Background: Vertebral body tethering (VBT) aims to gradually correct scoliosis using patients’ growth while preserving spinal motion. We report 5 to 8-year outcomes and complications in skeletally immature patients. Methods: This prospective single-center cohort study included 74 patients who had idiopathic scoliosis and a ≥5-year follow-up. Preoperative, first postoperative visit, 1-year, 2-year, and ≥5-year radiographs were analyzed. A ≥5° increase in the interscrew angle suggested tether breakage. Results: All 74 patients (5 male and 69 female) were skeletally immature at surgery. The mean age at surgery was 11.8 ± 1.3 years, and the mean follow-up time was 63.4 ± 8.4 months. Of the 74 patients, 68 patients were White, 4 were Black, and 2 were Middle Eastern or North African. VBT was performed on a mean of 7.4 vertebral levels. The maximum Cobb angle was 47.9° ± 9.4° preoperatively, whereas the instrumented Cobb angle measured 17.2° ± 12.3° at 2 years and 25.7° ± 14.0° at ≥5 years postoperatively. An unplanned return to the operating room occurred in 16 patients (21.6%). Forty-nine patients (66%) had a suspected broken tether at the final follow-up. The mean time of the first tether breakage was 38.1 ± 15 months. Forty-nine patients (66%) also had a curve of <40° without an unplanned return to the operating room at a minimum of 5 years postoperatively. Conclusions: In our cohort, 66% (49 patients) had a radiographically suspected tether breakage after 5 years and 13.5% (10 patients) required posterior spinal fusion to date. VBT yielded significant correction in the coronal plane (p < 0.001) and transverse plane (p = 0.006) postoperatively, with a reoperation rate of 21.6%. Level of Evidence: Therapeutic Level II . See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND:Vertebral body tethering (VBT) is a growth-modulating technique in treatment of AIS. While the use of a double row of screws for anchoring of the tether in the apex has been proposed to reduce the risk of tether breakage and improve correction, there is limited evidence supporting this. METHODS:Patients ≤16 years of age with AIS who underwent anterior VBT with 2-year minimum follow-up were included in the study. We performed 3 separate analyses comparing main thoracic only (T), thoracolumbar only (TL), and combined thoracic/thoracolumbar (T/TL) tether constructs used in either single-row (SRVBT) or double-row VBT (DRVBT). Independent sample t tests and χ 2 analyses were performed for comparison of characteristics and main outcomes, including percent surgical correction, rates of tether breakage, and rates of revision. RESULTS:A total of 227 patients were enrolled in the study (190 SRVBT: 37 DRVBT). Across T, TL, and T/TL cohorts, DRVBT patients were more skeletally mature based on differences in mean Rissers (2.9 vs. 0.7, P <0.05). In our TL cohorts, patients with DRVBT had significantly greater percent correction at early post-op (75% vs. 51%, P =0.003) and better correction at 2 years (DRVBT 50% vs. SRVBT 33%, P =0.279). SRVBT experienced higher rates of revision (39% vs. 7%, P =0.077) and had a higher conversion to fusion rate (23% vs. 0%, P =0.098) compared with DRVBT in the setting of a thoracolumbar tether. In our T analysis, though DRVBT had greater correction at post-op and 2 years, this was not statistically significant ( P >0.05). In addition, no significant differences were found in tether breakage (SRVBT 53% vs. DRVBT 50%, P =1.000) or revision (SRVBT 7% vs. DRVBT 0%, P =1.000). In patients with T/TL constructs, 2-year outcomes for correction, tether breakage (DRVBT 85% vs. SRVBT 79%, P =1.000), and revision (DRVBT 15% vs. SRVBT 0%, P =0.206) were statistically nondifferent between groups. CONCLUSIONS:While results of tether breakage were not statistically different between the SRVBT and DRVBT, DRVBT had greater initial and long-term correction for TL curves along with lower revision and fusion rates. LEVEL OF EVIDENCE:Level III.

