Milbrandt, Todd A.

Background: Scoliosis has various etiologies, ranging from idiopathic, congenital, to those with spinal cord abnormalities. Advanced imaging is not always feasible and limited by cost, low-yield, and anesthesia risks in children. Given artificial intelligence's potential, we hypothesize that a deep learning (DL)–based image classifier will demonstrate superior performance in radiographic classification of scoliosis etiology compared witht experienced spine surgeons based on spine radiographs. Methods: One thousand thirty-six pediatric patients from single institution with scoliosis diagnosis and paired anterior-posterior - lateral images were included. Patients were manually classified based on their scoliosis etiology from chart review, including previous spine imaging studies when available. Categories included idiopathic, congenital, and spinal cord pathology. Images were randomized and assigned for training, validation, and testing. A DL-classifier using EfficientNet B4 architecture was trained on the radiographs. Accuracy and positive predictive value as defined by precision, recall, and F1-score were calculated to assess final performance metrics. Results: The trained classifier performed well at identifying correct etiologies, with F1-Score (harmonic mean of precision-recall) of 0.97. Model precision was 0.99 for adolescent idiopathic scoliosis, 0.89 for congenital, and 0.78 for spinal cord pathology. Performance was higher on more common classes, with lower performance observed in class with fewer images. The algorithm has highest overall precision (0.96), recall (0.96), and F1 (0.96), while Surgeons 1 and 2 have lower accuracies (precision 0.80, recall 0.79, and F1 0.79 and precision 0.76, recall 0.67, and F10.71, respectively). There was no clear pattern identified regarding the surgeons' errors and poor agreement on which X-rays corresponded to underlying spinal cord pathology. Conclusion: A DL-convolutional-neural-network classifier has been trained to high degree of accuracy to distinguish between 3 scoliosis etiologies on pediatric spine radiographs. This model could provide a novel tool to clinicians to decide when to refer for axial imaging. It had superior diagnostic performance compared with experienced spine surgeons. After further validation and refinement, a clinician could put a patient's X-rays into the predictive tool for analysis and use the results to discuss with the family the risk of finding spinal cord pathology, helping them determine together the best timing for an MRI. Level of Evidence: Level III . See Instructions for Authors for a complete description of levels of evidence.

Background: Distal radius fractures involving the physis are among the most common upper extremity injuries in children and adolescents. Unlike transitional fractures of the distal tibia, known as Tillaux and triplane fractures, transitional fractures of the distal radius have not been well characterized. This study aims to evaluate Salter-Harris III and IV fractures of the distal radius in the pediatric transitional age population to determine if a characteristic fracture pattern exists analogous to the distal tibia. We hypothesized that pediatric transitional fractures of the distal radius would follow a pattern that would ultimately dictate treatment and predict outcomes. Methods: A retrospective chart review of pediatric patients with transitional fractures of the distal radius at a single institution was performed. Salter-Harris III and IV fractures of the distal radius with CT imaging were included. Two independent reviewers determined the metaphyseal fracture plane and the major intra-articular epiphyseal fracture fragments. Descriptive statistical analysis was performed. Results: Thirty patients who met inclusion criteria made the study cohort. There were 5 Salter-Harris III fractures and 25 Salter-Harris IV fractures. Mean age at the time of injury was 15±1.5 years. The metaphyseal fracture demonstrated a coronal fracture plane in all cases, and 20% had a sagittal plane component. The major epiphyseal fracture fragments were identified as dorsal ulnar corner in 70%, radial column in 43%, volar rim in 30%, and dorsal wall in 17%. Patients were treated with open reduction and internal fixation (N=12, 40%), closed reduction and percutaneous pinning (N=4, 13%), or cast immobilization (N=14, 47%). Most patients (N=24, 80%) did not demonstrate a growth disturbance after treatment. Angular deformity, however, was significantly higher in patients with a primary dorsal ulnar corner epiphyseal fragment (N=4, 19% vs. N=0%, P =0.03). Conclusion: Transitional fractures of the distal radius occurred on average at age 15. The injuries demonstrated a consistent pattern, with a coronal fracture plane in the metaphysis and a dorsal ulnar corner fragment in most epiphyses. The dorsal physis may be the strongest portion of the distal radius at the time of injury, though mechanism of injury may impact patterns as well. Level of Evidence: Level III.

