Department of Epidemiology, ASL RM/E, Rome, Italy

School of Health and Social Care, University of Teesside, Middlesbrough, UK

Faculty of Health, Staffordshire University, Stoke on Trent, UK

Orthopaedic and Trauma Department, “Tzanio” General Hospital of Piraeus, Greece

University of Medical Sciences, Poznan, Poland

Department of Orthopaedic Surgery, Saitama Medical University, Kawagoe, Japan

Thriasio General Hospital, Athens, Greece

To evaluate the efficacy of bracing in adolescent patients with AIS.

Cochrane systematic review

The following databases were searched with no language limitations: the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINHAL and reference lists of articles. Extensive hand searching of grey literature was also conducted. RCT's and prospective cohort studies comparing braces with no treatment, other treatment, surgery, and different types of braces were included. Two review authors independently assessed trial quality and extracted data.

Two studies were included. There was very low quality evidence from one prospective cohort study including 286 girls¹indicating that braces curbed curve progression, at the end of growth, (success rate 74%), better than observation, (34%) and electrical stimulation (33%). Another low quality evidence from one RCT with 43 girls indicated that a rigid brace is more successful than an elastic one (SpineCor) at limiting curve progression when measured in Cobb degrees². No significant differences between the two groups in the subjective perception of daily difficulties associated with brace wearing were found.

There is very low quality evidence in favour of using braces, making generalization very difficult. The results from future studies may differ from these results. In the meantime, patients' choices should be informed by multidisciplinary discussion. Future research should focus on short and long-term patient-centred outcomes as well as measures such as Cobb angles. RCTs and prospective cohort studies should follow both the SRS and the Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) criteria for bracing studies.

It was previously postulated that the IV disc wedging is a significant progressive factor for mild IS curves. The present report introduces an innovative comprehensive model of IS curves progression based on intervertebral disc (IV) diurnal variation and the subsequent patho-biomechanics of the deforming “three joint complex”, where vertebral growth occurs.

Throughout day and night, due to sustained loading and unloading, the scoliotic wedged IV disc expels fluid and imbibes it more convex-wise. The convex side of the IV sustains a greater amount of cyclic expansion than the concave side. Consequently the imposed, convex-wise, asymmetrical concentrated cyclical loads to the adjacent immature vertebral end plates and posterior elements of the spine lead to asymmetrical vertebral growth. More specifically the loading on the two facet-joins asymmetrically increases during the day, as the wedged IV space narrows due to expelled water and it asymmetrically decreases during the night, as the IV space swells due to imbibed water.

This 24 hour period cyclic asymmetric loading leads both to asymmetric growth of the end plates and wedging of the vertebral bodies, and to similarly asymmetric growth of the pedicles and arches posteriorly as an effect of Hüeter-Volkmann law. This model explains the well described anatomical findings of the more elongated pedicles and the larger facet joints in the convex side than in the concave in scoliotic spines

The aim of school screening is to identify most or all the individuals with unrecognized idiopathic scoliosis (IS) at an early stage when a less invasive treatment is more effective. The present study summarises the contribution of school screening in research of IS epidemiology, natural history and aetiology. In addition, school screening is a unique tool for research of IS in humans, as in most published articles, all aetiopathogenetic factors are studied in animals and not in humans.

Such contribution is beyond the original aim of school screening but is very important to expand our knowledge and adequately understand the pathogenesis of IS. The role of biological factors such as the menarche, the lateralization of the brain, the handedness, the thoracic cage, the intervertebral disc, the melatonin secretion, as well as the role of environmental factors such as the light and the impact of the geographical latitude in IS prevalence were studied in children referred from school screening. The present study provides evidence to support that school screening programs should be continued not only for early detection of IS but also as a basis for epidemiological surveys until we learn much more about the aetiology of IS

Melatonin’s concentration is high in early childhood and declines gradually thereafter. In the elderly serum melatonin levels are very low. Melatonin, the “light of night”, among other functions is involved in human sexual maturation and in osteogenesis.

Hormesis is the response of cells or organisms to an exogenous (eg drug or toxin) or intrinsic factors (eg hormone), where the factor induces stimulatory or beneficial effects at low doses and inhibitory or adverse effects at high doses [bimodal dose-response] or vice versa.

At the age around 10 years, when idiopathic scoliosis may appear, the circulating melatonin level is about 120 pg/ml – positive hormesis for menses – and menarche appears. Melatonin deficiency may result in a delay of the age at menarche and consequently the girl is susceptible to scoliosis. In these terms melatonin could be certainly involved in the scoliosis pathogenesis. Around the age of 45 years when the circulating melatonin levels are about 20 pg/ml – negative hormesis for menses, menopause starts and the woman has an increased risk for osteoporosis and fractures.

It is documented the bone-protecting effect of melatonin in ovariectomized rats which can depend in part on the free radical scavenging properties of melatonin. Additionally, melatonin may impair development of osteopenia associated with senescence by improving non-rapid eye movement sleep and restoring GH secretion. Whether modulation of melatonin blood levels can be used as a novel mode of therapy for scoliosis and augmenting bone mass in diseases deserves to be studied

PURPOSE: There is an argument in the literature regarding the use of intramedullary nail or the external fixation followed by intramedullary nail in tibial fractures with severe damage of soft tissues, threatened compartment syndrome, open type IIIA fractures and in polytrauma patients. The purpose of this retrospective study was to evaluate the results of non-jointed external fixators as a definite treatment for these type of tibial shaft fractures.

