to higher percentage of brace failures in a cohort of North American patients with adolescent idiopathic scoliosis relative to their peers in Italy., Summary of Background Data: Studies of bracing in United States have shown worse outcomes than studies from European centers, possibly due to sample characteristics or treatment approaches., Methods: Sample: Braced patients, aged 10 to 15, Risser <3, Cobb 20°- to 40°, observed to Cobb ≥40° and/or ≥Risser 4 selected from prospective databases. Comparators: Bracing per Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST) (TLSO) and Italian Scientific Spine Institute (ISICO) protocol (SPoRT braces with or without SEAS exercises). Baseline characteristics (sex, age, BMI, Risser, Cobb, curve type) and average hours of brace wear/day. Differences in programs (e.g., SEAS, type of brace, weaning protocol) were captured by a variable named "SITE.", Outcome: Treatment failure (Cobb ≥40 before Risser 4)., Statistics: Comparison of baseline characteristics, analyses of risk factors, treatment components, and outcomes within and between cohorts using logistic regression., Results: A total of 157 BrAIST and 81 ISICO subjects were included. Cohorts were similar at baseline but differed significantly in terms of average hours of brace wear: 18.31 in the ISICO versus 11.76 in the BrAIST cohort. Twelve percent of the ISICO and 39% of the BrAIST cohort had failed treatment. Age, Risser, Cobb, and a thoracic apex predicted failure in both groups. SITE was related to failure (odds ratio [OR] = 0.19), indicating lower odds of failure with ISICO versus BrAIST approach. With both SITE and wear time in the model, SITE loose significance. In the final model, the adjusted odds of failure were higher in boys (OR = 3.34), and those with lowest BMI (OR = 9.83); the odds increased with the Cobb angle (OR = 1.23), and decreased with age (OR = 0.41) and hours of wear (OR = 0.86)., Conclusion: Treatment at the ISICO resulted in a lower failure rate, primarily explained by longer average hours of brace wear., Level of Evidence: 3.

Background: Despite widespread use of single-stage open reduction and pelvic osteotomy for treatment of developmental dysplasia of the hip (DDH) after walking age, this aggressive strategy remains controversial. We directly compared dislocated hips treated with closed reduction (CR) to those treated with open reduction and Salter innominate osteotomy (OR/IO) to estimate the relative hazard of total hip arthroplasty (THA) and the THA-free survival time., Methods: In a series of patients 18 to 60 months of age, 45 patients (58 hips) underwent CR and 58 patients (78 hips) were treated with OR/IO and followed to a minimum 40 years post-reduction. Observations in the survival analysis were censored if no THA had occurred by 48 years. Multivariate Cox regression analysis was used to estimate the hazard of THA given treatment, age, and bilaterality. Complications and additional procedures were noted., Results: At 48 years of follow-up, 29 (50%) of the hips survived after CR compared with 54 (69%) after OR/IO. At 45 years, the survival probability after OR/IO was 0.63 (95% confidence interval [CI] = 0.50 to 0.78) compared with 0.55 (95% CI = 0.43 to 0.72) after CR. The hazard ratio (HR) of THA was modeled as a function of treatment, age at reduction, and bilaterality. The effect of age and treatment on the outcome of hips in patients with unilateral involvement was minimal. However, age did significantly alter the relationship between treatment and outcome in bilateral cases. In the bilateral group, the predicted HR of THA was lower after CR in hips that were reduced at the age of 18 months (HR = 0.16, 95% CI = 0.04 to 0.64) but higher in those that were reduced at 36 months (HR = 4.23, 95% CI = 2.00 to 8.95). Additional procedures were indicated for 17% and 22% of hips after CR and OR/IO, respectively., Conclusions: Osteoarthritis and THA was more likely after CR than OR/IO, but the data do not indicate a difference in unadjusted hip-survival time. In patients with bilateral disease, an older age at reduction was associated with an increased hazard of THA after CR than after OR/IO. Both treatments provided substantial benefit relative to the natural history of DDH, but THA is the expected outcome in middle adulthood., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Study Design: Survey., Objectives: Bracing is the mainstay of conservative treatment in Adolescent Idiopathic Scoliosis (AIS). The purpose of this study was to establish best practice guidelines (BPG) among a multidisciplinary group of international bracing experts including surgeons, physiatrists, physical therapists, and orthotists utilizing formal consensus building techniques. Currently, there is significant variability in the practice of brace treatment for AIS and, therefore, there is a strong need to develop BPG for bracing in AIS., Methods: We utilized the Delphi process and the nominal group technique to establish consensus among a multidisciplinary group of bracing experts. Our previous work identified areas of variability in brace treatment that we targeted for consensus. Following a review of the literature, three iterative surveys were administered. Topics included bracing goals, indications for starting and discontinuing bracing, brace types, brace prescription, radiographs, physical activities, and physiotherapeutic scoliosis-specific exercises. A face-to-face meeting was then conducted that allowed participants to vote for or against inclusion of each item. Agreement of 80% throughout the surveys and face-to-face meeting was considered consensus. Items that did not reach consensus were discussed and revised and repeat voting for consensus was performed., Results: Of the 38 experts invited to participate, we received responses from 32, 35, and 34 for each survey, respectively. 11 surgeons, 4 physiatrists, 8 physical therapists, 3 orthotists, and 1 research scientist participated in the final face-to-face meeting. Experts reached consensus on 67 items across 10 domains of bracing which were consolidated into the final best practice recommendations., Conclusions: We believe that adherence to these BPG will lead to fewer sub-optimal outcomes in patients with AIS by reducing the variability in AIS bracing practices, and provide a framework future research., Level of Evidence: Level IV.

