Publications by authors named "Daniel J Sucato"

137 Publications

Surgical outcomes of severe spinal deformities exceeding 100° or treated by vertebral column resection (VCR). Does implant density matter?: an observational study of deformity groupings.

Spine Deform 2022 05 19;10(3):595-606. Epub 2022 Mar 19.

Department of Orthopedics, Washington University School of Medicine, St. Louis, MO, USA.

Study Design: Prospective multicenter international observational study.

Objective: To investigate the effect of implant density on clinical outcomes in complex pediatric spine reconstruction. Implant density in spine deformity surgery has been a subject of much debate with some authors advocating higher density for better correction. Few studies have looked at the effect of implant density on severe curves > 100 deg or treated with vertebral column resection (VCR).

Methods: 250/311 pts with 2-year f/u enrolled in the FOX pediatric database from 17 international sites were queried for the impact of implant density and surgical outcomes. Patients were grouped into three implant density categories for comparative analysis Group 1 (density ≤ 1), Group 2 (1 < density < 1.5) and Group 3 (density; 1.5-2).

Results: 250 pts: 47 (Grp1)/99 (Grp2) /104 (Grp3); Pre-op age and etiology and curve types were similar in all groups, but body mass index (BMI) was higher in Grp3. Grps 1 and 2 had significantly higher sagittal deformity angular ratio (S-DAR) compared to Grp 3 (p < 0.001). Pre-op Halo Gravity Traction (HGT) was used in 55.3%/44.4%/31.7%, p = 0.017; Grp1/Grp2/Grp3, respectively. Average duration of surgery (min) was higher in Grp3 relative to Grp1 only: 352.5/456.5/515.0, p = 0.0029. Blood loss was similar in all Grps. Rate of VCR, PSO and SPO was similar in all Grps. Pre-op Coronal Cobb avg 96.1/83.6/88.6, p = 0.2342, attained similar correction after HGT (24.6%/27.2%/23.2%, p = 0.4864. Coronal Cobb corrections at 2-year follow-up (FU) were (37.1%/40.3%/53.5%, p = 0.0004). Pre-op sagittal Cobb was (105.4/101.9/75.9, p < 0.01.), achieved similar %correction in HGT (19.1%/22.3%/22.5%, p = 0.6851) and at 2-year FU (39.6%/41.4%/29.8%, p = 0.1916). After adjusting for C-DAR, S-DAR, pre-op coronal and sagittal Cobb, etiology, curve types, age, BMI and number of rods in multivariate analysis, the odds of developing post-operative implant complication was 11 times greater in group 1 compared to group 3 (OR = 11.17,95% CI 2.34-53.32). There was significant improvement in SRS scores in all Grps at 2-year FU.

Conclusion: Although higher implant density was observed to be associated with greater curve correction and lower rates of post-operative implant-related complication and revision in heterogeneous case groups, the results may not imply causality of implant density on the outcomes in severe pediatric spine reconstruction.
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http://dx.doi.org/10.1007/s43390-021-00460-xDOI Listing
May 2022

Development of consensus-based best practice guidelines for response to intraoperative neuromonitoring events in high-risk spinal deformity surgery.

Spine Deform 2022 07 15;10(4):745-761. Epub 2022 Mar 15.

Division of Pediatric Orthopaedic Surgery, Department of Orthopaedic Surgery, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Irving Medical Center, 3959 Broadway, CHONY 8-N, New York, NY, 10032-3784, USA.

Purpose: To expand on previously described intraoperative aids by developing consensus-based best practice guidelines to optimize the approach to intraoperative neuromonitoring (IONM) events associated with "high-risk" spinal deformity surgery.

Methods: Consensus was established among a group of experienced spinal deformity surgeons by way of the Delphi method. Through a series of iterative surveys and a final virtual consensus meeting, participants expressed their agreement (strongly agree, agree, disagree, and strongly disagree) with various items. Consensus was defined as ≥ 80% agreement ("strongly agree" or "agree"). Near-consensus was defined as ≥ 60% but < 80%. Equipoise was ≥ 20% but < 60%, and consensus to exclude was < 20%.

Results: 15 out of 15 (100%) invited surgeons agreed to participate. Final consensus supported inclusion of 105 items (53 in Response Algorithm, 13 in Ongoing Consideration of Etiology, 31 in Real-Time Data Scenarios, 8 in Patterns of IONM Loss), which were organized into a final set of best practice guidelines.

Conclusion: Detailed consensus-based best practice guidelines and aids were successfully created with the intention to help organize and direct the surgical team in exploring and responding to neurological complications during high-risk spinal deformity surgery.

Level Of Evidence: Level V.
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http://dx.doi.org/10.1007/s43390-022-00485-wDOI Listing
July 2022

Establishing consensus: determinants of high-risk and preventative strategies for neurological events in complex spinal deformity surgery.

Spine Deform 2022 07 23;10(4):733-744. Epub 2022 Feb 23.

The Daniel and Jane Och Spine Hospital at New York-Presbyterian/Allen, New York, NY, USA.

Purpose: To establish expert consensus on various parameters that constitute elevated risk during spinal deformity surgery and potential preventative strategies that may minimize the risk of intraoperative neuromonitoring (IONM) events and postoperative neurological deficits.

Methods: Through a series of surveys and a final virtual consensus meeting, the Delphi method was utilized to establish consensus among a group of expert spinal deformity surgeons. During iterative rounds of voting, participants were asked to express their agreement (strongly agree, agree, disagree, strongly disagree) to include items in a final set of guidelines. Consensus was defined as ≥ 80% agreement among participants. Near-consensus was ≥ 60% but < 80% agreement, equipoise was ≥ 20% but < 60%, and consensus to exclude was < 20%.

Results: Fifteen of the 15 (100%) invited expert spinal deformity surgeons agreed to participate. There was consensus to include 22 determinants of high-risk (8 patient factors, 8 curve and spinal cord factors, and 6 surgical factors) and 21 preventative strategies (4 preoperative, 14 intraoperative, and 3 postoperative) in the final set of best practice guidelines.

Conclusion: A resource highlighting several salient clinical factors found in high-risk spinal deformity patients as well as strategies to prevent neurological events was successfully created through expert consensus. This is intended to serve as a reference for surgeons and other clinicians involved in the care of spinal deformity patients.

Level Of Evidence: Level V.
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http://dx.doi.org/10.1007/s43390-022-00482-zDOI Listing
July 2022

Saturation mutagenesis defines novel mouse models of severe spine deformity.

Dis Model Mech 2021 06 18;14(6). Epub 2021 Jun 18.

Center for Pediatric Bone Biology and Translational Research, Scottish Rite for Children, Dallas, TX 75219, USA.

