Indications for Treatment and Outcomes Evaluation for the Orthotic Management of Idiopathic Scoliosis Thomas M. Gavin, C.O. BioConcepts, inc. Burr Ridge, Illinois, USA Musculoskeletal Biomechanics Laboratory. Veterans Administration Hospital, Hines, Illinois, USA Thomas M. Gavin, C.O. BioConcepts, inc. Burr Ridge, Illinois, USA Musculoskeletal Biomechanics Laboratory. Veterans Administration Hospital, Hines, Illinois, USA AOPA Seattle 2009

Timothy J. Newton, C.O. January 4 th 1949-September 13 th 2009

SRS Definition of Terms ACCEPTEDNOMENCLATURE FOR SPINAL RELATED CONDITIONS AND PROCEDURES RELATED TO SPINAL DEFORMITIES. ACCEPTEDNOMENCLATURE FOR SPINAL RELATED CONDITIONS AND PROCEDURES RELATED TO SPINAL DEFORMITIES.

IDIOPATHIC SCOLIOSIS

ORTHOTIC TREATMENT FOR IDIOPATHIC SCOLIOSIS n Why use an orthosis? n When do we use an orthosis? n How does an orthosis work? n How long should it be worn? n Which orthosis should I use? n Is part-time treatment effective? n What is the chance of still needing surgery after orthotic management? n Why use an orthosis? n When do we use an orthosis? n How does an orthosis work? n How long should it be worn? n Which orthosis should I use? n Is part-time treatment effective? n What is the chance of still needing surgery after orthotic management?

CURVE PATTERNS AND MEASUREMENTS

Left Lumbar Curve King Type I

Right Thoracic Primary Left Lumbar Compensatory Curves. King Type II

KingRight Thoracic Curve King Type III

Thoracolumbar Curve King Type IV

Cobb Angle 51°

ABCDE A. 0 Rotation. Neutral. No Rotation. B. +1 Rotation. Pedicle Towards Midline. Concave Direction. C. +2 Rotation. Pedicle 2/3 to Midline. D. +3 Rotation. Pedicle at Midline. E. +4 Rotation. Pedicle Beyond Midline. A. 0 Rotation. Neutral. No Rotation. B. +1 Rotation. Pedicle Towards Midline. Concave Direction. C. +2 Rotation. Pedicle 2/3 to Midline. D. +3 Rotation. Pedicle at Midline. E. +4 Rotation. Pedicle Beyond Midline. Vertebral Rotation.

Maturation and Development n Vertebral Ring Apophyses. n Line of Risser. n Development of Secondary Sex Characteristics. n Menarche. n Growth Velocity. n Vertebral Ring Apophyses. n Line of Risser. n Development of Secondary Sex Characteristics. n Menarche. n Growth Velocity.

VERTEBRALRING APOPHYSES

A BC A. Ring Apophysis Begins To Form. B. Ossification Complete, Not United With Body. C. Ossified and United With Body. Mature.

RISSER SIGN

Risser 1 = 25% Capping. Risser 2 = 50% Capping. Risser 3 = 75% Capping. Risser 4 = 100% Capping. Risser 5 = 100% Capping + Fusion. Line Of Risser

TANNER SIGNS

5 Stages of Breast and Pubic Hair Development

5 Stages of Genitalia and Pubic Hair Development

MATURITY AT ORTHOSIS INITIATION AFFECTS OUTCOMES

From Bunch and Patwardhan: Scoliosis; Making Clinical Decisions. CV Mosby Company, 1989 Bracing initiated at months Premenarchal

From Bunch and Patwardhan: Scoliosis; Making Clinical Decisions. CV Mosby Company, 1989 Bracing Initiated 6 Months Premenarchal to 6 Months Post Menarche

From Bunch and Patwardhan: Scoliosis; Making Clinical Decisions. CV Mosby Company, 1989 Bracing Initiated 6-18 Months Post-Menarche

Determining Clinical Curve Stiffness. n Side Bending Correction of Each Curve. n Expressed As % Correction From Normal. n % Correction Thoracic: % Correction Lumbar = “Flexibility Index” As Reported by King Et Al. n Side Bending Correction of Each Curve. n Expressed As % Correction From Normal. n % Correction Thoracic: % Correction Lumbar = “Flexibility Index” As Reported by King Et Al.

A. B.C. A. Normal Coronal Alignment. B. Right Side Bending. Primary Thoracic Curve Resists Corrective Forces. C. Left Side Bending. Compensatory Lumbar Curve Corrects To Nearly 0°. A. Normal Coronal Alignment. B. Right Side Bending. Primary Thoracic Curve Resists Corrective Forces. C. Left Side Bending. Compensatory Lumbar Curve Corrects To Nearly 0°.

Biological Changes in Bone Morphology Epiphyseal Growth Is Slowed When Epiphyses Are Compressed. (Hueter-volkman Principle) Epiphyseal Growth Is Slowed When Epiphyses Are Compressed. (Hueter-volkman Principle)

HUETER-VOLKMAN WEDGING. WEDGING. Concave Side Epiphysis Develops at a Slower Rate Than Convex Side Due to Compression. HUETER-VOLKMAN WEDGING. WEDGING. Concave Side Epiphysis Develops at a Slower Rate Than Convex Side Due to Compression.

