Avascular necrosis (AVN) of the femoral head is a potential complication in patients with slipped capital femoral epiphysis (SCFE), radiographically occurring in 3–60%. This may lead to early hip fusion or hip arthroplasty. Free vascularized fibular grafting (FVFG) may provide a reasonable means to preserve the femoral head. We asked: (1) What percentage of patients with AVN after SCFE treated with FVFG underwent subsequent THA or hip fusion and what was the lifespan of the FVFG? (2) Did the graft survival rate of FVFG for AVN after SCFE coincide with historically reported rates of FVFG for idiopathic AVN? And (3) did hip function improve after FVFG? We retrospectively reviewed 52 patients who underwent FVFG for SCFE. We calculated the longevity of the graft and factors associated with graft survival. Harris hip scores (HHS) were recorded pre- and postoperatively. Minimum followup was 1 month (median, 19 months; range, 1–136 months). Five of the 52 patients (10%) underwent conversion to THA (four) or hip fusion (one). Mean age was greater in these patients than in those not requiring further procedures: 16 versus 13 years. Median graft survival time before arthroplasty/fusion was 12 years (range, 2–16 years) while it is currently 8 years (range, 2–16 years) in patients not undergoing subsequent procedures. HHSs improved 35 points on average (38 points preoperatively to 73 points postoperatively). In patients undergoing FVFG for AVN secondary to SCFE, 90% have maintained their native hips for 8 years with improved hip function, similar to other published reports of FVFG. Further followup is needed of patients currently retaining their FVFGs as to eventual conversion to THA or fusion. Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Retrospective study. Previous studies have demonstrated that increased implant density (ID) results in improved coronal deformity correction. However, low-density constructs with strategically placed fixation points may achieve similar coronal correction. The purpose of this study was to identify key zones along the spinal fusion where high ID statistically correlated to improved coronal deformity correction. Our hypothesis was that high ID within the periapical zone would not be associated with increased percent Cobb correction. We identified patients with Lenke type 1 curves with a minimum 2-year follow up. The instrumented vertebral levels were divided into 4 zones: (1) cephalad zone, (2) caudal zone, (3) apical zone, and (4) periapical zone. High and low percent Cobb correction groups were compared, high percent Cobb group was defined as percent correction >67%. Total ID, total concave ID, total convex ID, and ID within each zone of the curve were compared between the groups. A multivariable analysis was performed to identify independent predictors for coronal correction. Subsequently increased and decreased thoracic kyphosis (TK) groups were compared, increased TK was defined as post-operative TK being larger than preoperative TK and decreased TK was defined as post-operative TK being less than preoperative TK. The cohort included 68 patients. The high percent Cobb group compared with the low percent Cobb group had significantly greater ID for the entire construct, the total concave side, the total convex side, the apical convex zone, the periapical zone, and the cephalad concave zone. The high percent Cobb group had greater pedicle screw density for the total construct, total convex side, and total concave side. In the multivariate model ID and pedicle screw density remained significant for percent Cobb correction. Ability to achieve coronal balance was not statistically correlated to ID (P = .78). Increased ID for the entire construct, the entire convex side, the entire concave side, and within each spinal zone was associated with improved percent Cobb correction. The ability to achieve coronal balance was not statistically influence by ID. The results of this study support that increasing ID along the entire length of the construct improves percent Cobb correction.

Despite many surgical advances in the treatment of early onset scoliosis (EOS) over the past two decades, this condition remains a challenge to address. While otherwise healthy children can have EOS, many of these patients have complicated comorbidities making proper treatment algorithms extraordinarily difficult. Non-operative measures can be successful when initiated early, but are many times utilized as a delay tactic until growth-friendly operative procedures can be safely performed. This article will summarize the current concepts in the treatment of EOS with a focus on the surgical advances that have recently been made.

Retrospective study. The objective of this study was to compare percent correction between apical and periapical pedicle screw (PS) and sublaminar wire constructs for Cobb correction and coronal balance correction. The current gold standard for deformity correction in adolescent idiopathic scoliosis (AIS) are PS constructs. Sublaminar wires provide an alternative means of fixation when PS fixation cannot be safely performed. Two previous studies have compared percent curve correction between sublaminar wires and PSs, with conflicting conclusions. The study was a retrospective review of Lenke type 1 curves with minimum follow-up of at least 1 year. Cases were divided into two groups: constructs using apical/periapical sublaminar wires (SL group) versus PS only constructs (PS group). Percent Cobb correction and coronal balance were compared between the two groups at 1 year. A multivariable regression model was used to determine the impact of apical/periapical wires on percent Cobb correction and coronal balance at 1 year when accounting for additional variables. The cohort included 71 patients who were predominantly female (80.2%), with average age of 14.2 years. Only 21 (29.5%) of constructs utilized apical/periapical sublaminar wires. There was a significant difference in percent Cobb correction at 1 year for the PS and SL groups (70.26% vs. 60.09%, p=0.05). No difference was observed in overall coronal balance. A multivariable model revealed that apical/periapical wires were negatively associated with percent Cobb correction at 1 year (coefficient=-8.49, p=0.023), while total implant density of the construct was positively associated with correction (coefficient=24.2, p<0.001). Use of PSs in the apical and periapical zones resulted in improved percent Cobb correction at 1 year in patients with AIS Lenke type 1 curves. Sublaminar wires remain a useful surgical option and result in equivalent coronal balance compared to PSs.