Embryonic formation and patterning of the vertebrate spinal column requires coordination of many molecular cues. After birth, the integrity of the spine is impacted by developmental abnormalities of the skeletal, muscular and nervous systems, which may result in deformities, such as kyphosis and scoliosis. We sought to identify novel genetic mouse models of severe spine deformity by implementing in vivo skeletal radiography as part of a high-throughput saturation mutagenesis screen. We report selected examples of genetic mouse models following radiographic screening of 54,497 mice from 1275 pedigrees. An estimated 30.44% of autosomal genes harbored predicted damaging alleles examined twice or more in the homozygous state. Of the 1275 pedigrees screened, 7.4% presented with severe spine deformity developing in multiple mice, and of these, meiotic mapping implicated N-ethyl-N-nitrosourea alleles in 21% of pedigrees. Our study provides proof of concept that saturation mutagenesis is capable of discovering novel mouse models of human disease, including conditions with skeletal, neural and neuromuscular pathologies. Furthermore, we report a mouse model of skeletal disease, including severe spine deformity, caused by recessive mutation in Scube3. By integrating results with a human clinical exome database, we identified a patient with undiagnosed skeletal disease who harbored recessive mutations in SCUBE3, and we demonstrated that disease-associated mutations are associated with reduced transactivation of Smad signaling in vitro. All radiographic results and mouse models are made publicly available through the Mutagenetix online database with the goal of advancing understanding of spine development and discovering novel mouse models of human disease.
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http://dx.doi.org/10.1242/dmm.048901DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8246263PMC
June 2021

Ponte osteotomies in a matched series of large AIS curves increase surgical risk without improving outcomes.

Spine Deform 2021 09 16;9(5):1411-1418. Epub 2021 Apr 16.

Department of Orthopedic Surgery, Texas Scottish Rite Hospital for Children, 2222 Welborn St, Dallas, TX, 75219, USA.

Purpose: The routine use of Ponte osteotomies in adolescent idiopathic scoliosis (AIS) surgery is controversial with conflicting data for coronal plane correction and little analysis in the sagittal plane. The objective of this study was to analyze the efficacy of Ponte osteotomies in large curve AIS.

Methods: A single institution, prospectively-collected series of consecutive AIS patients who had Ponte osteotomies (P cohort) was directly matched to patients with no Pontes (NP cohort) by age, gender, Lenke classification, surgeon, coronal, and sagittal Cobb angles. The radiographic review included adjusted values using a 3D-derived published formula for preoperative T5-T12 kyphosis. Patient-reported outcomes (PROs) were assessed with the SRS-30 and Spinal Appearance Questionnaire (SAQ).

Results: There were 68 patients (34/cohort) with minimum 2-year follow-up with no differences between P and NP cohorts in age, preoperative coronal Cobb (74.5° vs 70.8°), flexibility index, measured or 3D-adjusted T5-T12 kyphosis. Rod material/diameter, fusion levels, blood loss, and operative time did not differ, but implant density was higher in the P group (1.53 vs 1.31, p < 0.001). The P group had 7.9% greater coronal Cobb correction (66.6% vs 58.7%, p < 0.003) without difference in final Cobb angles (24.7° vs. 29.1°, p = 0.052). There were no differences in measured or adjusted T5-T12 kyphosis in the sagittal plane. The P group had a 15% rate of critical intraoperative neuromonitoring changes versus 0% in the NP group (p = 0.053). At follow-up, there were no differences in scoliometer measurements or any domain of SRS-30 or SAQ scores.

Conclusion: In this first reported matched series of AIS patients, Ponte osteotomies provide small radiographic gains in the coronal plane with no improvement in the sagittal plane and no change in truncal rotation. There was a higher risk of critical intraoperative neuromonitoring changes, and no benefits in patient-reported outcomes. This calls into question the routine use of Ponte osteotomies in AIS, even for curves averaging 70 degrees.

Level Of Evidence: II.
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http://dx.doi.org/10.1007/s43390-021-00339-xDOI Listing
September 2021

Late Hip Dysplasia After Normal Ultrasound in Breech Babies: Implications on Surveillance Recommendations.

J Pediatr Orthop 2021 Apr;41(4):e304-e308

Texas Scottish Rite Hospital for Children.

Background: There is significant controversy in the literature over rates of late-developing dysplasia following normal screening ultrasound in breech babies, with reported rates varying from 7% to 29%. The purpose of this study is to investigate the rates of radiographic dysplasia in breech babies after a normal ultrasound with a minimum of 1 year of radiographic follow-up.

Methods: This study was an institutional review board-approved prospective study of all patients referred by their pediatrician for concern for developmental dysplasia of the hip between July 2008 and August 2014. We identified all subjects with breech presentation and excluded those with an abnormal initial examination/ultrasound or with <12 months of radiographic follow-up. Anterior-posterior pelvis films were obtained after >12 months and acetabular indices (AIs) were measured and compared with contemporary normative data. Dysplasia was diagnosed as >2 SDs above the mean.

Results: A total of 654 patients were referred with a history of a breech presentation, and 150 (22.9%) were found to have clinical instability or sonographic evidence of dysplasia on initial presentation and were observed with serial imaging or treated. Of the remaining 504 subjects with a normal clinical examination and screening ultrasound, 133 (26.4%; 74.4% females, 25.6% males) were followed until at least 12 months of age. Of those presenting at age 12 to 14 months, the mean AI was 0.42±0.83 SD above the mean with a skew towards elevated AIs. At the final follow-up (mean: 20.7±6.7 mo), the mean AI was 0.05±0.92 SD above the mean, and only 3/133 (2.2%) patients had a dysplastic hip. No patients underwent treatment other than an observation during the study period.

Conclusions: One in 5 breech babies have dysplasia at presentation, but late dysplasia following normal screening ultrasound may be less common than previously reported and may be due to our prolonged follow-up period. We recommend surveillance of breech babies with follow-up visits after 12 months of age since earlier visits may offer limited benefits.

Level Of Evidence: Level II-prospective prognostic study.
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http://dx.doi.org/10.1097/BPO.0000000000001773DOI Listing
April 2021

Staged Management of Cervicothoracic Lordosis and Scoliosis in an Emery-Dreifuss VI Muscular Dystrophy Patient: A Case Report.

JBJS Case Connect 2021 01 14;11(1):e20.00289. Epub 2021 Jan 14.

Scottish Rite for Children, Dallas, Texas.

Case: We report the case of an 18-year-old man with extreme cervicothoracic lordosis and a progressive scoliosis secondary to Emery-Dreifuss Type VI muscular dystrophy. In a staged fashion, the patient underwent posterior cervical muscle release, halo-gravity traction, and posterior instrumented spinal fusion from C3-L4 with multiple posterior column osteotomies. The patient was followed over 2 years postoperatively with restoration of normal spinal alignment in both the coronal and sagittal profiles.

Conclusion: This is the first reported case illustrating the gradual correction of severe lordoscoliosis in this patient population.
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http://dx.doi.org/10.2106/JBJS.CC.20.00289DOI Listing
January 2021

The Association of α Angle on Disease Severity in Adolescent Femoroacetabular Impingement.

J Pediatr Orthop 2021 Feb;41(2):88-92

University of Texas Southwestern Medical Center.

Background: Femoroacetabular Impingement (FAI) is a common cause of hip pain in adolescent patients. Clinical exam and radiographic markers, such as α angle and lateral center edge angle (LCEA), are commonly used to aid in the diagnosis of this condition. The purpose of this study was to correlate preoperative α angle and LCEA with preoperative symptoms, intraoperative findings, and preoperative and postoperative patient reported outcomes (PROs) in the adolescent patient.

