Radiographic Outcome and Complication Rate of 34 Graduates After Treatment With Vertical Expandable Prosthetic Titanium Rib (VEPTR): A Single Center Report Background: The final strategy for graduates from growth-sparing surgery is challenging. The purpose of this study was to evaluate the radiographic outcome and complications of patients with early onset scoliosis (EOS) who have graduated from vertical expandable prosthetic titanium rib (VEPTR) treatment, either undergoing final fusion surgery or following a nonfusion approach. Methods: Final treatment for VEPTR graduates was divided in “VEPTR in situ without final fusion,” “removal of VEPTR without final fusion,” and “removal of VEPTR with instrumented final fusion.” Radiographic evaluations included main coronal Cobb angle and main kyphosis pre and post VEPTR implantation, at the end of implant lengthening, after final fusion (if applicable), and at latest follow-up. Complications during VEPTR treatment and in case of final fusion were reported. Results: In total, 34 VEPTR graduates were included; 17 underwent final fusion surgery, and 17 followed a nonfusion strategy. Average coronal Cobb angle before VEPTR implantation was 70±23 degrees (range, 21 to 121 degrees), and 65±22 degrees (range, 17 to 119 degrees) at latest follow-up. Average main kyphosis angle was 53±27 degrees (range, 6 to 137 degrees) before VEPTR, and 69±34 degrees (range, 10 to 150 degrees) at latest follow-up. There was a 41% complication rate with final fusion surgery. Conclusions: There is a high complication rate during VEPTR treatment and with final fusion surgery. The stiffness of the spine and thorax allow for only limited correction when performing a final instrumented spondylodesis. Avoiding final fusion may be a viable alternative in case of good coronal and sagittal alignment. Level of Evidence: Level IV—therapeutic.

The Association Between the Classification of Early-onset Scoliosis and Smith Complications After Initiation of Growth-friendly Spine Surgery: A Preliminary Study Background: Early-onset scoliosis (EOS) is a complex, heterogeneous condition involving multiple etiologies, genetic associations, and treatment plans. In 2014, Williams and colleagues proposed a classification system of EOS (C-EOS) that categorizes patients by etiology, Cobb angle, and kyphosis. Shortly after, Smith and colleagues validated a classification system to report complications of growth-friendly spine instrumentation. Severity refers to the level of care and urgency required to treat the complication, and can be classified as device-related or disease-related complications. The purpose of this study was to investigate if C-EOS can be used as a reliable predictor of Smith complications to better risk stratify these young, surgical patients. Methods: This study queried retrospective data from a large multicenter registry with regard to growth-friendly spine instrumentation in the EOS population. One-hundred sixteen patients were included in final data analysis to investigate the outcomes of their growth-friendly procedures according to the Smith complication classification system. Results: There were 245 Smith complications distributed among 116 patients included in this study (2.1 complications per patient). The majority of the complications were device related requiring at least one unplanned trip to the operating room (Smith Device Complication IIA or IIB; 111 complications). There were no complications that caused abandonment of growth-friendly instrumentation (Smith Complication III) and no mortalities (Smith Complication IV). The most severely affected EOS group was the hyperkyphotic syndromic group with a major curve angle >50 degrees (S3+), with 3.4 complications per patient. The least affect EOS group was the hyperkyphotic congenital group with a major curve angle between 20 and 50 degrees, with 0.3 complications per patient. Conclusions: The C-EOS simplifies a complex pathology and the Smith complication classification scheme creates a language to discuss treatment of known complications of growth-friendly spine surgery. Although there is an association between more advanced C-EOS and Smith complications, there does not appear to be a correlation that can satisfy a risk stratification at this time. Level of Evidence: Level II.