Background Tether breakage is a significant complication that can occur when performing vertebral body tethering (VBT) in patients with adolescent idiopathic scoliosis (AIS). While previous studies have reported tether breakage rates, the incidence of tether breakage across medical device manufacturers and VBT models remains unknown. This study aims to define the rate of tether breakage in second-generation device systems compared with their first-generation counterparts. Methods: A retrospective analysis of a prospectively collected, multicenter registry was performed for all patients with AIS treated from 2011 to 2021 who underwent thoracic VBT with at least 2 years of follow-up. Radiographic tether breakage, as defined by an increase in adjacent screw angle >5 degrees during the postoperative period, was analyzed across the first-generation and the second-generation vertebral body tethering devices from within the same product line. Wilcoxon rank tests and Fisher’s exact tests were performed to compare differences across cohorts. Results: Two hundred thirty-one patients across 12 centers were included in the final analysis. One hundred seventy-nine patients received first-generation implants from 2011 to 2018, and 52 patients from 2017 to 2021 received second-generation vertebral body tethering devices. In total, radiographically identified tether breakage occurred in 116 patients (50%). The rate of radiographic tether breakage did not differ across generations (52% vs. 44%; P =0.46). Four patients (8%) who received the newer VBT system underwent revision compared with 15 patients (8%) who were implanted with first-generation instrumentation ( P =0.87). In addition, only 1 patient (2%) who received the second-generation device and 8 patients (4%) who received the older VBT system were converted to posterior spinal fusion within 2 years of index surgery ( P =0.69). Interestingly, the surgeon observed rate of tether breakage significantly decreased from the first generation of VBT devices to the second (21% vs. 2%; P <0.001). Conclusion: Tether breakage remains high in cases when using the new tether devices and is comparable to rates observed with the older models, despite lower rates of surgeon-reported breakage. Level of Evidence Level III.

OBJECTIVE:Rates of revision surgery following operative treatment for adult symptomatic lumbar scoliosis (ASLS) are high, mostly due to mechanical complications, including proximal junctional failure (PJF) and pseudarthrosis/rod fracture (RF). How these revisions impact long-term clinical outcomes remains unclear. The aim of this study was to assess revision rates for the two most common mechanical complications (PJF and RF) and the potential impact of these revisions on patient-reported outcome measures over 8 years of follow-up for operatively treated patients with ASLS. METHODS:This retrospective review used data from a multicenter prospective ASLS study to assess operative versus nonoperative ASLS treatment. Patients were 40-80 years of age with ASLS (Cobb ≥ 30° and Oswestry Disability Index [ODI] score ≥ 20 or revised Scoliosis Research Society 22-item questionnaire [SRS-22r] score ≤ 4.0 in pain, function/activity, and/or self-image domains). Patients who underwent long-segment posterior fusion (thoracic spine to sacrum) were assessed for the impact of revision due to mechanical complications on outcomes (SRS-22r subscore and ODI score). RESULTS:Overall, 160 patients (141 female, median age 61.31 years) met inclusion criteria. Of these, 53 (33.1%) required revision (71 revisions, 25 for PJF and 46 for RF) for mechanical complications, with 1, 2, and 3 revisions in 39, 10, and 4 patients, respectively. By 8 years of follow-up, patients had a 38% estimated risk of revision for mechanical complications. The mean time to the first and second revisions was 3.0 years (SD 2.1) and 4.8 years (SD 2.3), respectively. In unadjusted analyses, patients with ≥ 1 revision had a significant negative impact on their 8-year ODI score (mean difference 9.40, 95% CI 3.68-15.13; p = 0.0013) and SRS-22r subscore (mean difference -0.27, 95% CI -0.49 to -0.05; p = 0.0141). Patients with ≥ 2 revisions experienced the greatest impact on both their ODI score (mean difference 14.48, 95% CI 4.89-24.07; p = 0.0031) and SRS-22r subscore (mean difference -0.38, 95% CI -0.74 to -0.02; p = 0.0361), with the impact exceeding the minimum detectable measurement difference for the ODI score (7) but not the SRS-22r subscore (0.4). In adjusted analyses, these differences were attenuated for patients with ≥ 2 revisions: ODI score (mean difference 14.14, 95% CI 4.52-23.75; p = 0.0040) and SRS-22r subscore (mean difference -0.30, 95% CI -0.67 to 0.06; p = 0.1001). CONCLUSIONS:By the 8-year follow-up, revision surgery for mechanical complications was required in an estimated 38% of operative ASLS patients. Patients who underwent ≥ 1 revision had a significant negative impact on ODI score and SRS-22r subscore, and this impact was greatest with ≥ 2 revisions. These findings emphasize the need for better techniques to reduce mechanical complications in ASLS surgery.

