Sandra Donaldson

The purpose of this paper is to review treatment strategies for simple bone cysts (SBCs). Recent studies have focused on disrupting the wall of the cyst in combination with injectable bone substitutes. Bone substitutes are minimally invasive, provide an osteoconductive scaffold, and are relatively easy to use. Many of these studies, however, have methodological issues (uncontrolled, not randomized, unblinded outcome assessment, or short-term follow-up) and inconsistent radiographic outcomes making it difficult to determine the benefits of these newer treatment strategies. Based on a single randomized clinical trial, steroids are the only evidence-based treatment for SBCs. Further basic science is needed to understand the pathoetiology and to develop future biologic solutions. Multimodal treatment strategies with opening of the medullary canal and disruption of the cyst wall, filling defect with a bone substitute, and possible biologic treatment of the cyst membrane may be the best strategy. When considering cysts of the lower extremity, structural support may be required in addition to treatment of the cyst.

Adolescents with idiopathic scoliosis who are considering spinal surgery face a major decision that requires access to in-depth information and support. Unfortunately, most online resources provide incomplete and inconsistent information and minimal social support. The aim of this study was to develop an online information and support resource for adolescent idiopathic scoliosis (AIS) patients considering spinal surgery. Prior to website development, a user-based needs assessment was conducted. The needs assessment involved a total of six focus groups with three stakeholder groups: (1) post-operative AIS patients or surgical candidates (10-18 years) (n = 11), (2) their parents (n = 6) and (3) health care providers (n = 11). This paper reports on the findings from focus groups with health care providers.

Treatment for unicameral bone cysts in long bones: an evidence based review

Background Results from clinical trials are generally not shared with participants unless they are thought to affect their future medical care. Few institutional review boards require that participants receive results of the research. Research in this area has largely focused on life-threatening medical conditions, and little is known about sharing clinical trial results in other populations. The purpose of this study was to determine the experience of patients with adolescent idiopathic scoliosis who had participated in a clinical trial and the best method for sharing clinical trial results. Methods The participants were adolescents with idiopathic scoliosis from a randomized clinical trial comparing 2 spinal implants. Patients, and their parents, were surveyed by mail before (May 2005) and after (January 2008) receiving the results of the study. The first survey focused on clinical trial experience, satisfaction with surgery, and eliciting the preferred method for receiving clinical trial results. The second survey examined patient and parent reactions to the trial results letter. Results Of 126 families who were mailed the pretrial results survey, 68% (86/126) of patients and 59% (74/126) of parents responded. Ninety-eight percent (84/86) of respondent patients and 96% (71/74) of respondent parents wanted to receive the results of the trial. Eighty-seven percent (75/86) of respondent patients and 86% (63/74) of respondent parents said the trial was a positive experience. Thirty-seven percent (32/86) of patients and 31% (23/74) of parents responded to the posttrial results survey, 25% (32/126) and 18% (23/126) of total trial participants, respectively. Sixty-three percent (20/32) of respondent patients and 70% (16/23) of respondent parents also felt that receiving the trial results by letter, with a telephone number for any questions, was the best way to receive the information. Seventy-two percent (23/32) of respondent patients and 70% (16/23) of respondent parents said they would participate in a future clinical trial. Conclusions Participating patients and parents want to know the results of research studies. Researchers should plan to inform patients by informing them of this option during the informed consent process. Levels of Evidence Cross-sectional survey.

Informed decision making for adolescents and families considering surgery for scoliosis requires essential information, including expected outcomes with or without treatment and the associated risks and benefits of treatment. Ideally families should also receive support in response to their individual concerns. The aim of this study was to identify health-specific needs for online information and support for patients with adolescent idiopathic scoliosis who have had or anticipate having spinal surgery.