Comparison of Ponte Osteotomies and 3-Column Osteotomies in the Treatment of Congenital Spinal Deformity Background: Congenital spinal deformity (CSD) has traditionally been treated with 3-column osteotomies [hemivertebrectomy (HV) or vertebral column resection (VCR)] to address rigid deformities. Alternatively, multiple Ponte osteotomies (PO) may provide correction while minimizing risk. The purpose of this study was to compare safety and outcomes of patients undergoing surgical treatment for CSD with these 3 procedures. Methods: Retrospective review of CSD patients treated with posterior spinal fusion between 1996 to 2013. Patients treated with multiple Ponte osteotomies (PO group) were compared with those managed with 3-column osteotomies (HV/VCR group). Patients with previous instrumentation, isolated cervical deformity, growing spine instrumentation, or <2 year follow-up were excluded. Deformity angular ratio (DAR) was calculated as curve magnitude divided by number of levels of the deformity. Results: There were 49 patients [17 PO, 32 HV/VCR (26 HV, 6 VCR)]. For the PO group, mean age was 14 years, and they had an average of 4 ponte osteotomies and 11 levels fused. Mean total DAR was 25 and mean number of congenital anomalies was 1.8 in the PO group. The HV/VCR group had a mean age of 7 years and 5 levels fused. Mean total DAR was 28 and mean number of congenital anomalies was 2.1 in the HV/VCR group. Patients had a mean of 54.1% correction of coronal deformity in the PO group and 54.4% in the HV/VCR group (P=0.78). Signal changes were observed less frequently with PO (1/17) and HV (1/26) than with VCR (4/6), P=0.001. Revision rates were 17.6% (3/17) in the PO group and 37.5% (12/32) in the HV/VCR group (P=0.35). Conclusions: Patients with CSD and a mean total DAR of 25 treated with multiple PO and long fusions had correction comparable with the HV/VCR group. Patients treated with VCR had the highest incidence of signal changes and postoperative neurologic deficits. Level of Evidence: Level III.

Risk Factors for Prolonged Postoperative Opioid Use After Spinal Fusion for Adolescent Idiopathic Scoliosis Background: Opioids are commonly used after posterior spinal instrumented fusion (PSIF) for adolescent idiopathic scoliosis (AIS). Prescription opioids use can potentially lead to misuse, abuse, dependence, and overdose death. Prolonged opioid use has not been extensively studied in the postoperative AIS population. The purpose of this study is to identify risk factors associated with prolonged opioid use after PSIF for AIS. Methods: A large insurance database was queried for AIS patients undergoing PSIF. Patients with prolonged postoperative opioid use were defined as those receiving new prescriptions for an opioid medication >6 weeks following the date of surgery, up to 8 months postoperatively. Preoperative and intraoperative risk factors for prolonged opioid use were then examined, including the number of spinal levels fused, preoperative opioid prescriptions, demographic variables, pertinent comorbidities (anxiety, depression, attention deficit hyperactivity disorder, and autism) and other preoperative prescriptions (anxiolytics, antidepressants, nonopioid analgesics, neuropathic medications, and attention deficit hyperactivity disorder medications). Each variable’s independent risk for prolonged postoperative opioid use was examined utilizing a multivariable binomial regression analysis. P<0.05 was considered statistically significant. Results: A total of 511 patients were included in the study. Of this 50 patients (9.78%) were found to have prolonged opioid use following scoliosis surgery. Preoperative opioid use (odds ratio, 2.93; P<0.001) was the most significant predictor of prolonged postoperative opioid use. In addition, female sex, obesity, a preoperative diagnosis of anxiety and a preoperative prescription for a muscle relaxer were also significant positive risk factors for prolonged postoperative opioid use. Several factors were found to be protective against prolonged postoperative opioid use. Fewer total fusion levels, compared with ≥13 levels, had a significantly lower risk of prolonged opioid use. Preoperative anxiolytic and antidepressant use were also both negative predictors of prolonged opioid use. Conclusions: Efforts at addressing preoperative opioid use, anxiety, obesity, and providing multimodal pain management strategies should be considered to reduce additional postoperative opioid prescriptions after PSIF for AIS. Level of Evidence: Level III—retrospective comparative study.

A Comparison of Pavlik Harness Treatment Regimens for Dislocated But Reducible (Ortolani+) Hips in Infantile Developmental Dysplasia of the Hip Background: Variation exists in the Pavlik harness (PH) treatment regimen for infantile developmental dysplasia of the hip (DDH). The purpose of this study was to determine if the daily PH wear duration (23 vs. 24 h) and frequency of follow-up visits affect the clinical and radiographic outcomes of infants with dislocated but reducible (Ortolani+) hips. Methods: This study reviewed prospectively enrolled patients with DDH in a single center who presented at age <6 months with Ortolani+ hips and were treated with PH. Recommended daily PH wear duration (23 vs. 24 h) and the frequency of clinic visits in first 4 weeks after the initiation of PH treatment were analyzed. The clinical success (stable hip that did not require closed or open reduction or the use of an abduction orthosis) and radiographic success based on the acetabular index at 2-year follow-up were compared between different PH regimen groups. Results: Sixty-two patients (74 hips, 53 females) with Ortolani+ hips had a mean age of presentation of 23±28 days (range, 4 to 128 d) and mean follow-up of 33.2±18.4 months (range, 8 to 85 mo). Overall clinical success rate of PH for Ortolani+ hips was 93% (69/74 hips) and radiographic success rate at 2 years was 84% (48/57 hips). There was no difference in clinical or radiographic success rate between the 23- and 24-hour wear groups (P>0.99, 0.73) or between hips assessed almost weekly compared with once or twice during the first 4 weeks of PH treatment (P>0.99 for both). Conclusions: The 23- versus 24-hour PH regimen and frequency of clinic visits in the first 4 weeks of PH treatment did not affect the clinical or radiographic success rate of Ortolani+ hips in infantile DDH. A strict weekly clinic visit and 24-hour PH regimen may not be necessary to obtain stable reduced hips in infants presenting <6 months of age with Ortolani+ hips. Level of Evidence: Level III—therapeutic.