STUDY DESIGN:Retrospective cohort. OBJECTIVE:To examine preoperative sagittal alignment using vertebral pelvic angles (VPA) in adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA:VPA describes sagittal spine shape accounting for magnitudes and distributions of sagittal curvatures. Normal adults stand with a C2Tilt (Odontoid-Hip axis) near 0° irrespective of pelvic incidence (PI) and an L1 pelvic angle (L1PA)=0.5*PI - 21( r2 =0.6). AIS is associated with thoracic hypokyphosis, though the spine "shape" has not been described. MATERIALS AND METHODS:A registry was queried for preoperative AIS patients with standardized, standing radiographs, including C2 and the hips. VPA, vertebral tilts, and PI were measured for all patients. Global balance was assessed by C2Tilt. Linear regression analyzed relationships between pelvic incidence and (1) L1PA, (2) lumbar lordosis (LL), and (3) T4 pelvic angle (T4PA). R2 measured the strength of the model fit. The correlation and the difference between T4PA and L1PA were calculated. The relationship between L1PA/T4PA and coronal Cobb angles was evaluated, controlling for PI. RESULTS:A total of 331 subjects were examined, 258 (78%) female, mean age 16.3 years (SD: 1.7), median Risser 4 (IQR: 4-5). Median C2 Tilt was 0.9° (IQR: -1.2 to 3.4°). LL did not have a meaningful relationship with PI alone ( r2 =0.1) while L1PA had a strong relationship with PI ( r2 =0.55, L1PA=0.5*pelvic incidence -19±7°). L1PA and T4PA had a nearly perfect, positive correlation ( r =0.89, P <0.001) with a tendency for T4 to be more dorsal than L1 with increasing PI. There were no relationships between thoracic/lumbar Cobb angles and L1PA. CONCLUSION:Sagittal alignments (as measured by L1PA/T4PA) and balance (as measured by C2 Tilt) in patients with AIS are similar to normal standing adults. L1PA and T4PA are strongly related to pelvic incidence, offering a reliable, patient-specific framework for description of the sagittal plane that moves beyond generic targets like thoracic kyphosis or lumbar lordosis.

Selective thoracic fusion (STF) of scoliosis due to adolescent idiopathic scoliosis in patients with flexible lumbar curves is a desirable option to preserve lumbar motion segments. No prior studies have evaluated clinical, radiographic and patient-reported outcomes of this technique at 10-year follow-up. A review of a prospectively collected multicenter database was performed for patients with Lenke 1C, 2C, 3C or 4C-type scoliosis curves treated with either STF (L1 LIV and proximal) vs non-selective fusion of both curves (NSF) (L2 LIV and distal) who had a minimum of 10-year follow-up. Baseline demographics, spinal deformity characteristics, complications, lumbar motion (forward flexion and lateral bending), and SRS-22 patient reported outcomes scores were compared at first post operative, 2-year, and 10-year follow-up. 52 NSF and 45 STF (97 total) patients were followed for 10 years after surgery. Preoperative main thoracic (MT, 62 ± 11° NSF vs 56 ± 10° STF, p = 0.02) and thoracolumbar ( TL, 52 ± 11° NSF vs 44 ± 17° STF, p < 0.001) curves were larger in the NSF group. At 10-year follow-up, patients with NSF had smaller residual lumbar curves (17° vs 23°, p < 0.001), and no difference in forward flexion or SRS-22 scores. Lateral flexion was decreased in NSF patients (p < 0.05). More NSF patients reached clinically meaningful improvement in self-image (83

