Obtaining autogenous bone graft from the iliac crest can entail substantial morbidity. Alternatively, bone graft can be harvested from long bones using an intramedullary (IM) harvesting system. We measured bone graft volume obtained from the IM canals of the femur and tibia and documented the complications of the harvesting technique. Donor site pain and the union rate were compared between the IM and the traditional iliac crest bone graft (ICBG) harvest. Forty-one patients (23 male, 18 female) with an average age of 44.9 years (range, 15-78 years) had graft harvested from long bones using an IM harvest system (femoral donor site, 37 patients; tibial donor site, four patients). Forty patients (23 male, 17 female; average age, 46.4 years; range, 15-77 years) underwent anterior ICBG harvest. We administered patient surveys to both groups to determine pain intensity and frequency. IM group reported lower pain scores than the ICBG group during all postoperative periods. Mean graft volume for the IM harvest group was 40.3 mL (range, 25-75 mL) (graft volume was not obtained for the ICBG group). Using an intramedullary system to harvest autogenous bone graft from the long bones is safe provided a meticulous technique is used.

The use of thoracic pedicle screws for the treatment of adolescent idiopathic scoliosis (AIS) has gained widespread popularity. However, the placement of pedicle screws in the deformed spine poses unique challenges, and surgeons experience a learning curve. The in vivo accuracy as determined by computed tomography (CT) of placement of thoracic pedicle screws in the deformed spine as a function of surgeon experience is unknown. We undertook a retrospective review to determine the effect of surgeon experience on the accuracy of thoracic pedicle screw placement in AIS. In 2005, we started to obtain routine postoperative CT scans on patients undergoing a spinal fusion. From a database of these patients, we selected AIS patients, who underwent a posterior spinal fusion. Fifteen consecutive patients for each of the following three groups stratified by attending surgeon experience were selected (N = 45): A) less than 20 cases of all pedicle screw constructs for AIS (surgeons \2 years of practice), B) 20-50 cases (surgeons 2-5 years of practice), and C) greater than 50 cases (surgeons greater than 5 years of practice). Intraoperative evaluation of all screws included probing of the pedicle screw tract, neurophysiologic monitoring, and fluoroscopic confirmation. A total of 856 thoracic pedicle screws were studied. Postoperative CT scans were evaluated by two spine surgeons and a consensus read established as follows: (1) In: intraosseous placement or B2-mm breach, (2) Out: [2-mm breach, either medial or lateral. Of the 856 screws, 104 demonstrated a [2-mm breach, for an overall rate of 12.1% (medial = 55, lateral = 49, P = 0.67). When the breach rates were stratified by surgeon experience, there was a trend toward decreased rate of breach for the most experienced surgeons, although this did not attain statistical significance (Group A: 12.7%, Group B: 12.9%, Group C: 10.8%, P = 0.58). However, the most experienced group (C) had a markedly decreased rate of medial breaches (3.5 vs. 7.4% and 8.4% for groups A and B, respectively, P \ 0.01). The breach rate for the concave periapical screws was not statistically different from the overall breach rate (13.0% vs. 12.1%, P = 0.93). In conclusion, the overall accuracy of placement of pedicle screws in the deformed spine was 87.9%, with no neurologic, vascular, or visceral complications. Meticulous technique allows spine surgeons with a range of surgical experience to accurately and safely place thoracic pedicle screws in the deformed spine. The most experienced surgeons demonstrated the lowest rate of medial breaches.

The Ponseti method has become a popular technique to treat idiopathic clubfoot. In most cases, a percutaneous Achilles tenotomy is required to correct residual equinus contracture. Bleeding has been reported as a complication of percutaneous tenotomy. We present a case of a baby who developed a pseudoaneurysm after undergoing an appropriate Ponseti percutaneous Achilles tenotomy at the age of 8 weeks. The diagnosis of pseudoaneurysm was confirmed by color ultrasonography, which showed active flow in the base of the mass. This complication has not been previously described after Ponseti percutaneous Achilles tenotomy. The large pseudoaneurysm mass together with an incomplete correction made bracing with straight last shoes and Denis Browne bar impossible, and the patient developed an immediate relapse of the clubfoot deformity. The relapsed deformity was successfully treated with 4 weeks of additional Ponseti casting, with an emphasis on applying pressure over the pseudoaneurysm by molding the cast. Repeat ultrasonogram at that time showed that the pseudoaneurysm completely resolved, making invasive treatment of the pseudoaneurysm unnecessary. Physicians should be aware that vascular injury could lead to pseudoaneurysm after performing this otherwise simple office procedure.