Radiographic and Clinical Outcomes of Adolescents With Acetabular Retroversion Treated Arthroscopically Background: Retroversion of the acetabulum is a cause of pincer impingement. Symptomatic retroversion has traditionally been treated with anteverting periacetabular osteotomy (PAO). However, arthroscopic rim trimming can also treat pincer impingement associated with acetabular retroversion. The purpose of this study was to report the outcomes and radiographic findings in a series of adolescent patients with symptomatic acetabular retroversion treated arthroscopically. Methods: Data were prospectively gathered at a single institution using an established hip preservation registry. Patients below 18 years with a retroverted acetabulum that underwent primary hip arthroscopy with 2-year follow-up were included. Acetabular retroversion was defined by 3 radiographic criteria: the presence of crossover, ischial spine sign, and posterior wall sign. Radiographic measurements of the lateral center-edge angle, anterior center-edge angle, alpha angle, and crossover percentage were reported preoperatively and postoperatively. Patient-reported outcome (PROs) measures included the modified Harris Hip Score, the non-Arthritic Hip Score, Hip Outcome Score Sports Subscale, visual analog scale, and patient satisfaction, recorded at 3 months, 1 year, and 2 years, postoperatively. In addition, International Hip Outcome Tool scores were gathered at 2 years. Results: Between April 2008 and July 2014, there were 43 patients (48 hips) treated with hip arthroscopy who met the inclusion criteria. The average age was 16.1 years (range, 13.9 to 17.9 y) and there were 38 females and 10 males. The average follow-up was 50.4 months, with a minimum of 2 years. Statistically significant improvements in all PROs were found at 2 years postoperatively. There were 9 hips with lateral center-edge angle ≤25 degrees; the PROs of this group was not different than patients with normal coverage. Three patients underwent arthroscopic revision. No patient subsequently underwent anteverting PAO during the study period. There were no reported complications. Conclusions: Femoroacetabular impingement caused by acetabular retroversion treated with hip arthroscopy demonstrates good outcomes at 2 years with a low complication rate. Symptomatic adolescents may be safely and successfully treated arthroscopically, potentially avoiding anteverting PAO. Study Design: Level of evidence 4—case series.

Clinical and Radiographic Characteristics of Atypical Slipped Capital Femoral Epiphysis Background: Slipped capital femoral epiphysis (SCFEs) can be idiopathic or atypical (associated with renal failure, radiation therapy, and endocrine disorders). It is important to estimate the likelihood that atypical SCFE shows different clinical and radiographic characteristics and complications with typical SCFEs. Methods: We retrospectively reviewed 53 patients (66 hips) with SCFEs managed between 1995 and 2016. Sex, age, weight, height, the duration of symptoms the laterality of the slip, and complications were recorded. Bilateral hip and lower extremity long bone radiographs were utilized to record slip angle, genu valgus deformity. Statistical analyses were performed. Results: Among 53 children (32 boys and 21 girls) with 66 SCFEs, 22 children had 29 atypical SCFEs, and 31 children had 38 typical SCFEs. The average age at the time of presentation for the initial SCFEs was 10.9±0.3 years. The average duration of symptoms was 14.1±21.8 weeks. The average Southwick slip angle difference was 23.3±14.8 degrees. There are 43 mild, 13 moderate, and 10 severe SCFEs. 58 were classified as stable, and 8 were unstable. There were significant differences in terms of average age (10.4±2.6 y for atypical SCFEs, 11.2±1.4 for typical SCFEs; P=0.036), average weight (36.2±22.3 kg for patients with atypical slips, compared with 56.9±9.9 kg for those with typical slips; P<0.001), height (132.1±17.6 cm for those with atypical slips, compared with 148.9±12.1 for those with typical slips; P<0.001), and the body mass index (19.4±5.6 kg/cm2 for those with atypical slips, compared with 25.8±4.6 for those with typical slips; P<0.001). In the group of 22 children with atypical slipped capital epiphysis, there were 19 children with neoplasm (8 neuroblastomas, 3 medulloblastomas, 3 retinoblastomas, 2 ependymomas, 1 craniopharyngioma, 1 Wilms tumor, 1 immature teratoma), 4 children with primary endocrine disorder. We categorized atypical SCFEs in 3 groups by etiology; endocrine disorder–associated (ENDA) SCFEs, chemotherapy-associated (CTA) SCFEs, and radiation therapy–associated (RTA) SCFEs. Subjects of RTA were included if exposed to pelvic irradiation or total body irradiation. There were 4 ENDA, 9 RTA, and 16 CTA. Atypical SCFEs had significantly more valgus slips (P<0.001) and genu valgus deformity (P<0.001) compared with in the group of typical slipped capital epiphysis. Among the group of atypical SCFEs, children with CTA had significantly low body weight, height, and body mass index. Conclusions: The markedly greater incidence of valgus displacement of proximal femoral epiphysis and genu valgum in childhood cancer survivors with pelvic irradiation and chemotherapy may be associated with atypical SCFE. The authors conclude that in pediatric cancer survivors with hip pain, consideration should be given to atypical SCFE with valgus slip and long-term follow-up of lower extremity alignment. Level of Evidence: Level III—retrospective comparative study. See instructions for authors for a complete description of levels of evidence.