Background: Motion-sparing approaches to scoliosis surgery such as vertebral body tethering (VBT) are growing in popularity. There is limited data evaluating motion preserving after the different tether approaches. We hypothesized that spinal motion would be preserved in both the sagittal and coronal planes in patients after thoracic, lumbar, and bilateral vertebral body tethering procedures. Methods: This was a retrospective comparison study of adolescent idiopathic scoliosis (AIS) patients who underwent VBT. Preoperative and postoperative coronal range of motion across the instrumented levels were compared using a standing microdose slot-scanning protocol. Flexion/extension radiographs were evaluated postoperatively to assess preserved sagittal arc of motion. Patients with known cord breakage were excluded. Results: The mean age at surgery was 12.9 years (range: 9.4 to 16.5) with mean follow-up period of 2.8 years. Skeletal maturity, defined as Risser sign ≥5, was observed in 29 patients. (26.9%). Overall, mean thoracic coronal arc of motion for postoperative VBT patients was 10 degrees in the thoracic spine and 20 degrees in the lumbar. This was a 59% (24 to 10 deg.) decrease in thoracic range of motion and a 51% (40 to 20 deg.) decrease in lumbar range of motion. Right-sided motion was greater in patients with thoracic instrumentation, whereas left-sided motion was greater in patients with lumbar instrumentation. In addition, patients also retained sagittal motion. Patients with single thoracic tethers had a total arc of motion of 22 degrees, whereas patients with single lumbar tethers had a total arc of motion of 25 degrees. It was noted that both groups had a greater degree of flexion than extension. Conclusions: Patients with single thoracic tethers saw a 60% decrease in the total coronal arc of motion. Patients with single lumbar tethers saw a 57% decrease in coronal motion. Patients had around 20 to 25-degree arc of motion preserved over the instrumented segments in the sagittal plane. Further work is needed to outline the functional benefits of motion preservation after VBT. Level of Evidence: Level III (retrospective cohort study).

Background: Pediatric orthopaedic surgery encompasses many areas of subspecialization. To improve patient care, quality improvement efforts should focus on high-volume procedures with high complication rates. This study aims to identify these procedures to better target research and quality-improvement initiatives. Methods: Patients undergoing one of the 30 most common orthopaedic procedures in NSQIP pediatric data from 2012 to 2022 were analyzed for 30-day complications, infections, unplanned reoperations, and unplanned readmissions. Multivariable models assessed associations between procedure type and adverse events, adjusted for patient characteristics. Tibial osteotomy (TO) was defined as the reference category for procedure in each model as it is a common procedure with a moderate risk profile and a similar complication rate across the cohort. Results: 191,381 patients were included in the analysis (median: 10 y, IQR: 5 to 13; 48.7% male). The 30-day overall complication rate was 2.3% (n=4401), with infections occurring in 1.6% of cases (n=3005). Unplanned reoperations occurred in 1.7% (n=3207), and the unplanned readmission rate was 2.0% per 30 person-days. The most performed procedures were posterior spine fusion (PSF; n=45,542; 23.8%), supracondylar humeral fracture (SCHfx) repair (n=45,479; 23.8%). Complication rates were highest for PSF in non-idiopathic cases (10.3%), followed by pelvic and femoral osteotomy (4.9%). Infectious complications were most frequent in PSF for non-idiopathic cases (6.1%) and tibial osteotomy (3.1%). Unplanned reoperation rates were elevated for non-idiopathic PSF (5.6%) and pelvic/femoral osteotomy (4.9%). On multivariable analysis, PSF for adolescent idiopathic scoliosis (OR=1.39; 95% CI: 1.05-1.86) and non-idiopathic causes (OR=2.16; 95% CI: 1.61-1.89) demonstrated increased odds of complications compared with TO. Factors associated with higher complication rates included BMI >95th percentile (OR=1.52; 95% CI: 1.40-1.65), developmental delay (OR=1.57; 95% CI: 1.43-1.73), seizure disorder (OR=1.41; 95% CI: 1.27-1.56), and ASA ≥2 (OR=2.14;95% CI: 1.90-2.41). Although PSF for non-idiopathic causes had the highest unplanned readmission rates (9.4% per 30 person-days), adjusted analysis showed a strong association with increased readmissions for pelvic/femoral osteotomy (HR=2.52; 95% CI: 1.58-4.03) compared with TO. SCHfx repair and calcaneal osteotomy consistently had lower rates of complications, infections, reoperations, and readmissions. Conclusions: After adjusting for covariates, PSF and tibial and femoral osteotomies, demonstrated significantly higher risks for adverse surgical outcomes compared with TO. Our findings identify SCHfx repair as a high-volume procedure with low complication, infection, reoperation, and readmission rates in contrast to PSF, one of the most common procedures with the highest complication rate.