Study Design: Prognostic study and validation using prospective clinical trial data., Objective: To derive and validate a model predicting curve progression to ≥45° before skeletal maturity in untreated patients with adolescent idiopathic scoliosis (AIS)., Summary of Background Data: Studies have linked the natural history of AIS with characteristics such as sex, skeletal maturity, curve magnitude, and pattern. The Simplified Skeletal Maturity Scoring System may be of particular prognostic utility for the study of curve progression. The reliability of the system has been addressed; however, its value as a prognostic marker for the outcomes of AIS has not. The BrAIST trial followed a sample of untreated AIS patients from enrollment to skeletal maturity, providing a rare source of prospective data for prognostic modeling., Methods: The development sample included 115 untreated BrAIST participants. Logistic regression was used to predict curve progression to ≥45° (or surgery) before skeletal maturity. Predictors included the Cobb angle, age, sex, curve type, triradiate cartilage, and skeletal maturity stage (SMS). Internal and external validity was evaluated using jackknifed samples of the BrAIST data set and an independent cohort (n = 152). Indices of discrimination and calibration were estimated. A risk classification was created and the accuracy evaluated via the positive (PPV) and negative predictive values (NPV)., Results: The final model included the SMS, Cobb angle, and curve type. The model demonstrated strong discrimination (c-statistics 0.89-0.91) and calibration in all data sets. The classification system resulted in PPVs of 0.71-0.72 and NPVs of 0.85-0.93., Conclusions: This study provides the first rigorously validated model predicting a short-term outcome of untreated AIS. The resultant estimates can serve two important functions: 1) setting benchmarks for comparative effectiveness studies and 2) most importantly, providing clinicians and families with individual risk estimates to guide treatment decisions., Level of Evidence: Level 1, prognostic., (Copyright © 2019 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

Rationale, Aims, and Objectives: A comprehensive electronic guide (e-module) describing an interprofessional, evidence-informed approach to HIV rehabilitation was developed as an education resource for rehabilitation professionals. We developed a guideline implementation tool, consisting of a 10-week, case-based education intervention delivered by email, that was perceived to increase rehabilitation professionals' (occupational therapists (OTs), physical therapists (PTs), and speech language pathologists (SLPs)) knowledge and confidence to apply best practices in HIV rehabilitation. This study aimed to increase understanding of how the design of the guideline implementation tool facilitated increased awareness of and access to the e-module among rehabilitation professionals., Methods: We conducted a single group intervention study with rehabilitation professionals in Canada and the United Kingdom. Six case studies targeting HIV pathophysiology and associated conditions, an interprofessional approach to rehabilitation assessment and treatment, and psychosocial issues experienced by people living with HIV, were emailed to participants at 2-week intervals. Individual semi-structured interviews were conducted post-intervention. Interview transcripts were analysed using a descriptive qualitative approach., Results: Twenty-six individuals (17 from Canada, and 9 from the UK; 16 PTs, 7 OTs, 3 SLPs) were interviewed. One main theme related to design features of the intervention that facilitated learning and access to the e-module emerged. Subthemes highlighted features of the case-based intervention, including technical feasibility, terminology, formatting and layout, hyperlinks, number and frequency of case studies, and diverse and realistic case scenarios relevant to the learner's practice, that participants described as facilitating access to information and learning., Conclusion: Electronically administered case studies were perceived as complementary knowledge tools that increased access to an evidence-informed guide to HIV rehabilitation. Findings provide guidance on using case studies as a guideline implementation tool to facilitate access to information and related resources to optimize learning., (© 2018 John Wiley & Sons, Ltd.)