Acetabular Protrusio in Patients With Osteogenesis Imperfecta: Risk Factors and Progression Background: Osteogenesis imperfecta (OI) is a genetic disorder commonly associated with osteopenia, osteoporosis, bone fractures, bone deformities, and other clinical features. A frequent radiologic finding with OI is acetabular protrusio (AP). We hypothesized that AP develops in patients with OI over time. In addition, we hypothesized that AP also develops in patients with OI without radiographic evidence of AP on initial examination. Methods: Medical records and radiographs of 55 patients (109 hips) diagnosed with OI evaluated at our institution were retrospectively reviewed. Previously established radiographic criteria using the center-edge (CE) angle of Wiberg, position of the acetabulum relative to the iliopectineal line, crossing of the acetabulum across the ilioischial (Kohler) line, and position of the teardrop figure relative to the ilioischial (Kohler) line were utilized to assess AP severity. In addition, pharmacological treatments and patient factors including body mass index (BMI) were recorded. Radiographs of patients with OI that were taken ≥2 years apart were analyzed utilizing AP radiographic criteria to assess for changes. The changes in AP-related measurements were standardized by distance or degree per year. In addition, patient factors were evaluated for associations with AP development. Results: In this series of 109 hips (55 patients), incidence of AP in earliest radiographs was 45% (49/109). Patients with OI type I and III demonstrated the highest incidence of AP (65%). Among the hips that did not meet the criteria for AP in their early radiographs, 24 (40%) were positive for AP by their latest radiograph. In the hips that initially presented with AP, 42% showed increased CE angles on later radiographs. Twenty-six hips (24%) showed either no observable changes or reduced CE angles. Risk factors that were significantly associated with greater odds of developing AP included (1) an age under 12; (2) a BMI>25; (3) presence of AP of the contralateral hip; and (4) female sex. Bisphosphonates, vitamin D, physical therapy, and other drugs related to treatment of OI reduced the risk of developing AP but did not achieve statistical significance. Conclusions: AP is a common finding in OI patients (54%). Among hips of OI patients that met criteria for AP in early radiographs, 42% (20/48) demonstrated greater CE angles in their latest radiographs. Similar changes were observed in OI patients who did not initially meet criteria for diagnosis for AP. However, CE angle measurements between the 2 groups did not significantly differ (P=0.71). In terms of Kohler line crossing, patients that met criteria for AP in early radiographs had significantly greater change per year than those that did not have AP criteria (P<0.05). The findings suggest AP may develop over time in patients with OI and may be influenced by patient factors such as age, sex, and BMI. In addition, unilateral AP may have a significant impact on the development of AP of the contralateral hip. Level of Evidence: Level IV—retrospective case series.