Clinical Evaluation and Mechanism of Action n Orthoses must be designed and fitted to: u Reduce Curve Maximally. u Reduce Any Decompensation. u Be Easily Adjusted. u Keep Constant Force On Curves. u Be As Comfortable As Possible.

NATURAL HISTORY: RISK OF CURVE PROGRESSION.

CURVE PROGRESSION n Age. u Older Children Are Less Likely to Progress at Curve Magnitudes That Are Progressive in Younger Children. n Magnitude. u Larger Curves Are More “Unstable” Than Smaller. n Curve Pattern. u Thoracic and Double Primary Curves Progress Less Than Single Lumbar or Thoracolumbar Curves. n Age. u Older Children Are Less Likely to Progress at Curve Magnitudes That Are Progressive in Younger Children. n Magnitude. u Larger Curves Are More “Unstable” Than Smaller. n Curve Pattern. u Thoracic and Double Primary Curves Progress Less Than Single Lumbar or Thoracolumbar Curves.

Risk of Progression by Risser Sign. Lonstein and Carlson 1984 JBJS

Risk of Progression by Chronological Age. Lonstein and Carlson 1984 JBJS

LONG-TERM CURVE PROGRESSION. (Avg. F/U 40 Years Post Diagnosis) From Weinstein et. al JBJS

Weinstein Zavala and Ponsetti 1984 JBJS n 68% progressed > 5 degrees. n 37% progressed in last 10 years. (avg. F/U 40 years post diagnosis.) n 68% progressed > 5 degrees. n 37% progressed in last 10 years. (avg. F/U 40 years post diagnosis.)

TREATMENT OUTCOME EXPECTATIONS.

Moe and Kettleson JBJS n 169 Patients Treated With Milwaukee Brace. n 23% Average Correction of Thoracic Curves Post-treatment. n 18% Average Correction of Lumbar and Thoracolumbar Curves Post- treatment. n Short Term Results. n 169 Patients Treated With Milwaukee Brace. n 23% Average Correction of Thoracic Curves Post-treatment. n 18% Average Correction of Lumbar and Thoracolumbar Curves Post- treatment. n Short Term Results.

Carr et. al. JBJS 1980 n Re-Reviewed Moe’s Patients From n Reported on Late Losses of Correction. n Showed Late Losses of Correction. n Results Showed Residual Curves Still Less Than Pre-orthosis Magnitude. n Re-Reviewed Moe’s Patients From n Reported on Late Losses of Correction. n Showed Late Losses of Correction. n Results Showed Residual Curves Still Less Than Pre-orthosis Magnitude.

Residual Curve 5-Years Post-Treatment By Menarche Value at Initiation Of Orthosis. Bunch and Patwardhan, Chapter 13, Scoliosis; Making Clinical Decisions

Surgical Rates Following Orthotic Treatment Based on Initial Risser Sign. From: Milwaukee Brace Treatment Of Ais. Lonstein and Winter. JBJS 1994

Bunch Reported Best Curve Reduction for Youngest Group and Lonstein Reported Highest Surgical Rates for Youngest Group?

Orthotic Outomes; Failure Boundary

PART-TIME VERSUS FULL-TIME

A META-ANALYSIS OF THE EFFICACY OF NONOPERATIVE TREATMENT FOR IDIOPATHIC SCOLIOSIS. Rowe et al. - J Bone and Joint Surgery [Am]. 79-A (5) , 1997.)

A Comparison Between The Boston Brace And The Charleston Bending Brace In Adolescent Idiopathic Scoliosis. Katz DE, Richards S, Browne RH, Herring JA. Spine, 22(12); ,1997.

Primary Goals. n Correct Curves >50%. n Maintain Correction Throughout Duration of Wear. n Address Psycho-social Issues. n Fulltime Until Proven Otherwise. n Maximal Comfort. n Minimal Structure. n Correct Curves >50%. n Maintain Correction Throughout Duration of Wear. n Address Psycho-social Issues. n Fulltime Until Proven Otherwise. n Maximal Comfort. n Minimal Structure.

SummarySummary n Orthoses Must Improve Stability To Yield Optimal Outcome! Optimizing Orthotic Treatment Requires; 1. Proper Patient Selection (Age, Magnitude, Documented Progression). 2. Utilization of All Mechanisms of Action to Improve Stability. 3. Frequent Follow-Up Adjustments To Restore Orthosis to Optimal Fit and Function. 3. Frequent Follow-Up Adjustments To Restore Orthosis to Optimal Fit and Function. 4. Sound Clinical Procedures! 4. Sound Clinical Procedures! n Orthoses Must Improve Stability To Yield Optimal Outcome! Optimizing Orthotic Treatment Requires; 1. Proper Patient Selection (Age, Magnitude, Documented Progression). 2. Utilization of All Mechanisms of Action to Improve Stability. 3. Frequent Follow-Up Adjustments To Restore Orthosis to Optimal Fit and Function. 3. Frequent Follow-Up Adjustments To Restore Orthosis to Optimal Fit and Function. 4. Sound Clinical Procedures! 4. Sound Clinical Procedures!

n In-Orthosis Correction of the Curve Should Always Exceed 50% n Orthosis Should NOT Increase Decompensation. n When Curve Appears to Progress From “Best In Brace” Magnitude, Orthosis Should Be Adjusted To Restore Curve Reduction. n Weaning Should Be Gradual! SummarySummary

Thank You For Your Attention!