Background: Adolescent idiopathic scoliosis (AIS) has been associated with unnecessary referrals, but the provider and patient costs associated with these referrals remain unknown. The purpose of this study was to determine the prevalence and associated costs of unnecessary referrals for AIS in a university hospital-based orthopaedic clinic. These data are required to estimate the cost-efficacy of scoliosis screening programs., Methods: We accessed the electronic medical records of all patients referred during 2013-2014 with suspected AIS. Spine radiographs were reviewed to determine whether the referral was "unnecessary," defined as a Cobb angle <20 degrees. Patient and provider costs were estimated. Patient costs included transportation expenses and parental lost wages. Provider costs included orthopaedic evaluation, diagnostic imaging, and overhead. Transportation costs were based on actual driving distances and the Internal Revenue Service standard mileage rate. Parental lost wages and the cost of evaluation by an orthopaedic surgeon were calculated with time-driven activity-based costing. Diagnostic imaging costs were calculated with a traditional activity-based costing methodology., Results: Three hundred thirty-seven patients were included. The prevalence of unnecessary referrals was 39% (n=131). 17% of patients had a Cobb angle <10 degrees and 22% had a Cobb angle between 10-20 degrees. Males were more likely to be referred unnecessarily than females, 49% to 35% (p=0.02) as were non-Caucasians (54% vs. 37%, p=0.04). No difference was noted related to source of insurance (private or public, p=0.18). The average total cost of an unnecessary referral was $782.13 USD, including $231.07 in patient costs and $551.06 in provider costs., Conclusions: Nearly 40% of all referrals for AIS were deemed unnecessary. The average cost of an unnecessary referral is approximately $780, imposing significant costs on both patients and the healthcare system. Level of Evidence: III., Competing Interests: Disclosures: The authors report no potential conflicts of interest related to this study.

Background: Proximal femoral growth disturbance (PFGD) can be the most devastating complication of the treatment of development dysplasia of the hip. The reported incidence ranges from 0% to 73%. The condition involves varying degrees of growth disturbances of the femoral capital epiphysis, the physeal plate or both., Purpose: This manuscript will discuss normal growth and development of the hip, the blood supply to the upper end of the femur, pathological and radiographic changes, classifications used to describe PFGD and, most importantly, the potential causes of these growth disturbances and the authors' strategies for avoiding PFGD.

This review summarizes evidence developed at the University of Iowa concerning the management and outcomes of developmental dysplasia of the hip beginning with the observations and analyses of Dr Arthur Steindler in the early 1900s. The strong evidence-based practice tradition established by Steindler 100 years ago continues as we critically evaluate our procedures and patient outcomes, only altering approaches when warranted by strong personal and research evidence. Our practice continues to be conservative in that we strive to produce the best environment possible for the hip to develop on its own and operate only when less invasive methods have failed.

