Proximal junctional kyphosis (PJK) is defined as adjacent segment kyphosis >10° between the upper instrumented vertebrae and the vertebrae 2 levels above following scoliosis surgery. There are few studies investigating the predictors and clinical sequelae involved with this relatively common complication. Our purpose was to determine the radiographic predictors of post-op PJK and to examine the association between PJK and pain/HRQOL following surgery for AIS.

The Post-Operative Recovery after Scoliosis Correction: Home Experience (PORSCHE) study was a prospective multicenter cohort of AIS patients undergoing spinal fusion surgery. Pre-op and minimum 2 year f/u scoliosis and sagittal spinopelvic parameters (thoracic kyphosis–TK, lordosis–LL, pelvic tilt-PT, sacral slope-SS, pelvic incidence-PI) were measured and compared to numeric rating scale for pain (NRS) score, SRS-30 HRQOL and to the presence or absence of PJK (proximal junctional angle >100). Continuous and categorical variables were assessed using logistic regression and binomial variables were compared to binomial outcomes using chi-square.

163 (137 females) patients from 8 Canadian centers met inclusion criteria. At final f/u, PJK was present in 27 patients (17%). Pre-op means for PJK vs No PJK: Age 14.1 vs 14.7yr; females 85 vs 86%; scoliosis 57±22 vs 62±15deg; TK 28±18 vs 19±16deg ∗, LL 62±11 vs 60±12deg, PT 8±12 vs 10±10deg, SS 39±8 vs 41±9deg, PI 47±14 vs 52±13deg, SVA −9±30 vs −7±31mm. Final f/u for PJK vs No PJK: Scoliosis 20±11 vs 18±8deg, final TK 26±12 vs 19±10deg∗, LL 60±11 vs 57±12deg, PT 9±12 vs 12±13deg, SS 39±9 vs 41±9deg, PI 48±17 vs 52±14deg, SVA −23±26 vs −9±32mm∗. Significant findings: Pre-op kyphosis >40deg has an odds ratio (OR) of 4.41 (1.50–12.92) for developing PJK∗. The presence of PJK was not associated with any significant differences in NRS or SRS-30. ∗denotes p<0.05.

This prospective multicenter cohort of AIS patients demonstrated a 17% risk of developing PJK. Pre-op thoracic kyphosis >40deg was associated with the development of PJK; however, the presence of PJK was not associated with increased pain or decreased HRQOL.

Purpose: Congenital idiopathic clubfoot is the most common congenital deformity in children and can be a major cause of disability for the child as well as an emotional stress for the parents. The Ponseti method of club-foot correction, consisting of serial manipulations and casting, is now the gold standard of treatment. It has traditionally been described using plaster of Paris (POP) above-knee casts, which are affordable, stiff, and easily moldable. Recently, semi-rigid fiberglass softcast (FSC, 3M Scotchcast) has grown in popularity due to ease of removal, durability, lighter weight, better appearance, ease of cleaning, and water resistance. There are currently no randomized controlled trials to prove its efficacy with respect to POP. The purpose of this study was to determine the influence of choice of cast material on the correction of congenital idiopathic clubfeet using the Ponseti method.

Method: A prospective, randomized controlled trial. Based on the results of a pilot study performed at our centre, a sample size of 30 patients was determined to be appropriate. Thirty consecutive patients presenting with congenital idiopathic clubfoot were randomized into POP and FSC groups prior to commencement of treatment with the Ponseti Method. Clubfeet secondary to non-idiopathic diagnoses were excluded. The Pirani classification was used to determine clubfoot severity (less severe, < =4; severe > 4), and for surveillance during casting. The primary outcome measure was the number of casts required to correct the clubfoot deformities to the point where the foot was ready for a percutaneous tendo-achilles tenotomy (TAL) or when the foot was completely corrected (Pirani=0). Secondary outcome measures include: number of casts by clubfoot severity, ease of cast removal, number of methods needed to remove casts, need for percutaneous tendo-achilles tenotomy.