MATERIAL AND METHOD: 86 patients (91 tibial shaft fractures) were treated at the authors’ institute with a non-jointed external fixator. The mean patient age was 35 years (range, 15–80). There were 70 male and 16 female patients. The average time of surgery from the accident was 10 hours. The indications for application an external fixator was: severe damage of the soft tissues in 11 fractures, an incipient compartment syndrome in 12 fractures, open type III Gustilo fractures in 57, and 11 tibia fractures in polytrauma patients. According to AO classification 46 fractures were type A, 32 type B and 13 type C.

RESULTS: The average follow up was 2.9 years (ranged, 1–5 years). The average operative time was 50 min. Complications included: 3 non-unions, 5 delayed unions, 1 malunions, 1 tibia shortening, 3 superficial infections of soft tissues in open fractures, 26 pin infections and 1 osteomyelitis in open fractures. In 2 patients fat embolism was diagnosed while pulmonary embolism was a complication in 2 patients. Deep venous thrombosis (DVT) developed in 5 patients. A re-operation was performed in 11 out of 91 fractures. Change of the method was necessary in 2 out of 91 fractures. The primary callus in 10 out of 91 fractures was due to the stiffness of the unilateral non-jointed external fixators and did not influence the final results. Mean time of fracture union for the open fractures that did not require change of the method nor bone graft was 25 weeks, while for the closed fractures was 18 weeks. The dynamization of the system and partial weight bearing was started at 6 weeks and all the patients had full weight bearing by the 12th week.

CONCLUSION: The unilateral external fixators were the definite treatment in 88 out of 91 fractures. The unilateral external fixators can be used as a definite treatment for tibial shaft fractures in the majority of the cases. Re-operation or change of the method is unusual and must be performed only when there is a delay in callus formation.

Aim: To study the postoperative results of an alternative method of pin placement for acute pelvic ring stabilization with an external fixation.

Introduction: External fixation for stabilization of pelvic ring fractures is the only and a safe method for emergency treatment. According to literature pins of the fixator should be placed urgently on the superior iliac rim and as soon as general condition of the patient permits, revision is required in order to manage in a finitive way the injury.

Material-Method: Inclusion criteria were high energy trauma, severe pelvic instability, heamodynamic instability, acute management of a pelvic fracture and minimum follow up of 2 years. Patients with a simultaneus major head, chest or abdominal injury were excluded from the study. Between 2000–01, 19 patients (15 male and 4 female with a mean age of 28 years old) underwent acute pelvic stabilization with an external fixation. In 12 patients, mechanism of injury was road accident and in 7 patients a fall from a height. Fracture type according to Tyle classification was 2 type A, 12 type B and 5 type C. In 6 patients the pins were placed in an oblique plane to the superior iliac rim (Group I) and in 13 patients there were placed in the sagital plane, just below the superior anterior iliac spine (Group II). The mean time for external fixation application was 15 min for group I and 22 min for group II.

Results: 14 patients were heamodynamically stabilized in the early postoperative period and 5 patients were transmitted to Intensive Care Unit. In 17 patients a rigid fixation of the pelvis was achieved and remained as a definite method of treatment and in 2 patients of Group I, replacement of the external fixator and an adjacent stabilization of posterior elements was required. No patient required adjacent posterior element stabilization as the primary reduction and stabilization was satisfactory. Mean time of stabilization was 7 weeks for type A, 10 weeks for type B and 11 weeks for type C fractures. 13 patients were totally recovered and returned to their previous occupation and 6 patients have minor problems that are attributed to the pelvic ring fracture.

Conclusions: External fixator’s placement for pelvic ring stabilization should be performed in a way that it will be a finitive method for osteosynthesis of the pelvis. We suggest pin placement in the sagital plane, below the superior anterior iliac spine instead of placement at the superior iliac rim.

Aim: The study of quality of life in adolescents with Idiopathic Scoliosis (IS) that are treated conservatively with a brace.

Introduction: Study of patients’ quality of life, especially of those suffering a chronic disease that requires long term treatment, is of great interest in recent years. Although there are a lot of studies for psycological sequences in IS, only a few papers in the available literature are dealing with quality of life measurement. SF-36 generic questionnaire provides the physician with valuable outcomes of treatment in patients over 14 years old.

Material-Method: Inclusion criteria were diagnosis of IS, a curve between 20o–40o, age of the child between 14–16 years old, follow up by the same physician or team, conservative treatment of IS and minimum duration of brace treatment for 2 years. Twenty-eight children, 25 girls with a mean age 14.8 years old and 3 boys with a mean age 15 years old were included in the study and filled the form of SF-36 questionnaire. All children are still wearing the brace. A control group of 30 children were also filled SF-36 form.

Results: Mean score of SF-36 questionnaire was 76.29 (SD 9.105). Most negatively affected domains are Mental Health (mean score 54.3, SD 11.5) and Vitality (mean score 62.86, SD 16.5). Physical Functioning (mean score 79.3, SD 20.7), Role limitation due to Emotional problems (mean score 76.3, SD 25.23), Social Functioning (mean score 77.9, SD 17.13), Bodily Pain (mean score 79.6, SD 19.5) and General Health Perception (mean score 77.1, SD 19.94) are less affected domains. Best scores are achieved in Role limitation due to Physical problems (mean score 96.4, SD 9.45) and Change in Health (mean score 82.1, SD 23.78) domains.

Discussion-Conclusion: This report appears that brace treatment has negative effect on childrens’ quality of life. The use of SF-36 questionnaire through detection of most affected domains provides the physician a measurable outcome for child’s quality of life in order to 1) interfere with the selected method of conservative treatment and its modalities in a way that it would less affect the child and 2) provide the child specific psychological support by the doctor, the orthotist, the parents and the various voluntary organizations.