Case: An 8-year-old boy underwent open reduction and internal fixation for pelvic and femoral fractures following a crush injury. At nine months postoperatively, computed tomography demonstrated a triradiate physeal bar contralateral to operated hemipelvis. A navigated physeal bar excision with O-arm navigation and low-dose radiation protocol was performed. Conclusion: Triradiate bar excision presents a technically challenging procedure that may be offset by O-arm navigation utilization, which provides accurate, real-time imaging that facilitates complete physeal bar excision while mitigating risk of damage to surrounding structures. Our low-dose protocol yielded a total exposure of 0.914 mSv, comparable with 1.5 pelvic radiographs.

Background/Objectives: Traditional fusion leads to a loss of spine mobility across the fused vertebrae. Vertebral body tethering (VBT) was developed with the goal of increasing flexibility and maintaining some spinal mobility. However, it is not known if the additional mobility leads to significant functional improvement. This prospective motion analysis study evaluates functional outcomes, specifically gait stability, in pre-operative, post-fusion, and post-VBT patients by using postural perturbations on a treadmill. Methods: Overall, 79 subjects underwent a computer-controlled treadmill study with postural perturbations, which simulated trips and slips. The subjects were harnessed for safety. Overall, 21 subjects were healthy controls, 18 patients were at least one-year post-VBT, 15 patients were at least one-year post-fusion, and 25 were pre-operative scoliosis patients. Subject weight, height, and treadmill acceleration were recorded and used to determine anteroposterior single (ASSTs, PSSTs) and multiple (AMSTs, PMSTs) stepping thresholds to describe the maximum torque a patient could withstand before failing to recover from the simulated trip. Independent t-tests were run to compare groups under the advice of a master statistician with expertise in orthopedic surgery. Results: Pre-operative scoliosis patients had lower PSSTs than healthy controls (uncorrected p = 0.036). No significant differences were observed between pre-operative and post-operative groups for both fusion and VBT. There was no significant difference in ASST, AMST, or PMST between any of the groups. Conclusions: The lower PSST in pre-operative scoliosis patients compared to healthy controls may reflect impaired reactive balance and potentially increased fall risk. Interestingly, there was no significant difference in reactive balance measures between pre-operative and post-operative scoliosis patients or between post-fusion and post-VBT patients.

Background: The purpose of this study was to report on 2-year results of vertebral body tethering (VBT), performed under a Food and Drug Administration protocol, to obtain insight into outcomes and complications. Methods: Forty prospectively enrolled patients with adolescent idiopathic scoliosis (AIS) who had a Sanders score of ≤4 or a Risser score of ≤2 underwent VBT for curves between 40° and 70°. Surgical, radiographic, and patient-reported outcomes were reviewed at a minimum 2-year follow-up. Results: Mean age at surgery was 13 (range, 10 to 16) years. The 40 patients were 90% female; 95% White, 2.5% other, and 2.5% unreported; and 92.5% non-Hispanic, 5% Hispanic, and 2.5% unreported. A mean of 8 (range, 5 to 12) levels were instrumented. Most patients were at Sanders 4 (65%) and Risser 0 (63%). Mean length of stay was 3 ± 1 days, estimated blood loss was 236 ± 158 (range, 25 to 740) mL, and operative time was 4.4 ± 1.4 hours. Mean correction of the major curve was 44% (range, 22% to 95%) on the 3-month standing radiograph, 49% at 1 year, and 46% (range, −10% to 93%) at 2 years. The mean major Cobb angle improved from 51° ± 8° (range, 40° to 70°) preoperatively to 27° ± 11° (range, 3° to 56°) at 2 years. Success at 2 years, defined by a Cobb angle of <35° and no reoperation, was seen in 30 patients (75%) and was associated with a mean Cobb angle of <35° on the first postoperative standing radiograph (p < 0.001). Twelve patients (30%) demonstrated improvement in the curve with growth. By 2 years, 2 (5%) of the patients underwent repeat surgery (1 release for overcorrection, 1 lumbar VBT for lumbar curve progression after thoracic VBT). The Scoliosis Research Society (SRS) satisfaction score improved 2 years following surgery (p < 0.001), but other SRS domains only remained stable over time. Beyond 2 years, 1 additional lumbar tether was required after thoracic VBT, 1 implant was removed, and 3 fusions were performed, for a 10% fusion rate and overall 20% reoperation rate at a mean of 3.8 ± 1.1 years of follow-up. The rate of cord breakage in the study population was 20%. Conclusions: In skeletally immature patients treated in the U.S. under a prospective Investigational Device Exemption, there was a 75% rate of successful outcomes at 2 years. Most correction was obtained at the time of surgery, and inadequate intraoperative curve correction was associated with a higher Cobb angle on the first postoperative standing radiograph and failure by 2 years. Level of Evidence: Therapeutic Level II . See Instructions for Authors for a complete description of levels of evidence.