Results: Of the 30 patients enrolled, 13 (40%) were randomized to POP and 18 (60%) to FSC. No patients were lost to follow-up. In the POP and FSC groups, eight (67%) and 11 patients (61%) underwent a TAL, respectively. In general, there were no differences in the mean number of casts required for clubfoot correction between the two groups (p=0.13). When analyzed by clubfoot severity, the mean number of casts for each material in the less severe group was equal (3 casts). In the severe group, the mean number of casts in the FSC group (6.4 casts) was considerably higher than for the POP group (4.7 casts) but our study was underpowered to verify this result. According to parents, POP was harder to remove than FSC (p< 0.001).

Conclusion: In general, FSC was found to be as efficacious as POP in the correction of idiopathic clubfeet by the Ponseti Method and was the preferred cast material by parents. For stiffer, more severe feet, POP seemed to show a faster correction time than FSC.

Purpose: Torso surface topography has reliably detected scoliosis severity. A quantification of torso shape patterns associated with healthy spines is important as a basis for scoliosis screening, monitoring progression, and evaluating treatment methods. The study objective was to examine differences in torso surface geometry associated with age and gender in healthy children.

Method: Seventy normal healthy adolescents were recruited into 3 age groups (8–11, 12–14, 15–18 years), with a goal of equal representation across groups. All consenting subjects met inclusion criterion of no history of back or neuromotor problems, and BMI ≤ 30. Torso surface topography was obtained with Inspeck optical digitizers (InSpeck Ltd., Montreal, PQ) using standard clinical protocols. Subject arm span, height, weight and activity level was recorded. Subjects stood within a positioning frame, while five scans (5s/scan) were acquired. Three-dimensional models of each torso scan were generated. Torso shape was quantified with indices based on established spine-torso shape relations in scoliosis patients. Statistical analyses (p=0.05) were performed for 4 indices: principal axis of orientation, back surface rotation (BSR), rib prominence and quarter area at S1; L3, T12& T7vertebral levels.

Results: Two groups based on gender resulted in similar age distributions with males (Group 1, n = 31) having mean age of 12.76 ± 0.07 years; and females (Group 2, n=39) having mean age 12.64±0.17 years. No statistically significant differences in torso indices were found between the entire female and male groups. When stratified by group, significant differences were obtained between the youngest male group (8–11, n=9) and both the youngest (8–11, n=8) and middle (12–14, n=18) aged females. The quarter surface areas at T7 for the youngest males were statistically significantly different from females of similar age (p=0.036), and from the next older age group (p=0.025). The BSR (p=0.033) and rib prominence (p=0.038) at the L3 level were also significantly different between the youngest males and middle aged females.

Conclusion: General torso shape indice curves can be developed for healthy children, based on a combined database of males and females. However, differences in several torso indices are present between the youngest males and the same and middle age group females.

The purpose of this study was to first determine if neuromuscular scoliosis results in greater peri-operative transfusion requirements compared to idiopathic scoliosis, and secondly to compare the effects of tranexamic acid (TXA) dosing on reducing transfusion requirements in scoliosis surgery. Previous studies have suggested that patients with neuromuscular scoliosis tend to have more blood loss during scoliosis corrective surgery as compared to patients with idiopathic scoliosis. Tranexamic acid has not been studied extensively in these populations and consensus regarding appropriate dosing has not yet been elucidated. A retrospective chart review of all patients who underwent posterior instrumentation and fusion for scoliosis for the years 1999 to 2006 was performed. Peri-operative transfusion requirements for idiopathic and neuromuscular scoliosis patients were compared and grouped according to TXA use. Transfusion requirements for those patients receiving either a low (10mg/kg loading, 1mg/kg/h infusion) or high (20mg/kg loading, 10mg/kg/h infusion) dose TXA were also compared.

Idiopathic patients had significantly decreased transfusion requirements overall (no TXA: idiopathic 1028.3 ± 558.7ml vs. neuromuscular 1400.7 ± 911.3ml, p = 0.02; with TXA: idiopathic 1082.9 ± 1005.5ml vs. neuromuscular 2043.8 ± 1397.5ml, p = 0.03). In the idiopathic group, high dose TXA resulted in a significant reduction in peri-operative transfusion requirements compared to low dose TXA (687.9 ± 778.1ml vs. 1355.0 ± 965.8ml, p = 0.04).

Neuromuscular scoliosis patients have significantly higher transfusion requirements as compared to idiopathic patients. For patients with idiopathic scoliosis, the use of the high dose TXA is suggested over low dose TXA given the relative reduction in transfusion requirements for the high dose group.