Self-confidence is one of the attributes often assigned to surgeons, but surgeons do not always feel self-confident in the operating room. A lack of confidence may lead to poor performance for both ...the surgeon and the surgical team. The ideal qualities of a self-confident surgeon, barriers to achieving confidence and strategies for becoming a more confident surgeon and leader in the operating room are outlined in this chapter.
BACKGROUND:Early-onset scoliosis is a heterogeneous condition, with highly variable manifestations and natural history. No standardized classification system exists to describe and group patients, to ...guide optimal care, or to prognosticate outcomes within this population. A classification system for early-onset scoliosis is thus a necessary prerequisite to the timely evolution of care of these patients.
METHODS:Fifteen experienced surgeons participated in a nominal group technique designed to achieve a consensus-based classification system for early-onset scoliosis. A comprehensive list of factors important in managing early-onset scoliosis was generated using a standardized literature review, semi-structured interviews, and open forum discussion. Three group meetings and two rounds of surveying guided the selection of classification components, subgroupings, and cut-points. Initial validation of the system was conducted using an interobserver reliability assessment based on the classification of a series of thirty cases.
RESULTS:Nominal group technique was used to identify three core variables (major curve angle, etiology, and kyphosis) with high group content validity scores. Age and curve progression ranked slightly lower. Participants evaluated the cases of thirty patients with early-onset scoliosis for reliability testing. The mean kappa value for etiology (0.64) was substantial, while the mean kappa values for major curve angle (0.95) and kyphosis (0.93) indicated almost perfect agreement. The final classification consisted of a continuous age prefix, etiology (congenital or structural, neuromuscular, syndromic, and idiopathic), major curve angle (1, 2, 3, or 4), and kyphosis (–, N, or +) variables, and an optional progression modifier (P0, P1, or P2).
CONCLUSIONS:Utilizing formal consensus-building methods in a large group of surgeons experienced in treating early-onset scoliosis, a novel classification system for early-onset scoliosis was developed with all core components demonstrating substantial to excellent interobserver reliability. This classification system will serve as a foundation to guide ongoing research efforts and standardize communication in the clinical setting.
BACKGROUND:A growing trend of survey-based research has been seen in the field of pediatric orthopaedics. The purpose of this study was to describe patterns of surveys of Pediatric Orthopaedic ...Society of North America (POSNA) membership and evaluate for associations between study characteristics and response rates in order to inform future research efforts. We hypothesized that studies with fewer survey questions and study group or committee involvement would demonstrate higher response rates.
METHODS:A systematic review of the literature was performed to identify all peer-reviewed survey publications targeting POSNA members published up to December 2017. Included studies were reviewed to identify author and publication characteristics, survey development and methodology, survey distribution procedures, and response rates. Statistical analyses were performed to describe publication patterns and evaluate for associations between study characteristics and response rates.
RESULTS:Thirty-four studies published from 1991 to 2017 were identified as meeting inclusion criteria, with a substantial increase noted over the last 3 years. Studies included 4.6 (SD 1.9) authors and 14.7% had affiliations with study groups or committees. Survey development methodology was detailed in only 1 study. Surveys included a median of 19.5 questions (3 to 108) and were primarily electronically distributed. The mean survey response rate was 42% with a downward trend noted over the studied time period. None of the studied author, publication, and design characteristics were associated with increased response rates.
CONCLUSIONS:Survey-based studies of the POSNA membership have become increasingly popular study designs in recent years. Response rates are lower than reports in other physician cohorts, and appear to be declining, possibly representative of respondent fatigue. No associations were identified between response rates and the modifiable study characteristics evaluated (number of authors, committee or subgroup affiliation, number of questions, and mode of distribution). Efforts should be made to identify tactics to sustain participation as these studies become more widely utilized within our field. Optimizing study design and implementation features while valuing physician time and effort spent on survey completion is important to avoid member survey fatigue.
LEVEL OF EVIDENCE:Level V—systematic review of Level V research.
