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Thomas M. Gavin, C.O. BioConcepts, inc. Burr Ridge, Illinois, USA

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.

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Thomas M. Gavin, C.O. BioConcepts, inc. Burr Ridge, Illinois, USA

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  1. 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

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

  3. SRS Definition of Terms ACCEPTED NOMENCLATURE FOR SPINAL RELATED CONDITIONS AND PROCEDURES RELATED TO SPINAL DEFORMITIES.

  4. IDIOPATHIC SCOLIOSIS

  5. ORTHOTIC TREATMENT FOR IDIOPATHIC SCOLIOSIS • 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?

  6. CURVE PATTERNS AND MEASUREMENTS

  7. Left Lumbar Curve King Type I

  8. Right Thoracic Primary Left Lumbar Compensatory Curves. King Type II

  9. King Right Thoracic Curve King Type III

  10. King Type IV Thoracolumbar Curve

  11. Cobb Angle 51°

  12. 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.

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

  14. VERTEBRALRING APOPHYSES

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

  16. RISSER SIGN

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

  18. TANNER SIGNS

  19. 5 Stages of Breast and Pubic Hair Development

  20. 5 Stages of Genitalia and Pubic Hair Development

  21. MATURITY AT ORTHOSIS INITIATION AFFECTS OUTCOMES

  22. From Bunch and Patwardhan: Scoliosis; Making Clinical Decisions. CV Mosby Company, 1989 Bracing initiated at 6- 18 months Premenarchal

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

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

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

  26. B. C. A. 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°.

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

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

  29. Clinical Evaluation and Mechanism of Action • 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.

  30. NATURAL HISTORY:RISK OF CURVE PROGRESSION.

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

  32. Risk of Progression by Risser Sign.LonsteinandCarlson 1984 JBJS

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

  34. LONG-TERM CURVE PROGRESSION.(Avg. F/U 40 Years Post Diagnosis)From Weinstein et. al. 1984 JBJS

  35. Weinstein Zavala and Ponsetti1984 JBJS • 68% progressed > 5 degrees. • 37% progressed in last 10 years. (avg. F/U 40 years post diagnosis.)

  36. TREATMENT OUTCOME EXPECTATIONS.

  37. Moe and Kettleson.1970 JBJS • 169 Patients Treated With Milwaukee Brace. • 23% Average Correction of Thoracic Curves Post-treatment. • 18% Average Correction of Lumbar and Thoracolumbar Curves Post-treatment. • Short Term Results.

  38. Carr et. al.JBJS 1980 • 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.

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