Background: Clinical evidence regarding the ability of braces to decrease the risk of curve progression to surgical threshold in patients with adolescent idiopathic scoliosis (AIS) continues to strengthen. Unfortunately, there is still a great deal of uncertainty regarding the impact of brace wear on psychosocial well-being or the impact of psychological well-being on brace wear adherence. The purpose of this study is to evaluate psychosocial well-being, in particular body image and quality of life (QOL), and brace wear adherence in female AIS patients undergoing brace treatment., Methods: The Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST) was a multicenter, controlled trial using randomized and preference assignments into an observation or brace treatment group. BrAIST patients were skeletally immature adolescents diagnosed with AIS having moderate curve sizes (20 to 40 degrees). Patients in the bracing group were instructed to wear a thoracolumbosacral orthosis, at least 18 h/d. Scores on the Spinal Appearance Questionnaire and the PedsQL4.0 Generic Scales from 167 female BrAIST patients who were randomized to brace treatment (n=58) and patients who chose brace treatment (n=109) were analyzed., Results: At baseline and at 12 months, no differences were found between the least-adherent brace wear group (<6 h/d) and most-adherent brace wear group (≥12 h/d) patients in terms of major curve, body image, and QOL. In the most-adherent group, poorer body image scores were significantly correlated with poorer QOL scores at baseline, at 6 months, and at 12 months but not at 18 months. In general, body image scores and QOL scores were not significantly correlated in the least-adherent group. When comparing patients that had a ≥6 degree increase of their major curve between baseline and 12 months to patients that did not, there were no significant differences in body image or QOL scores., Conclusions: For females adolescents with AIS, body image and QOL do not have a significant impact on brace wear adherence and are subsequently not significantly impacted by brace wear., Level of Evidence: Level II-therapeutic (prospective comparative study).

Background: Spinal muscular atrophy (SMA) is a progressive neuromuscular disease commonly including progressive scoliosis resulting in severe deformity and negatively affecting pulmonary function. Surgical correction and stabilization of this progressive deformity is generally recommended; however, the timing and method of surgical fixation remains controversial., Methods: Retrospective review of clinical, radiographic, and pulmonary function data from 16 children with SMA and surgically treated scoliosis between 1985 and 2013. Radiographic data included direct measures of major curve, coronal balance, pelvic obliquity, T1-T12 height, T1-S1 height, and T1-rod length. Estimations of rib collapse, thoracic cavity shape, and space-available-for-lung (T6:T12, width ratio; T6:T10, rib-vertebral-angle difference ratios; and lung height) were determined. Eleven patients were able to complete pulmonary function testing. Results were compared with published outcomes for growing rod constructs., Results: Posterior spinal fusion was performed at an average age of 9.8±3.6 years. The mean age at most recent follow-up was 19.4 years (range, 10 to 37 y), with a mean follow-up of 10.1 years (range, 3.1 to 26 y). Radiographic measurements improved from preoperative to latest follow-up as follows: major curve, 78±20 degrees to 27±24 degrees; coronal balance, 4.1±4.0 cm to 1.9±2.2 cm; pelvic obliquity (median), 23 to 5 degrees; T1-T12 height, 19±3 cm to 22±3 cm; T1-S1 height, 31±7 cm to 36±6 cm; T1-rod length, 0.8±1.1 cm (postop) to 2.8±1.6 cm (final); and space-available-for-lung ratio, 0.88±0.26 to 0.95±0.25. Rib collapse continued throughout the follow-up period in all but 1 patient. Pulmonary function testing demonstrated a decrease in rate of decline in forced vital capacity and forced expiratory volume when comparing preoperative with postoperative rates. Mean length of stay was 7.8±4.4 days. Complications included reintubation for low tidal volumes (n=1), pneumonia (n=1), superficial wound breakdown (n=1), and superficial infection (n=1)., Conclusions: Definitive posterior spinal fusion for treatment of scoliosis associated with SMA is effective at controlling curve progression and pelvic obliquity without negatively impacting the space-available-for-lung ratio, trunk height, or pulmonary function at 10 years follow-up., Level of Evidence: Therapeutic Level IV.