Background: Simple bone cysts are common benign lesions in growing children that predispose them to fracture and are sometimes painful. The purpose of this trial was to compare rates of healing of simple bone cysts treated with intralesional injections of bone marrow with rates of healing of those treated with methylprednisolone acetate. Methods: Of ninety patients randomly allocated to treatment with either a bone-marrow or a methylprednisolone acetate injection, seventy-seven were followed for two years. The primary outcome, determined by a radiologist who was blind to the type of treatment, was radiographic evidence of healing. The cyst was judged to be either not healed (grade 1 [a clearly visible cyst] or grade 2 [a cyst that was visible but multilocular and opaque]) or healed (grade 3 [sclerosis around or within a partially visible cyst] or grade 4 [complete healing with obliteration of the cyst]). Patient function was assessed with use of the Activity Scale for Kids, and pain was assessed with the Oucher Scale. Results: Sixteen (42%) of the thirty-eight cysts treated with methylprednisolone acetate healed, and nine (23%) of the thirty-nine cysts treated with bone marrow healed (p = 0.01). There was no significant difference between the treatment groups (p > 0.09) with respect to function, pain, number of injections, additional fractures, or complications. Conclusions: Although the rate of healing of simple bone cysts was low following injection of either bone marrow or methylprednisolone, the latter provided superior healing rates. Level of Evidence: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.

Background: Although many techniques for the surgical treatment of scoliosis have been described, we are not aware of any randomized trials that have compared implant systems. The relationship between surgeons' preferences for implants and patient outcomes is unknown. The purpose of the present study was to compare quality of life and curve correction associated with use of the Moss Miami system and the Universal Spine System for spinal fusion in patients with adolescent idiopathic scoliosis. Methods: The present study was a double-blind, randomized clinical trial. All adolescent patients with idiopathic scoliosis who were scheduled for posterior instrumentation and arthrodesis with or without anterior release were screened for eligibility. Patients were randomly allocated to treatment with either the Moss Miami system or the Universal Spine System. The primary outcome measure for this trial was Quality of Life Profile for Spinal Disorders. Results: Of the 129 subjects who were enrolled in the trial, sixty (95%) of sixty-three from the Universal Spine System group and sixty (91%) of sixty-six from the Moss Miami group were included in the final analysis. Two years postoperatively, the total Quality of Life score did not differ by the clinically important value of 5.5 between the two groups (difference, 1.07; 95% confidence interval, −3.67 to 5.82; p = 0.66). The percentage of Cobb angle correction was not significantly different for thoracic curves (55.1% ± 18.3% for the Moss Miami system group, compared with 54.1% ± 18.7% for the Universal Spine System group) (difference, −1%; 95% confidence interval, −7% to 5%; p = 0.77) or lumbar curves (45.4% ± 24.6% for the Moss Miami system group, compared with 41.9% ± 26.8% for the Universal Spine System group) (difference, −4%; 95% confidence interval, −16% to 11%; p = 0.57). Although surgeons were more satisfied with the Universal Spine System (difference, 42%; 95% confidence interval, 29% to 55%; p < 0.0001), satisfaction ratings were not related to any surgical outcomes. Conclusions: The Moss Miami system and the Universal Spine Systems provided similar quality of life and curve correction. Surgeon preference may be an unreliable means of selecting implants from the patient outcomes perspective. Levels of Evidence: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.

Study Design. Cross-sectional survey. Objective. The objective of this paper was to assess the reliability of surgeons’ decision-making in adolescent idiopathic scoliosis (AIS) based on patient photographs and clinical and radiographic data. Summary of Background Data. Orthopedic spine surgeons rated severity of deformity as the most important surgical consideration in AIS. However, studies have shown that surgeon reliability is highly variable when rating physical deformity. Surgeons’ unreliable ratings of patients’ physical deformity may lead to inconsistent decision-making. Methods. Four pediatric spine surgeons viewed 40 patients with varying severity of AIS on three occasions, 2 weeks apart. In the first viewing, surgeons viewed only patient photos and body image scores. In the second viewing, surgeons viewed patient photos, body image scores, and clinical data. In the third viewing, surgeons viewed patient photos, body image scores, a 3-ft anteroposterior spinal radiograph, and corresponding radiographic data. After viewing each patient, surgeons were asked if: 1) spinal fusion with or without thoracoplasty would improve the patient’s appearance; and 2) whether they would recommend this patient for spinal fusion with or without thoracoplasty. Results. Surgeons’ concordance in recommending patients for surgery and if they thought it would improve their appearance varied widely with kappa scores ranging from poor (0.34) to good (0.76). Recommendations for surgery were more consistent with the addition of radiographs but were not influenced by patients’ body image perceptions. Surgeons’ recommendations for surgery were also inconsistent with treatment actually received with overall kappa scores ranging from poor (0.32) to good (0.73). Conclusion. Surgical decision-making for AIS is inconsistent.