Initial Correction with the Boston Thoracic Brace

The Boston Thoracic Brace, i.e. a Boston Brace without superstructures, has been used for treatment of scoliosis in 57 patients with 91 major curves measuring 31.8 ± 6.5°, the apex of the scolioses varying from D 7 to L 3. There was a mean correction of 12.9 ± 6.4° (41 per cent), which was superior to that of the Milwaukee Brace also in the thoracic scolioses (mean correction 3.6 ± 5.8°) (10 per cent).     

Effect of the Boston thoracic brace on the frontal and sagittal curves of the spine

The purpose of the present study was to compare the sagittal and lateral curves in progressive idiopathic scoliosis treated conservatively with the Boston thoracic brace. The importance of the delordosation was confirmed. The correlation was, however, seen only between correction of the lumbar lordosis and correction of the lumbar scoliosis. The correction of the proximal thoracic scoliosis with the brace was equally good, without a similar correlation between correction of the proximal scoliosis and correction of the sagittal curves being observed.

A coupling between the correction of the two scolioses may therefore be suspected. Further, the correcting forces of the Boston thoracic brace seemed to be approximately the same, independent of the range of the scoliosis, at least between 10° and 40°.     

Operative Treatment of Scoliosis with Harrington Instrumentation Technique

Thirty-five patients with scoliosis were treated with posterior fusion including the Harrington instrumentation technique. The operation was followed by a 1-year period of treatment in a Milwaukee brace. The patients had a thoracic or a thoracolumbar curve averaging 74°. The mean initial correction was 45 per cent, and the mean final correction 33 per cent, after 2 3/4 years. There were no cases of pseudarthrosis and only one case of transient paresis. There were no deaths. It is concluded that these results are satisfactory and that the method is a safe one in experienced hands.     

Operative Treatment of Scoliosis with the Harrington Instrumentation Technique

Preliminary results of treatment of scoliosis with the Harrington instrumentation technique in 80 patients are presented. The curve correction at operation averaged 43.4 per cent with the best results being achieved in idiopathic single curves (49.3 per cent). Most of the patients had been treated conservatively for a long time prior to operation, and the curves were rather stiff. The initial loss of correction was 3.2°, and the overall loss at 2 years postoperatively averaged 6.5° in 28 patients. Complications occurred in 22.5 per cent of the patients, most often at the upper hook site. Serious complications were rare. It is concluded that the Harrington instrumentation technique is an effective means of treatment of scoliosis.     

Three-year results of bracing in scoliosis

We treated 107 patients with idiopathic scoliosis with the Boston brace. The primary correction was good in all the curve patterns. The follow-up time after weaning averaged 3 years. The best final result was achieved in thoracic and lumbar curves (mean 2°). The final correction was worse in patients with an initial curve less than 30° when compared with the patients with larger curves. Except the double major curves, there was a positive correlation between the primary correction, duration of the treatment, and the final result. The results in 14 patients with bracing for 12 hours daily did not differ from the remainder. Progression of the initial curve more than 5° after the treatment was noted in 24 patients. Three patients were operated on later because of progression. We conclude that bracing can prevent progress of scoliosis.     

Topical chemoprophylaxis with cerium (cerous) nitrate cream

In a controlled trial, burns of 28 patients dressed with a cream (SNC) containing 0·5 per cent silver nitrate and 0·2 per cent chlorhexidine gluconate, the control series, acquired Pseudomonas aeruginosa less often (9 of 270 swab samplings, 3·3 per cent) than did a comparable series of burns in 33 patients dressed with a cream (CeN) containing 1·74 per cent cerium nitrate (58 of 370 swab samplings, 16 per cent). No bacterial growth or very scanty growth (in liquid medium only) was found in 122 of 270 (45 per cent) swabs from burns in the SNC cream series and in 62 of 370 (17 per cent) swabs from burns in the CeN cream series.     

Osteotomy for kyphosis in ankylosing spondylitis

Twenty-two patients suffering from progressive kyphosis due to ankylosing spondylitis underwent one or more lumbar osteotomies during 1957-1983. The primary thoracic kyphosis was 80° (45°-155°). The mean correction obtained by one level osteotomy was 44° (30°-60°).

The mean loss of correction after 3 years was 5°. The use of internal fixation reduced the loss of correction from 9° to 1°, also allowing ambulatory after-care and a shorter period of immobilization in plaster or jackets. We had no fatal and relatively few non-fatal complications; three cases of retrograde ejaculation were observed however. All the patients reported subjective respiratory improvement.     