Methods: A retrospective analysis of prospectively collected data was conducted for all patients who underwent operative intervention for FAI at an academic institution over an 11-year period. Preoperative imaging was obtained and measured for LCEA and α angle. PROs (modified Harris Hip Score, Hip Disability and Osteoarthritis Outcome Score, and UCLA score) were collected preoperatively, as well as 1, 2, and 5 years postoperatively. Operative intervention was either open surgical hip dislocation or arthroscopic, and intraoperative disease was graded using the Beck Classification system. Patients with minimum 1-year follow-up were included in statistical analysis.

Results: There were 86 hips (64 female hips) included with an average age of 16.3 years (range, 10.4 to 20.5 y), with an average of 37 months of follow-up. There was no correlation between severity of preoperative symptoms or difference between pre and postoperative PROs for both α angle and LCEA. Overall, significant improvement was noted in modified Harris Hip Score, Hip Disability and Osteoarthritis Outcome Score, and UCLA Score (P<0.001 for each). Independent of preoperative symptoms, increased α angle correlated with more severe intraoperative labral disease (P<0.001), and longer length of labral tear (Corr 0.295, P<0.01). Femoral head and acetabular articular cartilage damage did not correlate with α angle or LCEA, nor did overall severity of disease.

Conclusions: In adolescent patients with FAI, increased α angle was found to significantly correlate with labral pathology, including increased length of tear and severity of disease, irrespective of preoperative symptoms or postoperative patient reported outcomes.

Level Of Evidence: Level III-retrospective.
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http://dx.doi.org/10.1097/BPO.0000000000001703DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7803481PMC
February 2021

New neurologic deficit and recovery rates in the treatment of complex pediatric spine deformities exceeding 100 degrees or treated by vertebral column resection (VCR).

Spine Deform 2021 03 9;9(2):427-433. Epub 2020 Oct 9.

Department of Orthopedics, Washington University School of Medicine, St. Louis, MO, USA.

Study Design: Prospective multicenter international observational study.

Objective: To investigate incidence of new neurologic deficit (NND) and the long-term recovery patterns following complex pediatric spine deformity surgery. The SRS M&M reports identify pediatric patients as having higher rate of new neurologic deficit compared with adults, while congenital and neuromuscular deformities are associated with higher new neurologic risks. Very few studies have had the large numbers of pediatric patients with curves exceeding 100 deg to ascertain the new neurologic deficit (NND) rates and recovery patterns as it relates to curve laterality and diagnosis.

Method: The FOX pediatric database from 17 international sites was queried for New Neurologic Deficit (NND) as characterized by change in American Spinal Injury Association (ASIA) Lower or Upper Extremity Motor Score. Recovery rates at specific intervals were recorded and related to the curve type and etiology.

Results: Data of 286 consecutive patients with normal pre-operative neurologic exams were reviewed. There were 160 females vs 125 males with an average age of 14.6 years. NND occurred in 27 patients (9.4%) in the immediate post-operative period. Diagnostic categories included idiopathic scoliosis (3 patients); idiopathic kyphoscoliosis(5 patients); congenital scoliosis (7 patients); congenital kyphoscoliosis (4 patients); congenital kyphosis (6 patients), other kyphosis (1 patient) and syndromic (1 patient). 1 patient was lost to follow-up (f/u) after discharge; 1 had chronic deficits at the first post-operative erect visit (from discharge to 9 months f/u) and was subsequently lost to follow-up; 2 patients were improving at 1-year f/u but lost to subsequent f/u. 16 patients had normal neurologic function by the time of the first post-operative erect visit, 21 patients at 1-year f/u and 21 patients at the 2-year f/u. 2 patients (0.69%) had improved NND at 2-year mark.

Conclusion: A significant proportion of patients with complex spine deformity experience NND. However, significant improvement in neurologic function can be expected over time as seen in this study without additional surgical intervention in most cases. Congenital deformities accounted for 63% of the patients experiencing NND.
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http://dx.doi.org/10.1007/s43390-020-00211-4DOI Listing
March 2021

Peroneal Nerve Function Before and Following Surgical Excision of a Proximal Fibular Osteochondroma.

J Pediatr Orthop 2021 Jan;41(1):61-66

Department of Orthopaedic Surgery, Texas Scottish Rite Hospital, University of Texas Southwestern Medical Center, Dallas, TX.

Background: Osteochondromas occur most commonly in the distal femur, proximal tibia, and humerus. There are no large studies reviewing the outcome of treatment for patients with an osteochondroma involving the proximal fibula. The purpose of this study is to specifically understand the manifestations of a proximal fibular osteochondroma (PFO) on the preoperative peroneal nerve function, and how surgical management of the osteochondroma affects function immediately postoperatively and at long-term follow-up.

Methods: This is an institutional review board-approved retrospective review of a consecutive series of patients with a PFO treated operatively at a single institution. The medical record was carefully reviewed to identify demographic data, clinical data especially the status of the peroneal function at various time points.

Results: There were 25 patients with 31 affected extremities who underwent surgical excision of the PFO at an average age of 12.4 years (range, 3.0 to 17.9 y). There were 16 males and 9 females. The underlying diagnosis was isolated PFO in 2 (8%) patients and multiple hereditary exostosis in 23 (92%) patients. Preoperatively, 9 (29%) had a foot drop and 22 (71%) did not. Those with a preoperative foot drop underwent surgery at a younger age (9.1 vs. 13.8 y) (P<0.004) and postoperatively 5 (55.5%) had complete resolution, 3 (33.3%) had improvement, and 1 (11.1%) persisted requiring an ankle foot orthosis. Of the 22 who were normal preoperatively, 5 (22.7%) developed an immediate postoperative foot drop, 3 (60%) completely resolved, 1 (20%) improved, and 1 (20%) persisted and was found to have a transected nerve at exploration. In total, 23 of the 25 (92%) patients who had a PFO excision, had a normal or near-normal peroneal nerve function including those who had poor function preoperatively.

Conclusions: Patients with a PFO have a preoperative peroneal nerve dysfunction 30% of the time and 23% of those who were normal preoperatively have postoperative dysfunction. Fortunately, nearly all patients have a complete recovery following excision of the osteochondroma.

Level Of Evidence: Level IV.
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http://dx.doi.org/10.1097/BPO.0000000000001688DOI Listing
January 2021

Does thoracoplasty adversely affect lung function in complex pediatric spine deformity? A 2-year follow-up review.

Spine Deform 2021 01 18;9(1):105-111. Epub 2020 Aug 18.

Department of Orthopedics, Washington University School of Medicine, St. Louis, Missouri, USA.

Study Design: Retrospective review of prospective multi-center cohort.

Objective: To investigate the impact of thoracoplasty on pulmonary function at 2-year follow-up among complex pediatric spine deformity patients. Complex pediatric spine deformities may be associated with significant rib prominence causing body image concerns. Surgical correction of spine deformity may include thoracoplasty to correct the rotational prominence. Some surgeons refrain from performing thoracoplasty due to its purported negative effect on pulmonary function. There is paucity of literature on the effect of thoracoplasty on pulmonary function at 2-year follow-up in pediatric patients with complex spine deformity.

Methods: We reviewed data of 312 patients (> 100°, with or without vertebral column resection (VCR)) or (< 100° with VCR)) from an international multicenter database. Data of 106 patients with complete radiographic and pulmonary function test (PFT) assessment with a minimum of 2-year follow-up was analyzed. Paired t test was performed to compare pre-op and 2-year PFT results. PFT comparison was stratified based on thoracoplasty status (thoracoplasty: Group 1 vs. no thoracoplasty: Group 2).

