James O. Sanders

Purpose: The primary concerning outcome in early onset scoliosis (EOS), pulmonary function, is challenging to measure in children. Surrogate measures, including thoracic length and curve magnitude, poorly predict patient outcomes. Activity capacity as determined by Metabolic Equivalents of Task (MET) is a potentially useful alternative or adjunct since it more directly reflects the tasks being performed. The objective of this pilot study was to assess MET values for varying intensity activities in children with EOS and explore their relationship to pulmonary function indices, scoliosis characteristics, and patient-reported outcome measures. Methods: For this pilot study, basal metabolic rate and physical activity MET values were measured using indirect calorimetry. MET values were assessed while performing video games representing low (bowling), moderate (boxing), and high intensity (active running) activities, and treadmill walking at low, moderate, and high intensity. MET values were compared to age-matched standardized energy expenditure values in youth (METy) for similar tasks. Pulmonary function testing was assessed using spirometry with percent predicted values based on arm span. Patient outcomes were obtained for each participant through the 24-question Early-Onset Scoliosis Questionnaire (EOSQ-24) and select assessments from the Patient-Reported Outcomes Measurement Information System (PROMIS). A linear mixed model assessed differences between groups. Spearman correlation coefficients assessed relationships between variables. Results: Eight children (ages 6-16y, 50% female) completed testing. Etiologies for scoliosis were congenital ( n = 3), syndromic ( n = 3), and idiopathic ( n = 2). Five had spirometry suggestive of severe restriction (FVC and FEV ₁ < 50% predicted). Children with EOS had a 0.6 lower mean MET video game value compared to published METy values ( p < 0.001). Increased intensity corresponded with increased MET values comparing hard to moderate and low intensities ( P < 0.001). Average percent predicted MET values across all tasks revealed a negative correlation with FEV ₁ /FVC ( R = − 0.927, p = 0.024). All eight children completed the low-intensity treadmill and low and moderate-intensity videogames; seven completed the moderate-intensity treadmill and high intensity videogame. Only five completed the high-intensity treadmill. Conclusion: MET values in children with EOS were directionally similar to values in normal children. Children unable to generate higher MET values appear to self-limit their activity. The relationship between MET and pulmonary function is complex and requires further exploration. Children with EOS and pulmonary impairment appear unable to generate the energy required for more vigorous activities. This could be due to poor pulmonary function, deconditioning from their underlying condition, or limitations in the tested video games. Level of evidence: II.

Purpose: This study describes spinal growth and predicts future growth by standardizing timing relative to the growth spurt. Methods: From a longitudinal cohort of normal, healthy children followed through their growth, we identified those who completed their growth and compared spinal heights to chronological age and timing relative to the growth spurt. Anthropometrics and radiographs were correlated to identify heights to C1, T1, and S1 using three separate methods with validation performed by comparing to heights predicted by pelvic width. Heights and spinal lengths were normalized to percentages of adult lengths, and multipliers of growth remaining determined for both age and timing relative to PHV_90% (peak height velocity defined by achieving 90% of final height) as adult length divided by current spine length. The age at PHV_90% is termed Peak Growth Age (PGA)_90%. Results: Fifty-four subjects completed their growth at the study terminus (35f, 19 m). We identified multipliers allowing calculations of adult spine length based on the child’s current timing relative to peak growth. At PHV_90%, children were 90% adult total height and 87% adult spine height. During childhood, spinal growth is 1.55 ± 0.21 cm/yr in girls, 1.14 ± 0.23 cm/yr in boys increasing to 1.75 ± 0.11 cm/yr in girls and 2 ± 0.11 cm/yr in boys during the growth spurt. Conclusion: This study identifies multipliers of spinal growth determination and identifies their values relative to the adolescent growth spurt timing which is known to be closely related to skeletal maturity. Timing compared to the PGA_90% provides reliable predictions of final spine length for both sexes.