The purpose of this study was to determine the potential long-term morbidity, and risk of unplanned return to the operating room (UPROR) at five years postoperative vertebral body tethering (VBT) surgery for idiopathic scoliosis. A total of 120 patients treated with VBT with five years of follow-up were included in this study. Prospectively collected clinical and radiographic data were analyzed retrospectively. Primary outcomes included radiographic Cobb angle and sagittal parameters, which were analyzed preoperatively, immediately post-operatively, and at 1, 2, and 5 years after surgery. Radiographically identified and clinical complications were categorized and reported using the modified Clavien-Dindo system (mCDS). Preoperatively, the mean patient age was 12.6 years (95

Adolescent Idiopathic Scoliosis (AIS) patients with a Lenke 5 curve pose a unique challenge due to their distinct alignment characteristics and the ambiguity surrounding whether to include the compensatory thoracic curve in the fusion construct. The aims of this study are to evaluate radiographic, alignment, and patient-reported outcome characteristics of Lenke 5 patients undergoing long vs. short posterior spinal fusion. A total of 277 Lenke 5 AIS patients were classified by surgical approach. Long fusion (LF) was defined as the upper instrumented vertebra (UIV) at levels T5 and above. Short fusion (SF) was defined as UIV at T9 or caudal. Patients were analyzed pre-operatively and at 2-year follow-up. 159 (57

Accurate, real-time assessment of spinal alignment is essential in Posterior Spinal Fusion Surgery (PSFS) for scoliosis correction. Image-guided surgery systems rely on the registration of a preoperative spine model to intraoperative images. In this work, we tackle the segmentation of vertebrae from textured 3D point clouds acquired during the surgery without any radiation. We trained a Point Transformer v3 for vertebra segmentation, demonstrating a 14.2 % improvement over prior U-Net-based architectures on the cadaveric SpineDepth benchmark. To overcome the critical scarcity of real intraoperative data, we establish a semi-synthetic training paradigm incorporating the SpineDepth data with an augmented dataset derived from 49 real scoliosis cases, featuring synthesized surgical texture. On top of that, we demonstrate the clinical feasibility of this approach through a pilot evaluation on a real intraoperative PSFS case, where our integrated method achieves promising segmentation results. This work marks a significant step toward eliminating reliance on intraoperative radiation for spinal assessment.

Vertebral body tethering (VBT) is a growth-modulating technique in treatment of AIS. While the use of a double row of screws for anchoring of the tether in the apex has been proposed to reduce the risk of tether breakage and improve correction, there is limited evidence supporting this. Patients ≤16 years of age with AIS who underwent anterior VBT with 2-year minimum follow-up were included in the study. We performed 3 separate analyses comparing main thoracic only (T), thoracolumbar only (TL), and combined thoracic/thoracolumbar (T/TL) tether constructs used in either single-row (SRVBT) or double-row VBT (DRVBT). Independent sample t tests and χ 2 analyses were performed for comparison of characteristics and main outcomes, including percent surgical correction, rates of tether breakage, and rates of revision. A total of 227 patients were enrolled in the study (190 SRVBT: 37 DRVBT). Across T, TL, and T/TL cohorts, DRVBT patients were more skeletally mature based on differences in mean Rissers (2.9 vs. 0.7, P <0.05). In our TL cohorts, patients with DRVBT had significantly greater percent correction at early post-op (75% vs. 51%, P =0.003) and better correction at 2 years (DRVBT 50% vs. SRVBT 33%, P =0.279). SRVBT experienced higher rates of revision (39% vs. 7%, P =0.077) and had a higher conversion to fusion rate (23% vs. 0%, P =0.098) compared with DRVBT in the setting of a thoracolumbar tether. In our T analysis, though DRVBT had greater correction at post-op and 2 years, this was not statistically significant ( P >0.05). In addition, no significant differences were found in tether breakage (SRVBT 53% vs. DRVBT 50%, P =1.000) or revision (SRVBT 7% vs. DRVBT 0%, P =1.000). In patients with T/TL constructs, 2-year outcomes for correction, tether breakage (DRVBT 85% vs. SRVBT 79%, P =1.000), and revision (DRVBT 15% vs. SRVBT 0%, P =0.206) were statistically nondifferent between groups. While results of tether breakage were not statistically different between the SRVBT and DRVBT, DRVBT had greater initial and long-term correction for TL curves along with lower revision and fusion rates. Level III.