Results: 106 patients (61 patients Group 1 vs. 45 in Group 2). The average age and gender ratio were similar in both groups (p  >  0.05). Group 1 had significantly lower body mass index (BMI) compared to Group 2 (18.4 kg m ± 2.8 vs. 19.9 kg m  ±  4.8, p  =  0.0351). The average baseline coronal and sagittal Cobbs were larger for Group 1 relative to Group 2 (p  < 0.05). The distribution of deformity etiology and curve types, and apices were similar between the two groups (p  >  0.05). The rate of pre-op utilization of halo gravity traction (HGT) was 52.5% vs. 26.7% (p  =  0.008), at an average duration of 103 days vs. 47 days, p  =  0.0001. The rate of surgical osteotomies was similar in both groups. Estimated blood volume (EBV) loss was greater in Group 1 (63.1% vs. 43.1%, p  =  0.0012). Post-op coronal and sagittal Cobb correction was similar in both groups. The incidence of post-op pulmonary complication was similar in both groups (8.2% vs. 8.9%, p  =  0.899). Baseline and 2-year follow-up PFT did not differ significantly between and within the groups. Vertebral column resection (VCR) did not negatively affect PFT in both groups.

Conclusion: Despite higher curve magnitudes in patients undergoing surgical correction and thoracoplasty for complex pediatric spine deformity, our findings revealed that thoracoplasty does not negatively affect pulmonary function at 2-year follow-up.
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http://dx.doi.org/10.1007/s43390-020-00188-0DOI Listing
January 2021

Rectus-sparing approach to the periacetabular osteotomy in adolescents preserves hip flexion strength.

J Child Orthop 2020 Jun;14(3):208-212

Texas Scottish Rite Hospital for Children, Dallas, Texas, USA.

Purpose: The classic periacetabular osteotomy (PAO) approach can result in hip flexor weakness in adolescents. The rectus-sparing approach (PAO-RS) preserves the origin of the rectus femoris tendon which may prevent hip flexor weakness and improve functional outcome.

Methods: This is a prospective analysis of adolescents treated with a PAO or PAO-RS. The PAO group included 24 hips/21 patients (18 female, meanage 16 years (sd 4)); the PAO-RS group included ten hips (eight female, mean age 16 years (sd 1)). Preoperatively, the PAO group had decreased hip flexion strength compared with the PAO-RS group (83 Nm/kg 102 Nm/kg). A subset of PAO patients (n = 13 hips/12 patients, nine female, mean age 15 years (sd 3)) were matched for preoperative flexion strength to the PAO-RS group. Radiographic parameters, modified Harris hip score (mHHS), isokinetic hip strength and instrumented motion analysis preoperatively, six months and one-year postoperatively were compared.

Results: There were no differences in preoperative deformity, postoperative correction or degree of correction between groups. Hip flexor strength decreased significantly at six months in the PAO group compared with the PAO-RS group (-35 Nm/kg -7 Nm/kg; p = 0.012), as did hip flexion pull-off power (1.33 W/kg PAO 1.76 W/kg PAO-RS; p = 0.010). Hip flexion strength improved from six months to one year in the PAO group, with no significant differences in strength at one year between groups (80 Nm/kg 90 Nm/kg). There were no differences between groups in mHHS any time point; both groups improved significantly postoperatively.

Conclusion: Preserving the rectus femoris may lead to improved short-term hip flexor strength and pull-off power. Further assessment at long-term follow-up is needed to determine if this strength leads to improved functional outcomes.

Level Of Evidence: II.
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http://dx.doi.org/10.1302/1863-2548.14.190168DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7302415PMC
June 2020

Strategies and Tools to Enhance Team Performance.

Authors:
Daniel J Sucato

J Pediatr Orthop 2020 Jul;40 Suppl 1:S25-S29

Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX.

Introduction: The ability for teams to work together in a coordinated manner may be where the greatest improvements in health care occur in the next generation. To perform at the highest level there are several key principles that all teams must have no matter what playing field they are on, including health care.

Methods: Several resources were used to identify the challenges we face in health care with respect to the delivery of quality care, improving outcomes and decreasing complications. A search of the lay press and scientific literature was evaluated to identify those key elements that lead to improvements in team performance. In addition, personal observations were accumulated with time and examples of strategies used at home institutions were identified.

Results: The teams in our pediatric orthopaedic practices are many and include those in the clinic, the operating room, research, and our administrative office. The Institute of Medicine, in their influential article in 1999, defined the alarming rates of complications/harm occurring in the US health care system. In response, the Agency for Healthcare Research and Quality (AHRQ) and the Department of Defense (DOD) collaborated to create the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) in 2006. This was implemented in military facilities and later civilian hospital settings with varied success in civilian hospital settings.

Discussion: They defined key principles based around team structure, communication, leadership, situation monitoring, and mutual support. Other important foundational attributes of a successful team include identifying the vision of the team, hiring top-talent in the form of hard and soft skills, having open communication, being goal-focused, practicing accountability, and having an organized team. We can look to excellent examples in medicine, business, and sports to see where and how high-functioning teams have existed and to learn from them to implement similar successful teams.

Conclusions: Team performance is a function of talented members who share a common vision, who have the opportunity to voice their thoughts/opinions, and have the ability to be accountable to each other. Surgeons need to lead by example, and provide each member of the team an opportunity to contribute in a meaningful way which ultimately will improve the lives of the patients we are honored to care for.
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http://dx.doi.org/10.1097/BPO.0000000000001526DOI Listing
July 2020

Two AIS spine surgeries on the same day by the same surgeon: is performance and outcome the same for the second patient?

Spine Deform 2020 10 23;8(5):977-981. Epub 2020 May 23.

Texas Scottish Rite Hospital for Children, University of Texas Southwestern Medical Center, 2222 Welborn St., Dallas, TX, 75219, USA.

Study Design: Retrospective case-controlled study.

Objectives: To analyze the overall performance and outcome of two-a-day surgery days for adolescent idiopathic scoliosis (AIS). As a method to improve efficiency and operating room utilization, some surgeons are now performing two surgeries for AIS in a single day.

Methods: A prospectively collected series of AIS patients who underwent posterior spinal fusion on the same day as a second AIS patient by the same surgeon and surgical team were retrospectively reviewed. Patients who underwent same-day surgery (SD) were grouped according to whether they were the first (SD1) or second (SD2) case of the day and were matched (M1 and M2) by surgeon, curve magnitude, Lenke classification, and fusion levels. Comparisons were made: SD1 vs. SD2, SD1 vs. M1, and SD2 vs. M2.

Results: There were 56 patients, with no differences between groups in age, gender, BMI, or curve magnitude (66° vs. 62° vs. 65° vs. 63°). Surgical time was shorter for the SD1 group (17.2 min/level) compared to M1 (20.5 min/level) for a 15% operative time reduction of 44 min (p = 0.008). There were no differences between the groups in curve correction (65.8% vs. 62.8% vs. 66.1% vs. 58.5%), estimated blood loss (EBL), length of stay, or complication rate. One SD2 patient had a malpositioned screw that required revision. There were no other complications.