Object There are few data on treatment results for patients with idiopathic infantile scoliosis (IIS). Thus, the authors have performed a retrospective review of their experience with treating these patients, particularly as newer technologies, such as the vertical expandable prosthetic titanium rib (VEPTR), emerge. Methods This retrospective study was conducted to evaluate the methods of treatment used to manage IIS at a single institution. The authors reviewed 31 consecutive patients with a primary diagnosis of IIS. Patients were screened to ensure that there were no confounding congenital anomalies or comorbidities that may have contributed to the spinal deformity. The average age at the time of initial treatment was 25 months. Treatment modalities included bracing, serial body casting, and VEPTR. Pretreatment, posttreatment, and most recent Cobb angles were compared to assess the overall curve correction, and patient charts were reviewed for the occurrence of complications. Results Of the 31 patients, 17 were treated with a brace, 9 of whom had curve progression and went on to other forms of treatment. Of the 8 who did respond, there was an overall improvement of 51.2%. The 10 patients who received body casts, who had a mean preoperative Cobb angle of 50.4°, demonstrated an average correction of 59.0%, with only a few skin irritations reported. The 10 patients treated with VEPTR devices demonstrated a mean preoperative Cobb angle of 90.0°, and an average correction of 33.8% was attained. Three of the VEPTR-treated patients (33%) experienced minor problems. Conclusions The authors' results suggest that body casting has utility for appropriately selected patients; that is, those with smaller, flexible spinal curves. Bracing had limited utility, with high levels of progression and the need for secondary treatments. The VEPTR device appears to be a viable alternative for large-magnitude curves.

Reliable electromyography (EMG) thresholds for detecting medial breaches in the thoracic spine are lacking, and there is a paucity of reports evaluating this modality in patients with adolescent idiopathic scoliosis (AIS). This retrospective analysis evaluates the ability of triggered EMG to detect medial breaches with thoracic pedicle screws in patients with AIS. We reviewed 50 patients (937 pedicle screws) undergoing posterior spinal fusion (PSF) with intraoperative EMG testing. Postoperative CT scans were used for breach identification, and EMG values were analyzed. There were 47 medial breaches noted with a mean threshold stimulus of 10.2 mA (milliamperes). Only 8/47 breaches stimulated at 2-6 mA. Thirteen of the forty-seven screws tested at an EMG value ≤6 mA and/or a decrease of ≥65% compared with intraosseously placed screws. The sensitivity and positive predictive value for EMG was 0.28 and 0.21. A subanalysis of T10-T12 screws identified six of seven medial breaches. Using guidelines from the current literature, EMG does not appear to be reliable in detecting medial breaches from T2 to T9 but may have some utility from T10 to T12.

OBJECTIVE The placement of thoracic pedicle screws, particularly in the deformed spine, poses unique challenges, and a learning curve. We measured the in vivo accuracy of placement of thoracic pedicle screws by computed tomography in the deformed spine by a single surgeon over time. METHODS After obtaining institutional review board approval, we retrospectively selected the first 30 consecutive patients who had undergone a posterior spinal fusion using a pedicle screw construct for adolescent idiopathic scoliosis by a single surgeon. The average patient age was 14 years, and their preoperative thoracic Cobb angle was, on average, 62.6 degrees. Patients were divided into 3 groups: group A, patients 1 to 10; group B, patients 11 to 20; and group C, patients 21 to 30. Intraoperative evaluation of all pedicle screws included probing of the pedicle screw tract, neurophysiologic monitoring, and fluoroscopic confirmation. Postoperative computed tomographic scans were evaluated by 2 spine surgeons, and a consensus read was established, as previously described (Kim YJ, Lenke LG, Bridwell KH, Cho YS, Riew KD. Free hand pedicle screw placement in the thoracic spine: is it safe? Spine. 2004;29(3):333–342), as (1) “in,” axis of pedicle screw within the confines of the pedicle; or (2) “out,” axis of pedicle screw outside the confines of the pedicle. RESULTS A total of 553 thoracic pedicle screws were studied (group A, n = 181; group B, n = 189; group C, n = 183) with 64 graded as out (medial, 35; lateral, 29), for an overall breach rate of 11.6%. When the breach rates were stratified by the surgeon's evolving experience, there was a temporal decrease in the breach rate (group A, 15.5%; group B, 10.6%; group C, 8.7%; P < .05). This decreased breach rate was reflected in fewer medial breaches over time (group A, 9.4%; group B, 5.8%; group C, 3.8%; P < .05). Similar trends were observed for the concave periapical screws, although statistical significance was not attained (group A, 21.2%; group B, 16.2%; group C, 10.5%). CONCLUSION The overall accuracy of placement of thoracic pedicle screws in the deformed spine was 88.4%, with no neurologic or visceral complications. One patient from group A returned to the operating room on postoperative day 2 for removal of an asymptomatic left T7 thoracic pedicle screw abutting the aorta. As surgeon experience increased, there was an overall decreased breach rate, which was mainly reflected in fewer medial breaches.