Objectives: To investigate the relationship between obesity and distal radius fracture severity after low-energy trauma and to identify patient-specific risk factors predictive of increasing fracture severity., Design: Retrospective review., Setting: Level 1 Trauma Center., Patients/participants: Four hundred twenty-three adult subjects with a history of fracture of the distal radius resulting from a fall from standing height., Intervention: Demographic data and injury characteristics were obtained. Preoperative wrist radiographs were reviewed and classified by the OTA classification system. Distal radius fractures were categorized as simple [closed and extra-articular (OTA 23-A)] and complex [intra-articular (OTA 23-B or 23-C) or open fracture or concomitant ipsilateral upper extremity fracture]. Multivariate logistic regression was completed to model the probability of incurring a complex fracture., Main Outcome Measurements: Simple versus complex fracture pattern., Results: Average age at the time of injury was 53.8 years (range, 18.9-98.4). Seventy-nine percent of subjects were female. The average body-mass index was 28.1 (range, 13.6-59.5). Two hundred forty-four patients (58%) suffered complex distal radius fractures per study criteria. Obese patients (body-mass index > 30) demonstrated increased fracture severity as per the OTA classification (P = 0.039) and were more likely to suffer a complex injury (P = 0.032). Multivariate regression identified male gender, obesity, and age ≥50 as independent risk factors for sustaining a complex fracture pattern., Conclusions: Obesity is associated with more complex fractures of the distal radius after low-energy trauma, particularly in elderly patients. This relationship may have important epidemiologic implications predictive of future societal fracture burden and severity in an obese, aging population., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Study Design: The Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST) included skeletally immature high-risk patients with adolescent idiopathic scoliosis (AIS) with moderate curve sizes (20°- 40°). BrAIST was a multicenter, controlled trial using both randomized and preference treatment arms into either an observation group or a brace treatment group., Objective: The aim of this study was to analyze and compare body image and quality-of-life (QOL) in female AIS patients who were observed or treated with a brace., Summary of Background Data: Brace treatment is an effective means for controlling progressive scoliosis and preventing the need for surgery, but there is no consensus regarding the effect of brace treatment on body image or on QOL in adolescents with AIS., Methods: Data from female BrAIST patients in the randomized (n = 132) or preference (n = 187) arms and were observed (n = 120) or brace treated (n = 199) were analyzed. Patients completed the Spinal Appearance Questionnaire (SAQ) and the Pediatric Quality of Life Inventory (PedsQOL) 4.0 Generic Scales at baseline and 6 month follow-up visits up to 2 years. Items on the SAQ measured three body image constructs (self, ideal, and overall). The PedsQOL measured health, activities, feelings, social factors, and school., Results: . In general, there were no significant differences within or between study arms or treatments regarding body image or QOL through 2 years of follow-up. Poorer body image was significantly correlated with poorer QOL during the first 2 years of follow-up regardless of study arm or treatment. Patients who crossed-over to a different treatment and patients with largest Cobb angles ≥ 40 degrees had significantly poorer body image, in particular self-body image, compared with those that did not., Conclusion: This study does not support findings from previous research indicating that wearing a brace has a negative impact on or is negatively impacted by body image or QOL., Level of Evidence: 2.

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.).

Study Design: Descriptive., Objective: To describe the design and development of Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST)., Summary of Background Data: Bracing has remained the standard of care for the nonoperative treatment of adolescent idiopathic scoliosis since the introduction of the Milwaukee brace in the late 1940s, but it has never been subjected to a rigorous evaluation of either its efficacy or its effectiveness. The BrAIST was designed to address the primary question: Do braces (specifically a thoracolumbosacral orthosis) lower the risk of curve progression to a surgical threshold (≥50°) in patients with adolescent idiopathic scoliosis relative to watchful waiting alone?, Methods: The authors describe the rationale for BrAIST, including the limitations of the current literature evaluating bracing for adolescent idiopathic scoliosis. Second, the authors describe the preliminary work, including the preparation of the National Institutes of Health clinical trials planning grant. Finally, the authors describe the trial design in detail., Results: BrAIST was conducted in 25 sites in North America. Subjects were treated either with a thoracolumbosacral orthosis or watchful waiting and followed every 6 months until they reached skeletal maturity or the surgical threshold of 50° Cobb angle., Conclusion: Clinical decision making will be improved by translation of the BrAIST results into evidence-based prognosis and estimates of how the prognosis, specifically the risk of progressing to surgery, may be altered by the use of bracing., Level of Evidence: N/A.