Conclusions: When performing two AIS surgeries on the same day, surgical time was reduced by 44 min, or 15%, on the first case compared to a matched control. This may be a reflection of the team moving along more efficiently, given the full operative day scheduled. The performance measures of curve correction, EBL, complications, and length of stay did not decline in this new model, and no increased incidence of complications was seen.
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http://dx.doi.org/10.1007/s43390-020-00136-yDOI Listing
October 2020

Intraoperative Prone Radiographs During Scheuermann Kyphosis Correction Closely Estimate Standing Thoracic and Lumbar Parameters at 2 Years.

J Pediatr Orthop 2020 Nov/Dec;40(10):581-586

Texas Scottish Rite Hospital for Children, Dallas, TX.

Background: In patients with Scheuermann kyphosis (SK) undergoing posterior spinal fusion with instrumentation (PSFI), intraoperative lateral radiographs assess deformity correction in the prone position. The relationship between thoracic and (partially un-instrumented) lumbar parameters on prone intraoperative versus standing postoperative radiographs is unknown.

Methods: Forty-five consecutive patients with SK who underwent PSFI between 2007 and 2014 were reviewed. Thoracic kyphosis (TK), lumbar lordosis (LL), instrumented level kyphosis [upper instrumented vertebrae (UIV)-lower instrumented vertebrae (LIV)], and traditional sagittal parameters were recorded from preoperative standing, intraoperative prone, first outpatient standing, and >2-year standing radiographs and time periods were compared. Exclusion criteria included reduction modification after intraoperative radiographs and postoperative construct revision prohibiting comparison to initial intraoperative radiographs.

Results: Twenty-five patients averaging 16 (12 to 20) years old during surgery with 3.1 (2 to 7) years follow-up met inclusion criteria. Average surgical variables included: 13±1 fusion levels, UIV at T2, LIV at L3, 3.8±1.6 osteotomies per patient, and 43±9% correction of TK. Preoperative TK and LL measured 82 and 76 degrees, respectively. TK on intraoperative (47 degrees), 6-week (49 degrees), and >2-year (50 degrees) radiographs changed significantly only between intraoperative and >2-year radiographs (P=0.03) by just 3 degrees. LL increased 5 degrees from intraoperative prone to 6-week standing radiographs (51 to 56 degrees, P=0.01) without further significant change at >2 years (59 degrees, P=0.09). Instrumented levels (UIV-LIV) had increased kyphosis at 6 weeks (32 to 35 degrees, P=0.01) without further change at >2 years (36 degrees, P=0.06).

Conclusions: TK on intraoperative prone radiographs during PSFI for SK should match the standing TK ∼6 weeks later. Intraoperative prone LL only slightly increases on early standing radiographs. Assuming a routine postoperative course, intraoperative radiographs slightly underestimate TK (by 3 degrees) and LL (by 8 degrees) on >2-year standing radiographs. These parameters (TK, LL, UIV-LIV) are visualized during surgery and should be used in future studies to predict long-term outcomes.

Level Of Evidence: Level IV-retrospective study.
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http://dx.doi.org/10.1097/BPO.0000000000001581DOI Listing
March 2021

The incidence and risk factors for perioperative allogeneic blood transfusion in primary idiopathic scoliosis surgery.

Spine Deform 2020 08 9;8(4):695-702. Epub 2020 Mar 9.

University of Texas Southwestern Medical Center, Dallas, USA.

Study Design: Case-control study.

Objectives: Evaluate the rate and risk factors for perioperative allogeneic blood transfusion (ABT) in primary idiopathic scoliosis surgery at a single institution. Avoiding perioperative ABT is ideal as transfusions are associated with adverse reactions, increased rates of infection, prolonged hospitalization, additional laboratory testing, and increased cost. Risk factors identified in other studies have differed, and to our knowledge, few studies have identified clinical strategies to predict patients at high risk for ABT.

Methods: We reviewed 402 idiopathic scoliosis patients who underwent primary posterior spinal fusion and instrumentation (PSFI) at a single institution from 2015 to 2017. Medical records and radiographs were reviewed for all patients. Transfused patients were compared to the remaining cohort to find significant differences and identify predictors of higher ABT risk.

Results: ABT occurred in 73 patients (18.2%), with the majority of transfusions occurring intraoperatively (41%) or postoperatively on the day of surgery (25%). The seven surgeons involved varied significantly in incidence of ABT (2.4-35.8%, p = 0.002). Patients who had ABT were younger (13.3 vs. 14.1 years, p < 0.01), had lower BMI (48th vs. 61st percentile, p < 0.001), and lower preoperative hemoglobin (13.1 vs. 13.7 g/dL, p < 0.01). Greater preoperative major Cobb angle (69° vs. 61.5°, p < 0.001), number of fusion levels (11.8 vs. 10.3, p < 0.001), and estimated blood loss (770 vs. 448 mL, p < 0.001) also predicted ABT.

Conclusions: ABT was associated with several risk factors, five of which are known preoperatively. Surgeons can use knowledge of these risk factors to assess transfusion risk preoperatively and plan surgery, blood management, and laboratory testing accordingly. The development of best practices for ordering ABT is possible given the variation amongst providers.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1007/s43390-020-00093-6DOI Listing
August 2020

Skeletally Immature Patients With Adolescent Idiopathic Scoliosis Curves 15°-24° Are at High Risk for Progression.

Spine Deform 2019 11;7(6):870-874

Texas Scottish Rite Hospital for Children, 2222 Welborn Street, Dallas, TX 75219, USA.

Study Design: Retrospective review.

Objectives: To evaluate the incidence of adolescent idiopathic scoliosis (AIS) curve progression and brace prescription in skeletally immature patients (Risser 0 to Risser 1) with curves 15°-24°.

Summary Of Background Data: Many skeletally immature patients with mild AIS ask about the likelihood of curve progression. No studies have answered these questions.

Methods: The charts and radiographs of 302 consecutive patients with curves 15°-24° at initial visit, Risser 0 to Risser 1, were reviewed until skeletal maturity (≥Risser 4) or surgery. Curves averaged 19.1° ± 2.9° at initial visit. The Risser grade was 0 in 247 patients (82%) and 1 in 55 patients (18%). Patients who were Risser 0 were compared with those who were Risser 1, curves 15°-19° were compared with curves 20°-24°.

Results: The majority of patients demonstrated curve progression ≥5° (65%). Patients who were Risser 0 did not progress significantly more than patients who were Risser 1 (10° vs. 8°) (p = .22). Patients with curves 20°-24° did not progress significantly more than patients with curves 15°-19° (10° vs. 9°) (p = .65).

Conclusions: Curve progression for small curves (15°-19°) is similar to curves between 20° and 24°. Close observation or perhaps early intervention for these patients is necessary. These data may suggest a paradigm shift to earlier brace initiation and call for early treatment in small curves.

Level Of Evidence: Level II.
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http://dx.doi.org/10.1016/j.jspd.2019.02.012DOI Listing
November 2019

Scoliosis Progression After the Nuss Procedure for Pectus Excavatum: A Case Report.

Spine Deform 2019 11;7(6):1003-1009

Texas Scottish Rite Hospital for Children, 2222 Welborn St., Dallas, TX, 75219, USA.