Study Design Retrospective, multicenter. Objectives This study aims to evaluate the immediate postoperative effect of, and define indications for, an anterior release (discectomy) in large AIS curves utilizing 3D deformity analysis. Methods A multicenter registry was queried for AIS patients with main thoracic curves ≥70° treated with either anterior/posterior (AP) or posterior-only surgery and biplanar stereoradiographic pre-operative and first-erect (FE) postoperative images. Standard 2D radiographic and 3D parameters were analyzed using custom MATLAB software. 3D thoracic kyphosis (3DTK) was calculated by removing the error induced by axial rotation and coronal deformity. Results 109 patients were included, 21 AP and 88 posterior-only. The AP group had larger (89° vs 76°, P < .001), less flexible (9% vs 21%, P = .001) curves, though greater percent correction (79% vs 71%, P = .003), producing similar postoperative curve magnitude (19° vs 22°, P = 0.1). The AP group had less preoperative 3DTK (−15° vs −3°, P < .001), though similar postoperative 3DTK (24° vs 20°, P = .1), nearly double the improvement (39° vs 23°, P < .001). No cases with preoperative 3DTK < −18° achieved postoperative 3DTK >25° without anterior release. Segmental data of each motion segment demonstrated anterior release led to greater change in the coronal ( P < .001) and sagittal ( P = .003) planes, though not axial rotation of the apical vertebra ( P = .157). Conclusion In a cohort of AIS patients with thoracic curve magnitude >70°, 3D analysis comparing anterior/posterior vs posterior-only approach demonstrated improved correction in the coronal and sagittal, but not the axial plane. If 3DTK preop was <−18° only anterior release patients achieved postoperative 3DTK >25°. Level of Evidence III.

Background/Objectives: Adolescent idiopathic scoliosis (AIS) is a complex, three-dimensional spinal deformity that requires monitoring of skeletal maturity for effective management. Accurate bone age assessment is important for evaluating developmental progress in AIS. Traditional methods rely on ossification center observations, but recent advances in deep learning (DL) might pave the way for automatic grading of bone age. Methods: The goal of this research is to propose a new deep neural network (DNN) and evaluate class activation maps for bone age assessment in AIS using hand radiographs. We developed a custom neural network based on DenseNet201 and trained it on the RSNA Bone Age dataset. Results: The model achieves an average mean absolute error (MAE) of 4.87 months on more than 250 clinical testing AIS patient dataset. To enhance transparency and trust, we introduced Score-CAM, an explainability tool that reveals the regions of interest contributing to accurate bone age predictions. We compared our model with the BoneXpert system, demonstrating similar performance, which signifies the potential of our approach to reduce inter-rater variability and expedite clinical decision-making. Conclusions: This study outlines the role of deep learning in improving the precision and efficiency of bone age assessment, particularly for AIS patients. Future work involves the detection of other regions of interest and the integration of other ossification centers.

Anterior vertebral body tethering (AVBT) has recently been utilized as a surgical alternative to posterior spinal fusion for a subset of pediatric scoliosis patients. Indications for AVBT are evolving and, while early results have been promising, there is a paucity of literature examining the behavior of the lumbar curve after exclusive tether of the thoracic region. It was hypothesized that thoracic tether leads to a spontaneous decrease in the un-instrumented lumbar curve. The study population consisted of 166 patients with idiopathic scoliosis enrolled in the Pediatric Spine Study Group registry undergoing thoracic tether with a minimum of two-year follow-up. Exclusion criteria included: patients with non-idiopathic scoliosis, patients with prior spine surgery, and patients instrumented below L1. Overall curve correction was notable, with mean pre-op, immediate post-op, and two-year follow-up angles of 51.3°, 29.7°, and 30.3° respectively for the thoracic curve and 32.7°, 22.9°, and 24.1° respectively for the un-instrumented lumbar curve. Overall, 124 subjects (74.7