Our objective was to identify all existing systematic reviews related to counselling, case management and health promotion for people living with HIV/AIDS. For the reviews identified, we assessed the quality and local applicability to support evidence-informed policy and practice. We searched 12 electronic databases and two reviewers independently assessed the 5,398 references retrieved from our searches and included 18 systematic reviews. Each review was categorized according to the topic(s) addressed, quality appraised and summarized by extracting key messages, the year searches were last completed and the countries in which included studies were conducted. Twelve reviews address topics related to counselling and case management (mean quality score of 6.5/11). Eight reviews (mean quality score of 6/11) address topics related to health promotion (two address both domains). The findings from this overview of systematic reviews provide a useful resource for supporting the development and delivery of evidence-informed support services in community settings.

Background: The "Gothic Arch" is a radio-graphic finding on AP pelvis x-rays postulated to be predictive of hip osteoarthritis., Purpose: The purpose of this study was to determine the reliability of measurement of the Gothic Arch in patients with no known hip pathology and patients with unilateral developmental dysplasia of the hip (DDH)., Patients and Methods: After obtaining IRB approval, nine skeletally mature patients (18 hips) with no known hip pathology were selected to serve as the control group. The AP pelvis x-rays at skeletal maturity of eight patients (16 hips) with unilateral DDH treated with closed reduction and casting comprised the comparison group. A digitizing program was designed to measure the Gothic Arch based on landmarks identified by the user. Two pediatric orthopaedic surgeons and two orthopaedic residents completed the program on two separate occasions. Intra-and interobserver reliability were determined using intraclass cor-relation coefficients (ICC) for continuous variables., Results: Both the unilateral DDH group and the control group demonstrated excellent inter- and intraobserver reliability (ICC >0.70) for base, height, area, and orientation of the Gothic Arch, but poor reliability (ICC <0.40) for medial and lateral sharpness., Conclusion: The Gothic Arch can be reliably measured on AP pelvis x-rays of patients with normal and dysplastic hips., Level of Evidence: III, Diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Purpose: Identify educational needs of parents of children born with clubfoot and the role of healthcare providers throughout the treatment process., Method: A qualitative study using interviews with 30 parents. All subjects were asked the same 12 questions regarding their perceptions and experiences. Common themes were identified from the data collected., Findings: The parents' educational needs fell into the following 2 categories: (1) understanding the process of treatment and (2) problems concerning the bracing portion of treatment. Themes exposed the effects on daily living and accommodations made to follow treatment. Parents perceive that the role of the healthcare provider is to present how-to information, specify consequences of the risks, promote awareness, provide encouragement and support, and remind them of positive effects to be expected when treatment is completed.

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.

Background: Randomized controlled trials are powerful tools to evaluate the outcomes of clinical treatments. However, these trials tend to be expensive and time-consuming, and their conclusions can be threatened by several limitations. This study estimated the strength of three common limitations (underenrollment, selective enrollment, and nonadherence to protocol) in a proposed study of adolescent idiopathic scoliosis., Methods: Patients with scoliosis and their parents were asked to complete a web-based survey about their preferences concerning a hypothetical randomized trial. Adolescents without scoliosis and their parents also participated. Surveys included questions about treatment preference, likelihood of participation, required risk reduction, and propensity to drop out or choose a different treatment while enrolled in the study., Results: Ninety adolescents and eighty-three parents participated. Observation was preferred to bracing by the majority of subjects. Overall, 33% of the parents and adolescents would both agree to participate in the hypothetical trial. Of the subjects who would not agree to participate, the majority would rather share the decision-making responsibility with the physician than have the treatment chosen in a random fashion. Many of the subjects would consider changing treatments during the course of the trial if they were not satisfied with the outcomes; the majority of parents who preferred bracing would consider crossing over to the bracing arm if their children were randomized to observation., Conclusions: Recruitment into a randomized trial of bracing compared with observation for the treatment of adolescent idiopathic scoliosis may well be problematic, considering the relatively small percentage of families who said they would consider randomization. Additionally, the threat of nonadherence to protocol may be strong and must be addressed in the protocol of the trial. Most families wanted to make the treatment decision with the physician in lieu of randomization; therefore, the role of the physician in patient recruitment and retention should not be underestimated.