A major complication of surgical scoliosis correction is permanent injury of the spinal cord. Intraoperative neuromonitoring continually evaluates spinal cord function through monitoring sensory and ...corticospinal motor tracts. There is no literature or manufacturer recommendation on whether transcranial motor evoked potential (tcMEP) monitoring can be performed safely in the presence of a deep brain stimulator (DBS) system. A 17-year-old adolescent boy with severe neuromuscular scoliosis presented for a posterior spinal fusion. The patient suffered from generalized dystonia treated with a DBS terminating in the left and right globus pallidus internus. The competing goals of monitoring motor function during the spinal fusion and preserving the integrity of the DBS system were discussed preoperatively. The DBS system was deactivated for the duration of surgery, and tcMEPs were used sparingly at the lowest suitable stimulation voltage. Intraoperative management focused on facilitating neurophysiologic monitoring through a total intravenous anesthetic of propofol, methadone, and remifentanil. The tcMEPS remained unchanged throughout the operation and the patient emerged able to move his lower extremities to command. Postoperatively, the DBS system was turned back on and showed retained settings, normal functioning, and unchanged impedance of the DBS leads. Neither the patient nor his parents reported any subjective changes in the symptoms of dystonia. The authors conclude that monitoring tcMEPs in the presence of a DBS implant may be done safely, when the clinical circumstances suggest that the added information gained from tcMEPs outweighs the theoretical risk to the DBS system and the course of the medical condition treated by the DBS.
Background: Cefazolin may minimize the risk of surgical site infection (SSI) following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). Cefazolin dosing recommendations vary ...and there is limited evidence for achieved tissue concentrations. Methods: We performed a randomized, controlled, prospective pharmacokinetic pilot study of 12 patients given cefazolin by either intermittent bolus (30 mg/kg every 3 h) or continuous infusion (30 mg/kg bolus followed by 10/mg/kg per hour) during PSF for AIS. Results: Patients were well matched for demographic and perioperative variables. While total drug exposure, measured as area-under-the-curve (AUC), was similar in plasma for bolus and infusion dosing, infusion dosing achieved greater cefazolin exposure in subcutaneous and muscle tissue. Using the pharmacodynamic metric of time spent above minimal inhibitory concentration (MIC), both bolus and infusion dosing performed well. However, when targeting a bactericidal concentration of 32 µg/mL, patients in the bolus group spent a median of 1/5 and 1/3 of the typical 6 h operative time below target in subcutaneous and muscle tissue, respectively. Conclusions: We conclude that intraoperative determination of cefazolin tissue concentrations is feasible and both bolus and infusion dosing of cefazolin achieve concentrations in excess of typical MICs. Infusion dosing appears to more consistently achieve bactericidal concentrations in subcutaneous and muscle tissues.
Anterior vertebral body tethering (AVBT) is an alternative to posterior spinal fusion (PSF) for the surgical treatment of scoliosis. The present study utilized a large, multicenter database and ...propensity matching to compare outcomes of AVBT to PSF in patients with idiopathic scoliosis.
Patients with thoracic idiopathic scoliosis who underwent AVBT with a minimum 2-year follow-up retrospectively underwent 2 methods of propensity-guided matching to PSF patients from an idiopathic scoliosis registry. Radiographic, clinical, and Scoliosis Research Society 22-Item Questionnaire (SRS-22) data were compared preoperatively and at the ≥2-year follow-up.