Adolescent Idiopathic Scoliosis (AIS) is the most common orthopedic condition requiring surgery, affecting 4% of adolescents. There is currently no proven method or prognostic test to identify symptomatic patients at risk of developing severe scoliosis who could benefit from growth-guided devices or minimally invasive non-fusion instrumentation surgeries. These innovative treatments must be performed at an early disease stage in younger patients to benefit from their growth potential. In this prospective cross-sectional study, we investigated the clinical utility of circulating microRNAs (miRNAs), an important class of small non-coding RNA, as biomarkers to predict the risk of developing severe scoliosis in AIS. Blood samples and clinical data were collected from 116 AIS patients who were followed until skeletal maturity and stratified according to their clinical outcome. Genome-wide expression profiling of miRNAs was performed with plasma obtained at the time of diagnosis of AIS (mean age of 13.3 ± 1.7 years with a mean Cobb angle of 24.4° ± 12.4°). This approach led to the identification of 15 circulating miRNAs that are upregulated in AIS patients who developed a severe scoliosis (Cobb angle ≥ 45°) at skeletal maturity compared to moderate and mild scoliosis groups (Cobb angle between 25°-44° and < 25° respectively). After optimization and the application of Random Forest Models a panel of six miRNAs (miR-1-3p, miR-19a-3p, miR-19b-3p, miR-133b, miR-143-3p, and miR-148b-3p) out of 15 led us to develop an algorithm predicting the risk of developing a severe scoliosis with great accuracy (100%), sensitivity (100%) and specificity (100%). Having a scoliosis predictive bioassay and decision-making tools to predict curve progression in order to find the best treatment plan will undoubtedly transform the orthopedic care system in the field of pediatric scoliosis by integrating innovative precision medicine approaches. In addition, investigation of genes targeted by these miRNAs could fill our gaps in our understanding of AIS pathogenesis and reveal new actionable targets.

INTRODUCTION:Vertebral body tethering (VBT) has continued to gain popularity for the treatment of idiopathic scoliosis (IS); however, complication and reoperation rates have been reported as high as 25%. There is a paucity of data on the clinical and long-term outcomes of VBT. The purpose of this study is to determine how complications from VBT effect patient quality of life (QOL) up to three years after surgery. METHODS:In this retrospective cohort study, the patients were identified via an analysis of multi-center electronic medical record data from the Pediatric Spine Study Group (PSSG). All patients who underwent VBT for IS were included. The dataset was screened to include only patients who had patient reported outcome data documented both before and after surgery. Patient demographics, surgery dates, complications, Early Onset Scoliosis Questionnaire (EOSQ) scores, and Scoliosis Research Society (SRS) scores were collected. Complications were classified using the modified Clavien-Dindo-Sink (mCDS) complication classification system. The analysis of QOL after surgery was determined comparing survey scores of patients with and without any complication over time. Additional analysis was similarly performed comparing patients with no or mild complications, defined as mCDS grade I and II, to those with severe complications, defined as mCDS grade IIIA or above. RESULTS:The study consisted of 339 total surveys from 81 patients with EOSQ data and 293 total surveys from 101 patients with SRS data. Among the 81 patients with EOSQ data, 15 patients experienced a complication, with eight patients suffering a severe complication. Among the 101 patients with SRS data, 42 patients experienced a complication, and 22 patients suffered a severe complication. When comparing patients with a complication to those with without a complication, patients with complications had significantly lower total EOSQ scores at 2, 2.5, and 3 years after surgery (p = 0.009, 0.001, and < 0.001 respectively); however, there was no difference in total SRS scores at any time point. In comparing patients with severe complications to pts with mild complications/no complication, patients with severe complications had significantly worse total EOSQ at 2, 2.5, and 3 years after surgery (p = 0.018, 0.002, & < 0.001) and SRS scores at 2, 2.5, and 3 years after surgery (p = 0.040, 0.018, 0.010). CONCLUSION:Patients with any complication from VBT had worse EOSQ scores at 2 years after surgery. Severe complications (mCDS > IIIA) following VBT manifest with decreasing EOSQ and SRS scores over time and become statistically significant at 2 years and beyond. The magnitude of difference in EOSQ and SRS scores between the groups also increases over time. Longer-term follow-up will ascertain whether these poorer QOL outcomes persist at time points greater than 3 years. Long-term follow up will be important following VBT to compare to PSF for improved patient and parent education.