Background/Objectives: The burden of scoliosis care extends beyond treatment costs and includes missed school for patients and lost income for parents. Chronic absenteeism, defined as more than 18 days of missed school, can have a significant impact on a child’s educational progression, but missed school and work due to scoliosis treatment are not well quantified in the literature. This study investigates absenteeism among scoliosis patients and their caregivers. Methods: We conducted a retrospective comparative study of survey results based on surgery timing and surgery type. Patients and caregivers presenting for clinic visits for scoliosis treatment at a single large tertiary care center from 2014 to 2022 were queried. Results: We collected 2772 surveys from 1104 unique patients. Of these, 223 surveys from 132 patients were within one year of surgery: 140 post-fusion surveys, 71 post-nonfusion surveys, and 11 post-halo/multistage surgery surveys. A total of 2280 surveys were from 1022 nonoperatively treated patients. School absenteeism was significantly higher for surgeries during the school year compared to summer in both the fusion and nonfusion groups, though work absenteeism showed no significant differences. Halo/multistage surgery patients had the highest rates of absenteeism. Conclusions: This study highlights the impacts of scoliosis surgery timing and type on absenteeism among patients and their caregivers. Surgery during summer breaks reduces school absenteeism and academic disruption. Halo/multistage surgery patients face the greatest risk of chronic absenteeism from school, indicating a need for targeted interventions. Optimized surgical timing and planning can help families navigate the educational and financial challenges of scoliosis treatment.

Objective: Lateral condyle fractures are the second most common pediatric elbow fracture after supracondylar humeral fractures. Early complications are frequent which can lead to development of long-term problems. Current literature has evaluated short-term outcomes, but few studies have investigated long-term outcomes into adulthood. Our hypothesis is that the majority of pediatric patients with a lateral condyle fracture will have minimal complications and few surgeries as they age. Methods: A population-based database was used to identify patients who sustained a lateral condyle fracture before the age of 18 between 1966 and 2012. Electronic medical records from all treatment centers in the county were reviewed for clinical and radiographic data. Analysis was performed to determine incidence and long term outcomes based on fracture type and treatment. Results: From 1966 to 2012, 227 pediatric lateral condyle fractures were identified. One hundred seventy-seven fractures (78%) had at least 10 year clinical follow up. Incidence was found to be 13.97 per 100,000. We identified 80 (45%) Weiss type 1, 61 (34%) type 2, and 37 (21%) type 3 fractures. The overall complication rate was 17%, of which 47% were identified >10 years from injury. There was no significant difference in complication rates based on fracture type (P = 0.18) or treatment type (P = 0.55). The most common complication was malunion (n = 15), followed by fishtail deformity (n = 4), stiffness (n = 3), lateral epicondylitis (n = 3), nonunion (n = 2), osteoarthritis (n = 2), and tardy ulnar nerve palsy (n = 1). Five patients underwent revision surgery for nonunion, cubitus valgus, malunion with loose bodies, capitellar osteochondral dessicans with malalignment, and ulnar nerve palsy. Conclusions: This population-based study estimated the overall incidence of pediatric lateral condyle fractures to be 14 per 100,000. Displaced fractures had a higher incidence than undisplaced fractures. Complications beyond 10 years are rare, but the need for future revision surgery is possible, therefore, proper patient and family education is necessary at the time of injury. This is the largest study with the longest follow-up for pediatric lateral condyle fractures. Complications were rare but resulted in a 17% complication rate and a 3% reoperation rate at a minimum. Level of Evidence: Level III.

Abstract Unstable osteochondritis dissecans lesions of the medial femoral condyle have classically been treated with open reduction and fixation under direct visualization through an open arthrotomy. Given the value of avoiding open arthrotomies, we present an arthroscopic approach for lesion elevation, debridement, and fixation. The lesion is first elevated using an arthroscopic elevator, leaving a laterally based osseous hinge. Once elevated, fibrous debris is debrided from the base of the lesion. Subsequently, the fragment is reduced, and percutaneous transpatellar instrumentation is used for fixation. The use of this technique allows for excellent mobilization, debridement, and fixation of the osteochondritis dissecans lesion while minimizing violation of periarticular soft tissues. Technique Video video See video under supplementary data.