Introduction: Pectus excavatum and scoliosis are associated conditions with a high rate of coincidence. However, there are no reports to guide surgeons on the management of adolescents with moderate scoliosis and pectus excavatum, because there are conflicting conclusions in the literature regarding how the Nuss procedure with substernal bar affects scoliosis.

Cases: In 2017, we encountered two patients with moderate scoliosis treated with a spinal orthosis. After undergoing the Nuss procedure for pectus excavatum, their scoliosis acutely progressed into surgical magnitude requiring posterior instrumented spinal fusion. The first patient progressed 26° despite the pre-Nuss radiographs showing him to be Risser 4/5, while the second patient also progressed 26° from the Nuss procedure. Both patients acknowledged noncompliance with brace wear because of discomfort after the Nuss procedure. However, their progression rate still doubles the rate of reported rapid accelerators, indicating that a significant component of curve progression is directly attributed to forces on the spine from the corrective maneuver with substernal bar.

Conclusion: The purpose of this case report is to describe the features of these two patients to help with clinical decision-making in patients with moderate scoliosis (curves >25°) who are contemplating the Nuss procedure for correction of pectus excavatum. We caution patients and providers that spinal deformity could worsen with surgical intervention of the pectus excavatum via the Nuss procedure and necessitate scoliosis surgery.
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http://dx.doi.org/10.1016/j.jspd.2019.01.009DOI Listing
November 2019

Physical Therapy Scoliosis-Specific Exercises May Reduce Curve Progression in Mild Adolescent Idiopathic Scoliosis Curves.

Pediatr Phys Ther 2019 07;31(3):280-285

Texas Scottish Rite Hospital for Children, Dallas, Texas.

Purpose: To evaluate the curve magnitude in participants with mild adolescent idiopathic scoliosis (AIS) at high risk of progression who received outpatient physical therapy scoliosis-specific exercises (PSSEs).

Methods: Participants with AIS curves 12° to 20° and Risser grade 0 chose either the PSSE or the control group. The PSSE group was instructed in the Barcelona Scoliosis Physical Therapy School. The control group was observed. Cobb angles were measured by one observer masked to group type at baseline, 6-month follow-up, and 1-year follow-up.

Results: Forty-nine participants were enrolled (26 exercise vs 23 controls). Thirty-three participants (19 exercise vs 14 controls) were seen at 1-year follow-up. At 1-year follow-up, the exercise group had smaller curves than controls (16.3° vs 21.6°, P = .04) and less curve progression (0° vs 5.6°, P = .02). Bracing was performed similarly between groups at 1-year follow-up (37% vs 43%).

Conclusions: In this small prospective series, PSSE resulted in significantly less curve progression compared with controls.
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http://dx.doi.org/10.1097/PEP.0000000000000621DOI Listing
July 2019

A Novel Posterior Rod-Link-Reducer System Provides Safer, Easier, and Better Correction of Severe Scoliosis.

Spine Deform 2019 05;7(3):445-453

Texas Scottish Rite Hospital for Children, 2222 Welborn St, Dallas, TX 75219, USA; Department of Orthopedic Surgery, University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Blvd., Dallas, TX 75390, USA.

Study Design: Retrospective review.

Objectives: To compare the Cobb >75° scoliosis correction obtained using a novel Rod-Link-Reducer (RLR) system versus traditional corrective techniques (TCT) in patients with severe adolescent idiopathic scoliosis (AIS).

Summary Of Background Data: Current implant strategies provide for good correction, especially for moderate curves; however, severe scoliosis continues to be challenging to obtain correction in a safe and effective manner.

Methods: A novel correction device was developed so that two provisional rods are placed on the convex side of the scoliosis proximally and distally, which are then linked to an external reduction device termed the RLR. A retrospective analysis was performed to compare the RLR versus the TCT in patients with curve >75° with the diagnosis of AIS with respect to the radiographic outcomes, operative time, intraoperative blood loss, complications, and SRS-30 scores of a minimum 2-year follow-up.

Results: A total of 36 patients were evaluated (RLR-18, TCT-18). The data sets were similar for age, gender, coronal Cobb, curve flexibility, and follow-up period. The mean preoperative Cobb for the RLR group was 91.7° (76°-113°) and 91.8° (78°-108°) for the TCT group. The mean coronal Cobb correction rate was significantly greater for the RLR group (73.1% vs. 56.6%, p < .0001). The mean operative time was 74.8 minutes shorter in the RLR group (316.6 minutes vs. 391.4 minutes, p = .03). There were 2 late-developing infections and 3 intraoperative neuro-monitoring changes during the correction maneuvers in the TCT group compared with none in the RLR group (p = .02).

Conclusion: In a matched cohort, the use of the RLR exhibited greater coronal Cobb correction, shorter operative time, and was less likely to have critical neuro-monitoring changes compared with the TCT group. The RLR provides safer and improved correction for severe curves without adding surgical risk.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1016/j.jspd.2018.09.001DOI Listing
May 2019

Restoration of normal pelvic balance from surgical reduction in high-grade spondylolisthesis.

Eur Spine J 2019 09 15;28(9):2087-2094. Epub 2019 Apr 15.

University of Montreal, Montreal, Canada.

Purpose: To investigate the effectiveness of surgical reduction in high-grade spondylolisthesis in maintaining or restoring a normal pelvic balance, as related to the QoL.

Methods: It is a retrospective analysis of prospectively collected data of 60 patients (17 males, 43 females) aged 15 ± 3.1 years who underwent surgery for high-grade spondylolisthesis and were followed for a minimum of 2 years after surgery. Patients with a residual high-grade slip following surgery were referred to the postoperative high-grade (PHG) group, while patients with a residual low-grade slip were referred to the postoperative low-grade (PLG) group. Pelvic balance was assessed from pelvic tilt and sacral slope, in order to identify patients with a balanced pelvis or unbalanced pelvis. The SRS-22 questionnaire was completed before surgery and at last follow-up.

Results: Postoperatively, there were 36 patients with a balanced pelvis and 24 patients with an unbalanced pelvis. The improvement in QoL was better in patients with a postoperative balanced pelvis. There were 14 patients in the PHG group and 46 patients in the PLG group. Four of seven patients (57%) in the PHG group and 21 of 26 patients (81%) in the PLG group with a preoperative balanced pelvis maintained a balanced pelvis postoperatively (P = 0.1). None of the patients in the PHG group and 11 of 20 patients (55%) in the PLG group improved from an unbalanced to a balanced pelvis postoperatively (P < 0.05).

Conclusions: Surgical reduction in high- to low-grade slip is more effective in maintaining and restoring a normal pelvic balance postoperatively. These slides can be retrieved under Electronic Supplementary Material.
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http://dx.doi.org/10.1007/s00586-019-05973-8DOI Listing
September 2019

What Are the Indications for Spinal Fusion Surgery in Scheuermann Kyphosis?

J Pediatr Orthop 2019 May/Jun;39(5):217-221

Mayo Clinic, Rochester, MN.

Background: Surgical indications for Scheuermann kyphosis are variable. We sought to evaluate the characteristics of patients undergoing operative versus nonoperative treatment of Scheuermann kyphosis to better understand current practices and the factors which contribute to the decision for surgical management.