Object Few options exist for the treatment of severe, early onset scoliosis. Goals of treatment include stabilizing curve progression while allowing for normal spine, chest, and lung growth. The vertical expandable prosthetic titanium rib (VEPTR) is a novel device designed to control the spine deformity while permitting lung and spine growth. In this paper the authors report their experience with using bilateral VEPTRs from the ribs to the pelvis for children with severe, early onset scoliosis. Methods Eleven children were identified who had been treated with bilateral VEPTRs from the ribs to the pelvis. The authors conducted a retrospective review and collected the following data: clinical diagnosis, age at surgery, number of lengthening procedures, and complications. In addition, pre- and postoperative radiographs were reviewed to measure maximum Cobb angle (both thoracic and lumbar), thoracic height, total spine height as measured from T-1 to S-1, thoracic kyphosis (T2–12), and lumbar lordosis (L1–S1). Results The average patient age at surgery was 71 months; the mean preoperative thoracic Cobb angle was 81.7°. This angle was corrected to 50.6° immediately postoperatively, and this correction was maintained; at the most recent follow-up the curves averaged 58°. Similarly, the preoperative kyphosis (T2–12) angle measured 43° preoperatively, 23° immediately postoperatively, and 37° at the most recent follow-up evaluation. The patients underwent a total of 41 lengthening procedures (average 3.7 lengthening procedures per patient), and overall spine length increased from 23.1 cm preoperatively, to 27.3 cm immediately postoperatively, to 29.4 cm at the final follow-up (an average of 25 months). Four (36.4%) of the 11 patients experienced complications. Conclusions The VEPTR offers a viable treatment option for children with severe, early onset scoliosis. It achieves and maintains spinal deformity correction, while allowing for continued spine and chest-wall growth. Complication rates are similar to those reported for other growing systems.

Back pain in children is a complex phenomenon, which has been shown to be associated with physical and psychosocial factors. None of the studies on Indian children have investigated the possible association between back pain and psychosocial factors. We decided to determine the prevalence of back pain in students and association with both physical and psychosocial factors. A cross-sectional study was conducted on 163 students from two city schools. Physical factors were evaluated using a structured questionnaire. Strengths and difficulties questionnaire was used to assess psychosocial factors. The studied sample consisted of 49.7% boys and 50.3% girls. Mean school bag weight was 6.1±2.4 kg (range: 2.2–15.6 kg). Mean weight of school bag as a percentage of body weight was 13.5±6.2%. Approximately 76% students carried more than 10% of their body weight. The prevalence of back pain (over last 1 month) was 53.9%. No associations were found between back pain and weight of school bag, weight of school bag as a percentage of body weight and physical activities. Significant associations were found between back pain and number of hours spent watching television [odds ratio (OR): 3.3, 95% confidence interval (CI): 1.5–7.5; P=0.003], history of injury to the back (OR: 4.8, 95% CI: 1.47–15.8, P=0.003), presence of a family member complaining of back pain (OR: 1.98, 95% CI: 1.25–3.14, P=0.002), conduct (P=0.042) and hyperactivity problems (P=0.045). Thus, there appears a need to consider psychosocial factors along with physical factors when evaluating a young student with back pain.