Background: Adolescent idiopathic scoliosis (AIS) is defined as a three-dimensional spinal deformity of unknown cause that affects children between the ages of 10 and 18 years. Studies have shown that girls with AIS have different anthropometric features than their peers such as taller stature and lower body mass index. Dysfunctional energy metabolism could be involved in the discrepancies observed in AIS patients, and the gut microbiota is an important regulator of metabolic hormones. In this study, we aimed to compare gut microbiota composition, diversity and short-chain fatty acid (SCFA) between patients with AIS and healthy controls and to study their relation to metabolic hormones, anthropometry, and bone density, while taking diet and exercise into account. Methods: Nineteen age-matched pairs of AIS and control female participants were included in the study. A subset of 20 participants (9 AIS girls and 11 controls) provided fecal samples. Dietary intake and physical activity were assessed using questionnaires. Gut microbiota composition was investigated using 16S rRNA sequencing, while SCFA concentrations in feces were quantified using liquid chromatography-mass spectrometry. Results: AIS participants consumed less dietary fibers and engaged in less moderate-to-intense physical activity compared to controls. Fecal concentrations of the SCFA isobutyrate, valerate and isovalerate tended to be higher in AIS, though differences were not statistically significant. Gut microbiota α/β diversities were not statistically different between AIS participants and controls, although there were trends for differences within AIS participant α-diversity based on disease severity. Furthermore, there were several genera which trended towards being different between these populations, and our results suggest a switch in bacterial succinotypes. Additionally, correlations between fecal SCFA and adipokines or incretins were inversed in AIS participants as compared to controls. Conclusion: This pilot study suggests that gut microbiota and SCFA may be associated with AIS, but further research is needed to clarify their potential roles in disease development and progression.

Orthopaedic procedures such as percutaneous pins or sutures removal represent a potential source of pain and anxiety for the paediatric patients, as well as a source of anxiety for parents and caregivers. Pain and anxiety contribute to children and families negative trauma experience with possible long-term sequelae. The aim of this trial was to examine the effect of VR distraction compared to passive distraction for pain and anxiety relief during percutaneous pins removal and/or removal of sutures in paediatric orthopaedic clinics. It was a multicenter pragmatic randomized controlled trial (RCT) using a parallel design with two groups: 1) immersive VR and 2) control - non-immersive video game on tablet in an equal ratio of participants per group. Pain and anxiety were assessed immediately before (T0) and after (T1) the procedure, as well as one week after (T2) (memory of pain) using the Numerical Rating Scale (NRS) and the Child Fear Scale (CFS) respectively. Satisfaction scale (0-10) was used for parents and children and a satisfaction survey was delivered to caregivers after the procedure. Analyses were carried out according to the intention-to-treat principle, with a significance level (α) of 0.025, considering Bonferroni's correction. Subgroups analyses were planned for age and sex. One hundred eighty-eight participants aged from six to 17 years with a mean age of 10.8 ± 3.3 years were recruited from three tertiary centers. No statistically significant differences between the two groups were observed for pain and anxiety scores at T0, T1 and T2. However, a significant difference was observed on anxiety at T1 in favor of teenage boys over 12 years in the VR group (p=0.025). Statistically higher level of satisfaction with the use of VR was reported by parents (p=0.015) and caregivers (p=0.009) with 100% of caregivers recommending immersive VR for future non-invasive paediatric orthopaedic procedures. Procedural time was comparable for the two interventions (p=0.10). This large multicenter RCT showed no statistically significant differences in reduction of pain and anxiety in children using immersive VR compared to non-immersive video game during percutaneous pins removal and/or removal of sutures in orthopaedic clinics. However, VR was efficacious in reducing anxiety in teenage boys. Parents and caregivers were highly satisfied with the use of VR during the procedure. Even if VR is probably not the only answer for reducing pain and anxiety levels, it is part of the tools available at relatively low costs for children undergoing painful and stressful procedures in paediatric orthopaedic clinics.