Methods: Multicenter prospective cohort study. We evaluated consecutive patients presenting with Scheuermann kyphosis. Patients underwent either surgical or nonoperative management according to surgeon and patient discretion. Preoperative patient-reported outcome measures (Scoliosis Research Society and Spinal Appearance Questionnaire scores), demographics, and radiographic characteristics were assessed.

Results: Overall, 150 patients with Scheuermann kyphosis were enrolled, with 77 choosing nonoperative treatment and 73 treated operatively. Compared with the nonoperative cohort, patients treated operatively were older (16.3±2.0 vs. 15.1±2.2, P=0.0004), and had higher body mass index (26.3±7.2 vs. 22.7±6.5, P=0.003), had greater T2-T12 kyphosis (71±14 degrees vs. 61±12 degrees, P<0.001), increased pelvic incidence (46 vs. 41 degrees, P=0.03) and pelvic tilt (10 vs. 3 degrees, P=0.03). There was no detected difference in maximal sagittal Cobb angle in the operative versus nonoperative patients (73±11 vs. 70±12 degrees, P=0.11). Functionally, the operative patients had worse Scoliosis Research Society pain scores (3.7±0.9 vs. 4.1±0.7, P=0.0027) and appearance scores (2.9±0.7 vs. 3.4±0.8, P <0.0001).

Conclusions: Patients undergoing surgical management of Scheuermann disease were more likely to have large body mass index and worse pain scores. Other factors beyond radiographic measurement likely contribute to the decision for surgical management of Scheuermann kyphosis.

Level Of Evidence: Level II.
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http://dx.doi.org/10.1097/BPO.0000000000000931DOI Listing
June 2019

Partial Tibial Nonunion due to Entrapment of Anterior Tibial Artery: A Case Report.

J Orthop Case Rep 2019 ;9(5):51-54

Department of Orthopaedic Surgery, Texas Scottish Rite Hospital for Children, 2222 Welborn Street Dallas, TX 75219, USA.

Introduction: Arterial injury/entrapment is an uncommon sequelae of long bone fractures, particularly in closed injuries. The proximity of the anterior tibial artery to the distal tibia poses a risk of entrapment with a fracture at this level. To the best of our knowledge, this is the first case report of a partial nonunion due to entrapment of the anterior tibial artery in a healed tibia fracture in a pediatric patient.

Case Report: We describe a case of a 16-year-old male who presented with leg pain 2 years after a left distal third oblique tibia fracture. The fracture was initially treated non-operatively with excellent alignment. He did well for many months and returned to playing football with some vague persistent discomfort in his leg. Two years after the original injury, he was hit while playing football and started experiencing increasing left leg pain. The subsequent evaluation and findings are outlined here.

Conclusion: This is an original case report of an adolescent patient with a partial tibial nonunion requiring surgical intervention. Possible entrapment of neurovascular structures should be considered when managing these patients following injury.
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http://dx.doi.org/10.13107/jocr.2250-0685.1530DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7276617PMC
January 2019

Predictive Value and Interrater Reliability of Radiographic Factors in Neurofibromatosis Patients With Dystrophic Scoliosis.

Spine Deform 2018 Sep - Oct;6(5):560-567

Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN 55455, USA. Electronic address:

Background: Scoliosis in patients with neurofibromatosis type I (NF1) can manifest as dystrophic or nondystrophic curves. Dystrophic scoliosis is rapidly progressive, rendering treatment challenging. Radiographic characteristics have been reported to predict dystrophic scoliosis, but their reliability and predictive value have not been well described. The purpose of this study is to assess the interobserver reliability for eight radiographic characteristics of dystrophic scoliosis and to evaluate the sensitivity and specificity of these characteristics relative to the gold standard of a definitive clinical diagnosis.

Methods: Spine radiographs of 122 NF1 patients from multiple institutions were graded by five spine surgeons as dystrophic or nondystrophic, based on eight radiographic characteristics of dystrophic modulation: rib penciling, vertebral rotation, scalloping, wedging, spindling of transverse processes, short sharp angular curve, widened interpedicular distance, and atypical location. The curves were classified by each submitting institution as dystrophic or nondystrophic based on clinical outcome. Interobserver reliability analysis was performed using Fleiss kappa.

Results: For the 122 cases, the interrater agreement among the five readers for the diagnosis of dystrophic scoliosis was good at 0.61. The agreement for individual radiographic characteristic ranged from 0.62 for wedging to 0.14 (poor) for scalloping. Surgeons underestimated the number of dystrophic curves, rating from 45% to 67% of the curve patterns as dystrophic, compared to the gold standard, which revealed 68% of the curves to be dystrophic. On multivariate analysis, rib penciling, vertebral rotation, vertebral wedging, and atypical location were significantly associated with true dystrophic status (odds ratios of 2.4, 3.0, 2.4, and 3.0, respectively).

Conclusion: Overall dystrophic diagnosis can be assessed by radiographic characteristics. Better understanding of the predictive value of specific radiographic features may assist in early diagnosis of patients with dystrophic NF and assist surgeons in identifying dystrophic curve patterns and instituting prompt, appropriate treatment.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1016/j.jspd.2018.02.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6110107PMC
January 2019

Approach to the Hip for SCFE: The North American Perspective.

Authors:
Daniel J Sucato

J Pediatr Orthop 2018 Jul;38 Suppl 1:S5-S12

Texas Scottish Rite Hospital for Children, Department of Orthopaedics, University of Texas at Southwestern Medical Center, Dallas, TX.

The treatment of slipped capital femoral epiphysis (SCFE) in North America has seen a change over the past 15 to 20 years due to a better understanding of the blood flow supplying the femoral head, the ability to monitor the pressure/flow in real time and greater access to the deformity with the development of surgical approaches providing that access. These advances have mainly affected the treatment of the unstable SCFE to mitigate the risk of avascular necrosis but have also been utilized for the stable SCFE when severe deformity remains. This paper will provide a summary of some of the current techniques utilized in North America in the treatment of SCFE and will focus on the studies reported on this condition from this continent. In addition, I wanted this report to reflect the opinions and practices of North American surgeons and so I polled an audience that was representative of the current North American pediatric orthopaedist.
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July 2018

The Lumbar Gap Measurement in Lenke 1-4C Curves.

Spine Deform 2018 May - Jun;6(3):241-249

Texas Scottish Rite Hospital for Children, Department of Orthopaedic Surgery, UT-Southwestern Medical Center at Dallas.

Study Design: Retrospective review.

Objectives: To assess whether the lumbar gap (LG) measurement, which is the distance between the center sacral vertical line and the concave edge of the apical vertebra of the lumbar curve, would be a useful tool to predict the need for lumbar curve fusion in the Lenke 1-4C curves.

Summary Of Background Data: The current treatment guidelines of selective thoracic fusion in the Lenke 1-4C curves are not routinely accepted.

Methods: One hundred three adolescent idiopathic scoliosis (AIS) patients had undergone either selective thoracic fusion (STF) or both thoracic and lumbar curves fusion (TLF) for Lenke 1-4C curves. The correlations between the fusion decision making and preoperative LG, coronal balance, thoracic and lumbar Cobb, apical vertebra translation, and rotation were analyzed. The radiographic outcomes and SRS-30 of a minimum 2-year follow-up were reviewed in each group.