Pediatric ACL Reconstruction and Return to the Operating Room: Revision Is Less Than Half of the Story Background: Although there are several causes of unplanned return to the operating room (RTOR) following pediatric anterior cruciate ligament (ACL) reconstruction (ACLR), prior outcomes studies focus primarily on the risk of graft failure. We sought to comprehensively describe indications for RTOR in pediatric primary ACLR patients, estimate associated rates of RTOR, and assess the impact of concomitant meniscal procedures on these rates. Methods: This retrospective cohort study considered patients who underwent primary ACLR at an urban, pediatric tertiary care hospital between 2013 and 2015. Cohorts were defined based on the presence or absence of a concomitant surgical meniscal procedure with the index ACLR. The primary outcome was RTOR for an indication pertaining to ACLR or a potential predilection for knee injury. Cases of RTOR were cataloged and classified according to indication. Survival analyses were performed using the Kaplan-Meier estimation and competing-risks regression. Comparisons of any-cause RTOR rates were done using log-rank tests. Results: After exclusion criteria were applied, 419 subjects were analyzed. RTOR indications were organized into 5 categories. The overall rate for any RTOR by 3 years after surgery was 16.5%. Graft failure and contralateral ACL tear were the most common indications for RTOR, with predicted rates of 10.3% and 7.1%, respectively. ACL graft failure accounted for less than half of RTOR cases cataloged. Patients who had a concomitant meniscus procedure had lower rates of RTOR. Conclusions: Approximately 1 in 6 pediatric ACLR patients underwent ≥1 repeat surgery within 3 postoperative years for indications ranging from wound breakdown to contralateral ACL rupture. While previous studies revealed high rates of complication after pediatric ACLR due primarily to graft failure, we found that re-tear is responsible for less than half of the 3-year RTOR risk. As almost half of re-tears in our sample occurred before clearance to return to full activities, we suspect that the high rate of complication is largely attributable to pediatric patients’ high activity levels and difficulties adhering to postoperative restrictions. Early treatment of meniscus pathology may reduce rates of RTOR. Level of Evidence: Level III—therapeutic.

Adolescent and Caregiver-derived Utilities for Traumatic Patella Dislocation Health States Introduction: The treatment of a first-time traumatic patella dislocation in children and adolescents remains controversial. Preference-based health utility assessments can provide health-related quality of life information for orthopaedic conditions and their subsequent treatment. The purpose of this study was to determine utilities for pediatric acute traumatic patella dislocation and subsequent treatment health states from both children with patellar dislocation, and their parents. Methods: Adolescents with acute first-time patella dislocations and their parents were identified. Six patella dislocation health states were defined: (1) Immediate post injury (Injury), (2) Postdislocation and nonoperative treatment with physical therapy (Rehabilitation), (3) Immediately poststabilization surgery (Postsurgical), (4) Recurrent dislocation after treatment (Recurrent dislocator), (5) Stable knee after initial treatment but unable to participate in sport at previous level (Stable return to lower function), and (6) Stable knee after initial treatment and fully able to participate in sport at previous level (Stable return to same function). Classic feeling thermometer utilities acquisition was performed, with self-report (patient) and proxy-report (parent) interviews performed separately. Patients’ physical activity levels were collected using the UCLA Activity Score and the HSS Pedi-FABS. Comparisons between groups were made using Mann-Whitney U test and Wilcoxon signed-rank test. Results: Ninety-five adolescents and 95 parents were included. Median (interquartile range) patient utilities for Injury, Rehabilitation, Postsurgical, Recurrent dislocator, Stable return to lower function, and Stable return to same function health states were: 25 (10 to 45), 50 (35 to 62.5), 30 (15 to 48.5), 20 (10 to 40), 70 (50 to 80), and 100 (100 to 100), respectively. Caregiver-derived utilities for children going through these health states were: 25 (10 to 49.5), 50 (25 to 60), 40 (15 to 60), 20 (5 to 40), 60 (50 to 77.5), and 100 (100 to 100). Stable return to a lower function was assigned a significantly higher utility by adolescents than their caregivers (P=0.03); highly active adolescents assigned a significantly higher utility to achieving a stable return to same function (P=0.02) while assigning significantly lower utility to health states in which they were not fully participating in sport. Conclusions: Adolescents and their parents felt that successful treatment of an acute patella dislocation was equivalent to perfect health (utility=1); however, adolescents assigned a significantly higher utility to a stable but lower functioning health state compared with their parents. Baseline functional status is an important modifier of health state preference—highly active adolescents assign a significantly greater disutility to health states in which they are not participating in sports at their regular level of play. These findings provide insight into the health-related quality of life impact for acute patella dislocations and their management, and potentially support minimizing time out of play and more aggressive treatment of first time acute patellar dislocations in athletic adolescents. Level of Evidence: Level III.