Background:The relationship between tether tension and spinal growth modulation following vertebral body tethering (VBT) has not been studied in growing children. Aims:This study aims to explore the relationship between vertebral body growth modulation under varying tether tension. Materials and Methods:A retrospective, multicenter pediatric registry was queried for idiopathic scoliosis patients treated with right-sided VBT, with recorded intraoperative tension (using an ordinal scale of 0-3), and 3D reconstructions from biplanar radiographs at the first erect (FE) and 2-year post-operative visits. Custom MATLAB code was used to calculate vertebral height (mm) on the untethered and tethered sides from T5-T12. Generalized linear mixed models were used to analyze the effect of tension on vertebral body growth. Results:Fifty-two subjects (47 female) were included with a mean age of 12.5 ± 1 years. Patients were skeletally immature (triradiate cartilage open in 23 patients) with Proximal Femoral Maturity Index scores of 2 (nine patients), 3 (21 patients), 4 (20 patients), and 5 (two patients). A total of 330 vertebral bodies were analyzed. Mean height change of the vertebral bodies from FE to 2 years was 1.6 + 1.9 mm (untethered) and 1.2 + 1.8 mm (tethered). On the tethered side, greater tension resulted in less height change, with the greatest differential growth observed between maximal tension and no tension (0.8 mm vs. 0.2 mm, p = 0.02). Greater tension resulted in less vertebral body growth and greater differential growth. Future studies should quantify forces applied during VBT surgery, as well as the forces maintained in the post-operative period with spinal motion. Conclusion:Intraoperative intervertebral tensioning significantly affects vertebral body growth over 2 years.

BACKGROUND:Understanding outcomes of spinal fusion (SF) in children with cerebral palsy (CP) beyond the short term is important to determine efficacy and durability. This study examined complications, unplanned returns to the operating room (UPROR), and radiographic and clinical outcomes after SF in children with CP. METHODS:Patients with GMFCS IV or V CP who had been followed for a minimum of 5 years after SF were identified in a prospective multicenter database and analyzed. The major Cobb angle and pelvic obliquity (PO) were recorded. Data regarding complications and any UPROR were collected prospectively. The Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD) questionnaire was completed preoperatively and at 2 and 5 years postoperatively. Data were analyzed using a generalized estimating equation (GEE), repeated-measures analysis of variance (RM-ANOVA), and the Kaplan-Meier method. RESULTS:One hundred and eighty-nine patients (mean age, 13.4 ± 2.7 years; 94 male and 95 female; 45% White, 24% Hispanic, 16% Black, and 4% Asian as self-reported) were included in the study. The preoperative Cobb angle (82.8° ± 23.0°) was improved at 2 years (29.9° ± 16.2°; p < 0.001), and the improvement was maintained at 5 years (30.2° ± 17.0°; p = 0.284). The preoperative PO (27.4° ± 15.6°) was improved at 2 years (9.7° ± 9.1°; p < 0.001), and the improvement was maintained at 5 years (9.9° ± 9.8°; p = 0.997). There were 46 patients (24.3%) with major complications and 25 patients (13.2%) who required UPROR, mostly within the first year. The probability of remaining free of major complications and of having no UPROR at 5 years was >75% and >87%, respectively. Improvements in CPCHILD scores were observed at 2 years and remained improved at 5 years compared with baseline. RM-ANOVA demonstrated no significant differences in the change in scores over time in patients with complications or UPROR compared with those who did not. Those with complications or UPROR showed no evidence of a major decline in CPCHILD scores. CONCLUSIONS:SF resulted in durable radiographic correction and sustained improvements in caregiver-reported quality of life over a minimum of 5 years. Patients with major complications or UPROR showed no deterioration in CPCHILD scores. These findings support SF as an effective treatment option for appropriately selected patients with GMFCSIV or V CP. LEVEL OF EVIDENCE:Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.