Background: Severe adolescent idiopathic scoliosis (AIS) can be treated with instrumented fusion, but the number of anchors needed for optimal correction is controversial. Methods: 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%. Results: 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). Conclusions: 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. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

TGFβ1 induces age-related bone loss by promoting degradation of TNF receptor-associated factor 3 (TRAF3), levels of which decrease in murine and human bone during aging. We report that a subset of neutrophils (TGFβ1⁺CCR5⁺) is the major source of TGFβ1 in murine bone. Their numbers are increased in bone marrow (BM) of aged wild-type mice and adult mice with TRAF3 conditionally deleted in mesenchymal progenitor cells (MPCs), associated with increased expression in BM of the chemokine, CCL5, suggesting that TRAF3 in MPCs limits TGFβ1⁺CCR5⁺ neutrophil numbers in BM of young mice. During aging, TGFβ1-induced TRAF3 degradation in MPCs promotes NF-κB-mediated expression of CCL5 by MPCs, associated with higher TGFβ1⁺CCR5⁺ neutrophil numbers in BM where they induce bone loss. TGFβ1⁺CCR5⁺ neutrophils decreased bone mass in male mice. The FDA-approved CCR5 antagonist, maraviroc, reduced TGFβ1⁺CCR5⁺ neutrophil numbers in BM and increased bone mass in aged mice. 15-mon-old mice with TGFβRII specifically deleted in MPCs had lower numbers of TGFβ1⁺CCR5⁺ neutrophils in BM and higher bone volume than wild-type littermates. We propose that pharmacologic reduction of TGFβ1⁺CCR5⁺ neutrophil numbers in BM could treat or prevent age-related osteoporosis.