A total of 237 AVBT patients were matched with 237 PSF patients. In the AVBT group, the mean age was 12.1 ± 1.6 years, the mean follow-up was 2.2 ± 0.5 years, 84% of patients were female, and 79% of patients had a Risser sign of 0 or 1, compared with 13.4 ± 1.4 years, 2.3 ± 0.5 years, 84% female, and 43% Risser 0 or 1 in the PSF group. The AVBT group was younger (p < 0.001), had a smaller mean thoracic curve preoperatively (48 ± 9°; range, 30° to 74°; compared with 53 ± 8°; range, 40° to 78° in the PSF group; p < 0.001), and had less initial correction (41% ± 16% correction to 28° ± 9° compared with 70% ± 11% correction to 16° ± 6° in the PSF group; p < 0.001). Thoracic deformity at the time of the latest follow-up was 27° ± 12° (range, 1° to 61°) for AVBT compared with 20° ± 7° (range, 3° to 42°) for PSF (p < 0.001). A total of 76% of AVBT patients had a thoracic curve of <35° at the latest follow-up compared with 97.4% of PSF patients (p < 0.001). A residual curve of >50° was present in 7 AVBT patients (3%), 3 of whom underwent subsequent PSF, and in 0 PSF patients (0%). Forty-six subsequent procedures were performed in 38 AVBT patients (16%), including 17 conversions to PSF and 16 revisions for excessive correction, compared with 4 revision procedures in 3 PSF patients (1.3%; p < 0.01). AVBT patients had lower median preoperative SRS-22 mental-health component scores (p < 0.01) and less improvement in the pain and self-image scores between preoperatively and the ≥2-year follow-up (p < 0.05). In the more strictly matched analysis (n = 108 each), 10% of patients in the AVBT group and 2% of patients in the PSF group required a subsequent surgical procedure.
At a mean follow-up of 2.2 years, 76% of thoracic idiopathic scoliosis patients who underwent AVBT had a residual curve of <35° compared with 97.4% of patients who underwent PSF. A total of 16% of cases in the AVBT group required a subsequent surgical procedure compared with 1.3% in the PSF group. An additional 4 cases (1.3%) in the AVBT group had a residual curve of >50° that may require revision or conversion to PSF.
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Severe adolescent idiopathic scoliosis (AIS) can be treated with instrumented fusion, but the number of anchors needed for optimal correction is controversial.
We conducted a multicenter, randomized ...study that included patients undergoing spinal fusion for single thoracic curves between 45° and 65°, the most common form of operatively treated AIS. Of the 211 patients randomized, 108 were assigned to a high-density screw pattern and 103, to a low-density screw pattern. Surgeons were instructed to use ≥1.8 implants per spinal level fused for patients in the high-implant-density group or ≤1.4 implants per spinal level fused for patients in the low-implant-density group. The primary outcome measure was the percent correction of the coronal curve at the 2-year follow-up. The power analysis for this trial required 174 patients to show equivalence, defined as a 95% confidence interval (CI) within a ±10% correction margin with a probability of 90%.
In the intention-to-treat analysis, the mean percent correction of the coronal curve was equivalent between the high-density and low-density groups at the 2-year follow-up (67.6% versus 65.7%; difference, -1.9% 95% CI: -6.1%, 2.2%). In the per-protocol cohorts, the mean percent correction of the coronal curve was also equivalent between the 2 groups at the 2-year follow-up (65.0% versus 66.1%; difference, 1.1% 95% CI: -3.0%, 5.2%). A total of 6 patients in the low-density group and 5 patients in the high-density group required reoperation (p = 1.0).
In the setting of spinal fusion for primary thoracic AIS curves between 45° and 65°, the percent coronal curve correction obtained with use of a low-implant-density construct and that obtained with use of a high-implant-density construct were equivalent.
Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.
Thoracic anterior vertebral body tethering (TAVBT) is an emerging treatment for adolescent idiopathic scoliosis. Tether breakage is a known complication of TAVBT with incompletely known incidence. We ...aim to define the incidence of tether breakage in patients with adolescent idiopathic scoliosis who undergo TAVBT. The incidence of tether breakage in TAVBT is hypothesized to be high and increase with time postoperatively.
All patients with right-sided, thoracic curves who underwent TAVBT with at least 2 and up to 3 years of radiographic follow-up were included. Tether breakage between 2 vertebrae was defined a priori as any increase in adjacent screw angle >5 degrees from the minimum over the follow-up period. The presence and timing of tether breakage were noted for each patient. A Kaplan-Meier survival analysis was performed to calculate expected tether breakage up to 36 months. χ 2 analysis was performed to examine the relationship between tether breakage and reoperations. Independent t test was used to compare the average final Cobb angle between cohorts.