Background: Requested project of the Pediatric Orthopaedic Society of North America Evidenced-Based Medicine Committee., Methods: The English literature was systematically reviewed for scientific evidence supporting or disputing the common practice of elective removal of implants in children., Results: Several case series reported implant removal, but none contained a control group with retained implants. No articles reported long-term outcomes of retained implants in large numbers. Several small series describe complications associated with retained implants without evidence of causation. The existing literature was not amenable to a meta-analysis. By compiling data from the literature, it is possible to calculate a complication rate of 10% for implant removal surgery. The complication rate for removal of implants placed for slipped capital femoral epiphysis is 34%. Articles regarding postmarket implant surveillance and basic science were also reviewed., Conclusions: There is no evidence in the current literature to support or refute the practice of routine implant removal in children.

Background: There is a normal transition from the kyphotic alignment that is present in the spine of the newborn to the normal sagittal contours that are present in the adult spine. Although abnormal kyphosis at the thoracolumbar junction in infants is rare, it can result from congenital anomalies and bone dysplasias. We report the cases of seven otherwise normal infants who had thoracolumbar kyphosis due to lumbar hypoplasia, with total spontaneous resolution over time., Methods: The medical records of seven patients who met the inclusion criteria were reviewed. Clinical data and radiographs were analyzed to rule out the presence of congenital anomalies or bone dysplasias. Progression of kyphosis was measured on serial radiographs made with the patient sitting and standing., Results: All patients were managed conservatively with observation alone. No patient had a neurologic deficit. The average age at the time of the initial diagnosis was 5.3 months, and the average duration of follow-up was 5.7 years. Three cases of kyphosis were secondary to L1 hypoplasia, and four were secondary to L2 hypoplasia. The average initial kyphosis was 34.2 degrees, which progressed to 0.4 degrees of lordosis at the time of the latest follow-up., Conclusions: Thoracolumbar kyphosis in normal infants secondary to lumbar hypoplasia may resolve spontaneously. After congenital anomalies and bone dysplasias are ruled out, a period of observation is advised.

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.

Background: Type III growth disturbance (T3GD) following reduction for developmental dysplasia of the hip (DDH) is a relatively rare, but potentially devastating complication. This study evaluated the long-term outcomes of patients treated for DDH who developed a T3GD hip compared to those who didn't, with an emphasis on possible risk factors., Methods: A case-control design was used. All radiographs of a consecutive set of patients with DDH were evaluated. Twenty-two patients (29 hips) developed T3GD. The control group consisted of 57 patients (72 hips) without any sign of growth disturbance. Variables examined included age at reduction, type of reduction and serial radiographic parameters reflecting pre- and post-reduction status. Average age at final follow up was 26 years in the T3GD group and 34 years in the control group., Results: Evidence of T3GD was first noticed radiographically at 11 months after reduction and healing of the epiphysis occurred an average of 8.5 months later. Univariate analysis demonstrated no increased risk of T3GD related to age at presentation, presence or absence of the ossific nucleus, type of reduction, initial acetabular index or Smith's centering ratios. However, the Tönnis grade was significantly associated with an increased risk of T3GD. Tönnis grade 4 hips (high-degree dislocations) had 3.43 times greater risk of developing T3GD compared to those with lower dislocations. At maturity, 90% of the T3GD hips were classified as Severin III/IV, compared to 35% of the controls. At last follow-up, 7 of the 29 T3GD hips (32%) had undergone total hip replacement at an average age of 39 years (range 19 to 57 years)., Conclusions: T3GD remains the most severe and devastating complication after treatment of DDH in children. In most cases, poor acetabular development and flattening of the femoral head lead to early degenerative changes in the hip joint. The risk increases in high-degree dislocations, independent of the treatment performed.

Purpose: To describe the relationship between pain-sensitive temperament and self-report of pain intensity following surgery., Design and Methods: Fifty-nine adolescents and young adults (average age 14 years) undergoing spinal fusion for adolescent idiopathic scoliosis completed the Sensitivity Temperament Inventory for Pain-Child version (STIP-C). The Pearson correlation between STIP-C scores and the highest pain intensity for each of the first three postoperative days was investigated., Results: There was a small but significant correlation between the Perceptual Sensitivity and Symptom Reporting subscales of the STIP-C and pain intensity measured on the third postoperative day., Practice Implications: Aspects of the pain-sensitive temperament may be important in understanding the variability in postoperative pain. This is the first investigation of the relationship between pain-sensitive temperament and surgical pain. More research is needed in this area.