Results: A total of 51 patients (49.5%) underwent an STF, and 52 patients (50.5%) underwent a TLF. The mean LG was 22.0 ± 8.8 mm in the TLF, which was 2.3 times greater than the STF (9.6 ± 3.9 mm) (p < .0001). Only 5% of the lumbar curves were fused when the LG was 10 mm or less. Ninety percent of the lumbar curves were fused when the LG was 16 mm or greater, and 100% lumbar curves were fused with an LG of 21 mm or greater. The preoperative coronal imbalance to the left in the TLF was significantly greater than the STF. A mean 47% thoracic correction corresponded to a mean 39% spontaneous correction of the lumbar curve obtained in the SFT, which was significantly different from the TLF (56% and 65%). There were no differences in the SRS-30 scores at 2 years postoperatively between the STF and the TLF.

Conclusion: The lumbar curve should not be fused when the LG was 10 mm or less, and very likely should be fused when the LG exceeds 20 mm in the Lenke 1-4C AIS patients.

Level Of Evidence: Level III.
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January 2019

Development of the HOOS to Assess Patient-Reported Outcomes in Patients Undergoing Hip Preservation Procedures.

Am J Sports Med 2018 03 18;46(4):940-946. Epub 2018 Jan 18.

Investigation performed at the University of Kentucky, Lexington, Kentucky, USA.

Background: The creation of a single patient-reported outcome (PRO) platform validated across hip preservation, osteoarthritis (OA), and total hip arthroplasty (THA) populations may reduce barriers and streamline the routine collection of PROs in clinical practice. As such, the purpose of this study was to determine if augmenting the Hip disability and Osteoarthritis Outcome Score-Joint Replacement (HOOS, JR) with additional HOOS questions would result in a PRO platform that could be used across a wider spectrum of hip patient populations.

Hypothesis: The HOOS, JR would demonstrate a notable ceiling effect, but by augmenting the HOOS, JR with additional HOOS questions, a responsive PRO platform could be created.

Study Design: Cohort study (diagnosis); Level of evidence, 2.

Methods: Using preoperative and postoperative HOOS responses from a sample of 304 patients undergoing periacetabular osteotomy (PAO), additional items were identified to augment the HOOS, JR. The psychometric properties of a newly created PRO tool (HOOS) were then compared with the HOOS, JR and other PRO instruments developed for patients with hip OA and/or undergoing THA.

Results: By augmenting the HOOS, JR with 2 additional questions, the HOOS was more responsive than all other included PRO tools and had significantly fewer maximum postoperative scores than the HOOS, JR ( P < .0001), HOOS-Physical Function Short form ( P < .0001), Western Ontario and McMaster Universities Osteoarthritis Index ( P = .02), University of California, Los Angeles activity scale ( P = .0002), and modified Harris Hip Score ( P = .04). The postoperative HOOS score threshold associated with patients achieving the patient acceptable symptom state (PASS) was 62.5.

Conclusion: The HOOS is a valid and responsive PRO tool after PAO and may potentially provide the orthopaedic community with a PRO platform to be used across hip-related subspecialties. For patients undergoing PAO, a postoperative HOOS score ≥62.5 was associated with patients achieving the PASS.
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http://dx.doi.org/10.1177/0363546517749585DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6942686PMC
March 2018

Atraumatic Spine Distraction Induces Metabolic Distress in Spinal Motor Neurons.

J Neurotrauma 2017 06 22;34(12):2034-2044. Epub 2017 Mar 22.

1 Bioengineering Department, University of Texas at Dallas , Richardson, Texas.

Corrective forces during spine deformity surgery, including distraction, impart significant stresses to the spinal cord that may result in permanent injury. Intraoperative neuromonitoring is commonly used by surgeons to recognize possible damage to the spinal cord in cases of evident traumatic or vascular damage to the spinal cord. However, mild insult to the spinal cord that does not result in obvious trauma or electrophysiological changes present a major clinical challenge as the mechanisms of this type of spinal cord injury (SCI) remain largely unknown, and thus preventive strategies are lacking. We used a sustained bidirectional spinal distraction animal model to determine the role of stretch-induced hypoxia in mild SCI. Direct measurement of intraparenchymal oxygen revealed an immediate decrease in partial pressure (47.08 ± 5.79% pO) distal to the injury site following a 5-mm distraction. This hypoxic insult induced mitochondrial dysfunction as evidenced by an acute increase (216%) in protein oxidation 30 min post-injury, as well as a 37% decrease in perikaryal size and a 42% decrease in nuclear area (pyknosis) in ventral motor neurons at the injury site. These results indicate that hypoxic events during mild spine distraction may lead to cellular metabolic impairments and permanent functional deficits. The development of strategies targeting the prevention of hypoxic injury during spine distraction may be useful in protecting the cellular metabolic damage that may occur during spine surgery in the absence of overt mechanical or vascular SCI.
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http://dx.doi.org/10.1089/neu.2016.4779DOI Listing
June 2017

Descriptive Epidemiology of Acetabular Dysplasia: The Academic Network of Conservational Hip Outcomes Research (ANCHOR) Periacetabular Osteotomy.

J Am Acad Orthop Surg 2017 Feb;25(2):150-159

From the Department of Orthopaedic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA (Dr. Sankar); the Department of Orthopaedic Surgery, University of Kentucky, Lexington, KY (Dr. Duncan), the Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO (Ms. Baca, Dr. Schoenecker and Dr. Clohisy), the Department of Orthopaedic Surgery, University of Ottawa, Ottawa, Ontario, Canada (Dr. Beaulé), the Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA (Dr. Millis and Dr. Kim), the Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT (Dr. Peters), the Department of Orthopaedic Surgery, Texas Scottish Rite Hospital, Dallas, TX (Dr. Podeszwa and Dr. Sucato), the Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN (Dr. Sierra and Dr. Trousdale), the Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY (Dr. Sink), and the Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak, MI (Dr. Zaltz).

Background: Periacetabular osteotomy (PAO) is an established treatment for symptomatic acetabular dysplasia, which is a well-recognized cause of hip pain, functional limitations, and secondary osteoarthritis. The purpose of this study was to describe the demographics of patients undergoing PAO, the baseline patient-reported outcome measures for this population, and the types of adjunctive procedures performed at the time of PAO surgery.

Methods: Demographics, disease characteristics, and patient-reported functional measures were prospectively collected from all patients who underwent PAO performed by 12 surgeons from 2008 to 2013.

Results: We enrolled 950 consecutive patients (982 hips) in the study; 83% were female and 17% were male, with an average age of 25.3 years and an average body mass index (BMI) of 24.6 kg/m. Most patients were Caucasian (87%), and 15% had undergone previous hip surgery. Before PAO was performed, most patients had had symptoms for 1 to 3 years. Baseline modified Harris Hip and University of California Los Angeles activity scores (61.8 and 6.6, respectively) indicated that patients had considerable functional limitations.

Discussion: Patients undergoing PAO for symptomatic dysplasia were predominantly young, female, and Caucasian with a normal BMI. Many patients had undergone prior hip surgery, and most had had symptoms for several years before treatment. Baseline patient-reported functional scores demonstrated marked functional limitations. Adjunctive procedures for intra-articular pathology, especially femoral osteochondroplasty and hip arthroscopy, are commonly performed at the time of PAO.
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http://dx.doi.org/10.5435/JAAOS-D-16-00075DOI Listing
February 2017
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