In total, 208 patients from 10 centers were included in our review. Radiographically identified tether breakage occurred in 75 patients (36%). The initial break occurred at or beyond 24 months in 66 patients (88%). Kaplan-Meier survival analysis estimated the cumulative rate of expected tether breakage to be 19% at 24 months, increasing to 50% at 36 months. Twenty-one patients (28%) with a radiographically identified tether breakage went on to require reoperation, with 9 patients (12%) requiring conversion to posterior spinal fusion. Patients with a radiographically identified tether breakage went on to require conversion to posterior spinal fusion more often than those patients without identified tether breakage (12% vs. 2%; P =0.004). The average major coronal curve angle at final follow-up was significantly larger for patients with radiographically identified tether breakage than for those without tether breakage (31 deg±12 deg vs. 26 deg±12 deg; P =0.002).
The incidence of tether breakage in TAVBT is high, and it is expected to occur in 50% of patients by 36 months postoperatively.
Level IV.
Background: Caregiver preferences represent one potential barrier to the uptake of 'minimalist', splint-based strategies in the management of pediatric buckle fractures of the wrist as opposed to ...traditional casting. This study sought to examine caregiver treatment preferences and factors of influence in the management of this injury. We hypothesized that caregivers would prefer cast immobilization. Methods: A 22-item caregiver survey was created to assess demographics, treatment preferences and influential factors. Caregivers were also presented with information regarding the equivalent outcomes of available treatment options. The survey was completed by a convenience sample of caregivers presenting with patients of any diagnosis to our Pediatric Orthopaedic Clinic. Results: A total of 297 surveys were obtained from unique respondents who were predominantly mothers (81.2%) caring for 2.4 (SD 1.3) children. Forty-one percent had previously cared for a child with a fracture. Caregivers accompanied patients who were 9.0+/-5.0-years-old, 34% of whom were actively being treated for an orthopaedic injury. Caregiver immobilization preferences for buckle fractures of the wrist were: no preference (43.1%), cast (32.3%) and splint (24.6%). The doctor's recommendation was the most influential factor on this decision while the child's gender was the least of the factors assessed. Those who rated treatment durability and child's activity level higher were associated with a preference for casting, while those who rated comfort higher were associated with a preference for splinting. There were no other significant factor variables associated with treatment preferences. Conclusions: This study is the first to characterize caregiver preferences regarding immobilization devices in the realm of buckle fractures of the wrist. Findings identified that preferences are mixed, with the interest in casting being less than anticipated. Factors influencing caregiver preference include the doctor's recommendation, durability, the patient's activity level, and comfort. This knowledge can be utilized by providers who are seeking to implement a splint-based immobilization strategy for buckle fractures as they approach the treatment discussion and plan.
Background Semirigid fiberglass (SRF) is an alternative material to plaster of Paris (POP) for idiopathic clubfoot casting in the Ponseti method. The purpose of this study was to evaluate early ...clinical outcomes in a series of idiopathic clubfoot patients treated with SRF at a single institution and to compare these findings to historical norms with POP casting present in the literature. Methods A series of idiopathic clubfoot patients managed exclusively with SRF in the Ponseti method was identified. Treatment efficacy was evaluated by number of casts, change in Pirani score, frequency of treatment-related complications, and frequency of surgery other than tenotomy. A comprehensive literature review was used for comparative historical norms. Results The study included 34 feet in 26 patients. Pirani score was 4.7±1.3 at presentation and 1.9±1.4 at the end of casting, representing a score change of 2.8±1.3 with SRF. Initial correction was obtained with 6.9±1.4 casts. Treatment-related complications occurred in six treated feet (17.6%) including 13 cast slippages in five feet and one cast-related thigh abrasion. A total of 25 (73.5%) feet underwent tenotomy. Two feet required an additional surgical procedure. Conclusion Clubfoot patients treated with SRF demonstrated acceptable deformity correction following Ponseti-style casting. The quantitative clinical outcomes evaluated appeared similar to norms using POP present in the literature. The findings of this study support SRF as a viable alternative to plaster casting for clubfoot correction utilizing the Ponseti method. As such, further investigation for rigorous comparative assessment is warranted.
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