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
AOPA Seattle 2009
Timothy J. Newton, C.O.
January 4th 1949-September 13th 2009
SRS
Definition of Terms
ACCEPTED
NOMENCLATURE
FOR SPINAL RELATED
CONDITIONS AND
PROCEDURES RELATED TO
SPINAL DEFORMITIES.
IDIOPATHIC
SCOLIOSIS
ORTHOTIC TREATMENT FOR
IDIOPATHIC SCOLIOSIS
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Why use an orthosis?
When do we use an orthosis?
How does an orthosis work?
How long should it be worn?
Which orthosis should I use?
Is part-time treatment effective?
What is the chance of still needing
surgery after orthotic management?
CURVE PATTERNS
AND
MEASUREMENTS
King Type I
Left Lumbar Curve
Right Thoracic Primary
Left Lumbar Compensatory
Curves.
King Type II
King Type III
King
Right Thoracic Curve
King Type IV
Thoracolumbar Curve
51°
Vertebral Rotation.
A
B
C
D
E
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.
Maturation and Development
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Vertebral Ring Apophyses.
Line of Risser.
Development of Secondary
Sex Characteristics.
Menarche.
Growth Velocity.
VERTEBRALRING
APOPHYSES
A
B
C
A. Ring Apophysis Begins To Form.
B. Ossification Complete, Not United
With Body.
C. Ossified and United With Body.
Mature.
RISSER
SIGN
Line Of Risser
Risser 1 = 25% Capping.
Risser 2 = 50% Capping.
Risser 3 = 75% Capping.
Risser 4 = 100% Capping.
Risser 5 = 100% Capping + Fusion.
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 6- 18 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.
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Side Bending Correction of Each
Curve.
Expressed As % Correction From
Normal.
% 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°.
Biological Changes
in Bone Morphology
Epiphyseal Growth Is Slowed
When Epiphyses Are
Compressed.
(Hueter-volkman Principle)
HUETER-VOLKMAN
WEDGING.
Concave Side Epiphysis
Develops at a Slower Rate
Than Convex Side Due to
Compression.
Clinical Evaluation and
Mechanism of Action
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Orthoses must be designed and fitted to:
Reduce
Curve Maximally.
Reduce Any Decompensation.
Be Easily Adjusted.
Keep Constant Force On Curves.
Be As Comfortable As Possible.
NATURAL
HISTORY:
RISK OF CURVE
PROGRESSION.
CURVE PROGRESSION
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Age.
Older
Children Are Less Likely to Progress at
Curve Magnitudes That Are Progressive in
Younger Children.
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Magnitude.
Larger
Curves Are More “Unstable” Than
Smaller.
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Curve Pattern.
Thoracic
and Double Primary Curves Progress
Less Than Single Lumbar or Thoracolumbar
Curves.
Risk of Progression by Risser Sign.
Lonstein and Carlson 1984 JBJS
% Progressed
68 %
80%
70%
60%
Risser 0-1
50%
23 %
22%
40%
30%
Risser 2-4
1.6%
20%
10%
0%
5-19 deg.
20-29 deg.
Risk of Progression by
Chronological Age.
Lonstein and Carlson 1984 JBJS
% Progressed
up to 10 yrs
100%
100%
11-12 yrs
61%
80%
60%
40%
20%
45%
37%
23%
8%
4%
13-14 yrs
16%
15 and older
0%
5-19 deg
20-29 deg
LONG-TERM CURVE PROGRESSION.
(Avg. F/U 40 Years Post Diagnosis)
From Weinstein et. al. 1984 JBJS
% Progressed
50%
29%
40%
30%
10%
20%
0%
10%
0%
< 30 Deg
30-50 Deg
50-75 Deg
Weinstein Zavala and Ponsetti
1984 JBJS
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68% progressed > 5 degrees.
37% progressed in last 10
years. (avg. F/U 40 years post
diagnosis.)
TREATMENT
OUTCOME
EXPECTATIONS.
Moe and Kettleson.
1970 JBJS
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169 Patients Treated With
Milwaukee Brace.
23% Average Correction of Thoracic
Curves Post-treatment.
18% Average Correction of Lumbar
and Thoracolumbar Curves Posttreatment.
Short Term Results.
Carr et. al.
JBJS 1980
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Re-Reviewed Moe’s Patients From 1970.
Reported on Late Losses of Correction.
Showed Late Losses of Correction.
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. 1989.
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Residual Curve as % of Initial Curve
100%
80%
63%
18 - 6 Mo. Pre
6 Pre - 6 Post
6-18 Post
Surgical Rates Following Orthotic Treatment
Based on Initial Risser Sign.
From: Milwaukee Brace Treatment Of Ais. Lonstein and Winter. JBJS 1994
% of Patients Requiring Surgery After Orthotic Treatment
60%
45%
50%
40%
Risser 0 -1
32%
30%
20%
18%
12%
Risser 2+
10%
0%
20-29 DEG
30-39 DEG
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) 664-674, 1997.)
Weighted Mean Proportion Of Success
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
99%
91%
60%
62%
49%
Control
Charleston Brace 16-Hour TLS O
23-Hour TLS O
23 Hour
Milwaukee Brace
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); 1302-1312 ,1997.
Risser 0-1 Patients Only
80%
60%
Boston
Brace
61%
41%
31%
40%
19%
20%
0%
Success (p=0.001)
Surgery (p= 0.021)
Charleston
Brace
Primary Goals.
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Correct Curves >50%.
Maintain Correction Throughout Duration
of Wear.
Address Psycho-social Issues.
Fulltime Until Proven Otherwise.
Maximal Comfort.
Minimal Structure.
Summary
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.
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4. Sound Clinical Procedures!
Summary
In-Orthosis Correction of the Curve
Should Always Exceed 50%
 Orthosis Should NOT Increase
Decompensation.
 When Curve Appears to Progress From
“Best In Brace” Magnitude, Orthosis
Should Be Adjusted To Restore Curve
Reduction.
 Weaning Should Be Gradual!
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Thank You For Your
Attention!
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