Background: Despite its importance for clinical decisions, the long-term consequences of posterior spinal instrumentation and fusion (PSIF) for adolescent idiopathic scoliosis (AIS), particularly in the lower lumbar spine, remain unclear. This study evaluates the long-term health-related quality of life and the need for a further surgical procedure in patients treated with Harrington instrumentation from 1961 to 1977 according to the lowest instrumented vertebra (LIV) and in comparison with age-matched norms. Methods: A search was performed to identify and contact the 314 identified patients with AIS treated with PSIF by Dr. L.A. Goldstein. The assessment included identified subsequent spine surgery, the Oswestry Disability Index (ODI), Scoliosis Research Society-7 (SRS-7), EuroQol-5 Dimensions (EQ-5D), and Patient-Reported Outcomes Measurement Information System-29 (PROMIS-29). The health-related quality of life was compared with U.S. norms and, within the cohort, was compared by patient factors, LIV, and subsequent spine surgery. Results: In this study, 134 patients (42.7%) were identified; 24 (7.6%) had died, 81 (25.8%) consented to participate in the study, and 29 (9.2%) declined participation. The mean follow-up was 45.4 years (range, 40 to 56 years). There were 81 patients who completed the surveys, 77 patients who completed the SRS-7, 77 patients who completed the ODI, and 76 patients who completed the PROMIS-29 and EQ-5D. There were 12.8% of patients with LIV L3 or proximal and 36.4% with LIV L4 or distal who had an additional surgical procedure (odds ratio, 3.98). Comparing the ODI of patients who had undergone an additional surgical procedure with those who had not showed 42% and 73% minimal disability, 53% and 23% moderate disability, and 5% and 2% severe disability. Of the patients who had not undergone an additional surgical procedure, those with LIV L3 or proximal had mean scores of 14.12 points for the ODI and 23.3 points for the SRS-7 and those with LIV L4 or distal had mean scores of 17.9 points for the ODI and 22.7 points for the SRS-7; these differences were not significant. The mean PROMIS-29 and EQ-5D scores were not different from normal U.S. age-based means. Conclusions: Patients with AIS treated with PSIF at a mean 45-year follow-up and LIV L4 or distal had a higher rate of undergoing an additional surgical procedure than those with LIV L3 or proximal. Patients undergoing an additional surgical procedure had lower health-related quality of life than those who did not. Despite this, there was no difference in health-related quality of life for patients with LIV L4 or distal compared with patients with LIV L3 or proximal. This cohort of patients with AIS treated with PSIF demonstrates normal self-reported health-related quality of life compared with the age-matched general population. These long-term outcomes of PSIF for AIS are encouraging. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background: The ability to make a continuous skeletal maturity estimate from a wrist radiograph would be useful in the treatment of adolescent forearm fractures, scoliosis, and other conditions. We attempted to create a reliable, rapid, and accurate method to do this. Methods: Many anteroposterior wrist radiographic parameters from 3 skeletal maturity systems were simplified to 23 based on relevance to the peripubertal age range, univariate correlation with skeletal maturity, and reliability. These 23 parameters were evaluated on serial peripubertal anteroposterior hand-wrist radiographs. We determined the Greulich and Pyle (GP) skeletal age and Sanders hand system (SHS) stage. We used stepwise linear regression and generalized estimating equation (GEE) procedures to identify important radiographic and demographic parameters for estimating skeletal maturity, creating the “Modified Fels wrist skeletal maturity system.” Its accuracy predicting skeletal maturity was evaluated and compared with that of 4 other systems: (1) GP system, (2) SHS, (3) GP parameters along with age and sex, and (4) SHS parameters along with age and sex. Results: Three hundred and seventy-two radiographs of 42 girls (age range, 7 to 15 years) and 38 boys (age range, 9 to 16 years) were included. Fifteen radiographic parameters were excluded from the Modified Fels wrist system by stepwise regression and GEE analyses, leaving age, sex, and 8 radiographic parameters in the final model. Use of the Modified Fels wrist system resulted in more accurate skeletal maturity estimations (0.34-year mean discrepancy with actual skeletal maturity) than all other systems (p < 0.001 for all). The Modified Fels wrist system had a similar rate of outlier skeletal maturity estimations as the age, sex, and SHS model (1.9% versus 3.5%, p = 0.11) and fewer outliers than all other systems (p < 0.05 for all). Conclusions: A system that included demographic factors and 8 anteroposterior wrist radiographic parameters estimates skeletal maturity more accurately than the 2 most-used skeletal maturity systems in the United States. Clinical Relevance: The Modified Fels wrist skeletal maturity system may allow for more accurate, reliable, and rapid skeletal maturity estimation than current systems, and also may be used when treating adolescent forearm fractures as it does not require imaging past the metacarpals. Level of Evidence: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: Several methods are available to estimate leg lengths at maturity to facilitate the determination of timing of epiphysiodesis. We compared the Paley multiplier, Sanders multiplier, and White-Menelaus methods in an epiphysiodesis-aged cohort. We assessed intra- and interrater reliability for Sanders skeletal stages and Greulich and Pyle atlas skeletal age. Methods: Actual growth was recorded in healthy, unoperated femoral and tibial segments from an epiphysiodesis database. The predicted and actual lengths were compared with use of the Paley multiplier and White-Menelaus methods, Greulich and Pyle skeletal age, and the Sanders multiplier using Sanders stages. Intra- and interrater reliability were assessed in a separate group of 76 skeletal age films. Results: The cohort included 148 femora and 195 tibiae in 197 patients. Femoral length at maturity was slightly underestimated by the Sanders multiplier and staging, was overestimated by the Paley multiplier and skeletal age, and was most accurately predicted with use of the White-Menelaus formula and skeletal age. All methods overestimated tibial length at maturity. The whole-leg prediction accuracy of the Sanders multiplier and White-Menelaus formula were comparable and were more accurate than that of the Paley multiplier. For Sanders skeletal staging, the interrater reliability varied from 0.86 to 0.88 and the intrarater reliability varied from 0.87 to 0.96. For Greulich and Pyle skeletal age, the interrater reliability varied from 0.87 to 0.89 and the intrarater reliability varied from 0.91 to 0.95. Conclusions: Use of the Sanders multiplier and skeletal stages was more accurate than the Paley multiplier and skeletal age in this cohort. Use of the White-Menelaus formula and skeletal age was slightly more accurate in predicting femoral length and slightly less accurate in predicting tibial length compared with the Sanders multiplier. Intra- and interrater reliability were similar between Sanders skeletal stages and Greulich and Pyle atlas skeletal age. The White-Menelaus formula and skeletal age was the recommended method for predicting lower-extremity segment lengths at maturity and epiphysiodesis effect. Although easier to recall without referencing an atlas and not sex-specific, Sanders skeletal staging does not correspond directly to years of growth remaining, and thus cannot be used with the White-Menelaus formula. Clinical Relevance: The Greulich and Pyle atlas to determine skeletal age and the White-Menelaus formula to determine growth remaining are reliable predictors of epiphysiodesis effect in the lower extremities.

Case: Isolated unilateral congenital patellar tendon absence is a rare condition that has not been well described. We report on 2 patients with congenital patellar tendon absence that underwent soft-tissue reconstruction of their patellar tendon. We present the clinical and radiographic features, surgical management with both single-stage and multistage approaches, and postoperative outcomes for the treatment of this condition. Conclusion: Soft-tissue reconstruction of the patellar tendon led to satisfactory outcomes, providing active knee extension and improved ambulation in both cases. In cases of significant superior migration, multiple procedures may be required to mobilize the patella to an appropriate position.