Objective: To determine if community equipoise exists concerning the effectiveness of bracing in adolescent idiopathic scoliosis., Background Data: Bracing is the standard of care for adolescent idiopathic scoliosis despite the lack of strong reasearch evidence concerning its effectiveness. Thus, some researchers support the idea of a randomized trial, whereas others think that randomization in the face of a standard of care would be unethical., Methods: A random of Scoliosis Research Society and Pediatric Orthopaedic Society of North America members were asked to consider 12 clinical profiles and to give their opinion concerning the radiographic outcomes after observation and bracing., Results: An expert panel was created from the respondents. They expressed a wide array of opinions concerning the percentage of patients within each scenario who would benefit from bracing. Agreement was noted concerning the risk due to bracing for post-menarchal patients only., Conclusions: : This study found a high degree of variability in opinion among clinicians concerning the effectiveness of bracing, suggesting that a randomized trial of bracing would be ethical.

Little substantive data is available in the literature on the long-term clinical and radiological results of Cotrel-Dubousset instrumentation (CDI) for the treatment of adolescent idiopathic scoliosis. We therefore retrospectively investigated the long-term clinical and radiographic outcome of patients who underwent (CDI) for right thoracic adolescent idiopathic scoliosis. 54 consecutive patients (45 females, 9 males) who underwent CDI for right thoracic adolescent idiopathic scoliosis with an average age of 14 years (range 10-21 years) at surgery were included in this series. There were 18 King Type II, 19 Type III, 5 Type IV, 3 Type V and 9 double major curves. The average coronal Cobb angle of the primary thoracic curve preoperatively, postoperatively and at latest follow-up was 55 degrees, 17 degrees and 22 degrees, respectively. The lumbar curve (secondary and double major) averaged 40 degrees, 21 degrees and 23 degrees, respectively. Coronal balance (deviation from the central sacral line) was slightly improved from 13 mm to 11 mm. The average shoulder elevation increased from 3 degrees to 5 degrees, presumably as a result of the rod derotation maneuver. Thoracic kyphosis (20 degrees to 22 degrees) and lumbar lordosis (49 degrees to 54 degrees) was preserved or even improved by the instrumentation. All patients were doing well and had no complaints with regard to a substantial limitation of professional or sports activity. There were no apparent non-unions, infections or neurological complications. CDI of adolescent right thoracic idiopathic scoliosis provides encouraging clinical and radiographic results at an average follow-up of 9 years (2 to 16 years). Overall patient satisfaction, functional status and subjective cosmetic improvement is high.

This paper evaluates the efficacy the Moss-Miami System instrumentation for surgical treatment of spinal deformity. Eight-five patients with AIS underwent a posterior spinal fusion with using this system between 1994 and 1998. Radiographs of the spine were taken preoperatively, at discharge, one year after surgery, and at the latest follow-up (average of 2.5 year, range 2 to 6 years). All radiographs were assessed for curve magnitude, coronal balance, kyphosis, lordosis, junctional kyphosis, and sagittal balance. The Scoliosis Research Society instrument was administered at the final follow-up. The average curve correction ranged from 53 to 65 percent. All patients showed solid fusion by final follow-up. Three patients required a second operation for complications related to their scoliosis; two patients showed a rod fracture without evidence of pseudoarthrosis or curve progression. Two transient neurological complications related to the surgery were observed. SRS results were favorable with regard to function and cosmetic appearance.

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.

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.

A fundamental goal of research in developmental dysplasia of the hip (DDH) has been the identification of radiographic quantitative factors predictive of long-term outcome. The rapid development of digital imaging modalities opens the possibility for more systematic, automated measurement of radiographs. The authors have developed a software program for the study of DDH that integrates a user interface to select, store, and edit prescribed landmarks on digital radiographs. These points are used to construct and display reference lines analogous to those commonly drawn on physical films. Measurements are stored as a printable text file and as a data record. The results of this study demonstrated very good intrarater and interrater reliability coefficients and intermethod validity coefficients for the digitizing program. If this program is added to a software reporting system, measurements can be done on a real-time basis and can be included in the patient's medical record.