Effect of the Boston thoracic brace on the frontal and sagittal curves of the spine

The purpose of the present study was to compare the sagittal and lateral curves in progressive idiopathic scoliosis treated conservatively with the Boston thoracic brace. The importance of the delordosation was confirmed. The correlation was, however, seen only between correction of the lumbar lordosis and correction of the lumbar scoliosis. The correction of the proximal thoracic scoliosis with the brace was equally good, without a similar correlation between correction of the proximal scoliosis and correction of the sagittal curves being observed. A coupling between the correction of the two scolioses may therefore be suspected. Further, the correcting forces of the Boston thoracic brace seemed to be approximately the same independent of the range of the scoliosis, at least between 10 degrees and 40 degrees.     

Effectiveness of the boston brace in treatment of large curves in adolescent idiopathic scoliosis

STUDY DESIGN: This is a retrospective study of 50 patients with adolescent idiopathic scoliosis with curves measuring 35 degrees to 45 degrees who were treated with a Boston brace. OBJECTIVES: The purpose of this study was to determine whether the Boston brace could effectively halt long-term progression in skeletally immature adolescents with idiopathic scoliosis who had a curve between 35 degrees and 45 degrees. SUMMARY OF BACKGROUND DATA: The Boston brace has been shown to be effective in preventing curve progression in adolescent idiopathic scoliosis, but its efficacy in large curves has not been fully studied. METHODS: Fifty adolescents were treated with a Boston brace for idiopathic scoliosis curves of 35-45 degrees (mean, 38.55 degrees ). All were judged to be skeletally immature based on menarcheal status (mean, 2.6 months before menarche), Risser sign (mean, 0.90; range, 0-2), and chronologic age (mean, 13 +/- 1 years). Patients were recalled for long-term follow-up at a mean of 9.7 years (range, 6.23-13.22 years) after brace discontinuation. Three well-matched patient subsets were then identified based on compliance. Group 1 (n = 24) consisted of patients who were compliant with the brace program and wore the brace 18 or more hours per day, Group 2 (n = 14) contained patients who wore the brace 12-18 hours per day, and Group 3 (n = 12) contained patients who wore the brace 0-12 hours per day. RESULTS: There was a significant difference in the amount of initial correction seen in the brace between the groups: 49%, 45%, and 33% curve correction in the brace for Groups 1, 2, and 3, respectively (P < 0.05). At long-term follow-up there was a statistically significant difference between Groups 1, 2, and 3 in the percentage of patients in whom the curve had progressed to more than 45 degrees (P < 0.001), who had more than 5 degrees of curve progression (P < 0. 05), or who had undergone posterior spinal fusion (P < 0.001). CONCLUSIONS: These long-term data confirm that the Boston brace when used 18 or more hours per day is effective in preventing progression of large curves at a mean of 9.8 years after bracing is discontinued.     

The effect of lumbar flexion and Boston Thoracic Brace on the curves in idiopathic scoliosis

The correction of scoliosis induced by pure lumbar flexion was compared with the correction with the so-called Boston Thoracic Brace. Ten patients with idiopathic scoliosis were studied. There were 11 primary curves (31 +/- 6 degrees) (mainly thoracic) and four secondary curves (22 +/- 1 degree). Pure lumbar flexion reduced the primary curves by 6 +/- 2 degrees and the secondary curves by 8 +/- 3 degrees. The brace reduced the curves by 16 +/- 6 degrees and 14 +/- 5 degrees, respectively. Lumbar flexion per se produces a correction of the scoliosis of the same degree as the Milwaukee brace. Our results emphasize the importance of reduction of the lumbar lordosis in the conservative treatment of scoliosis.     

Application of a lumbar brace for thoracic and double thoracic lumbar scoliosis: a comparative study

A pilot study was performed to determine if thoracic and double thoracic lumbar scolioses can successfully be treated by applying a lumbar brace. In some of the patients application of a thoracic brace yielded insufficient correction of the lumbar curve. As the response of a curve to application of a brace is said to be the best guideline for prediction of the results of brace treatment, it was thought important to focus more attention on the behaviour of the lumbar curve. It was assumed that a lumbar brace would result in a better fit and might lead to better correction of the lumbar curve. In total 21 patients were treated according to the above-described method. Three patients were omitted from the study because of incomplete radiographic data. Thus, 18 patients treated with a thoracic brace, who showed insufficient correction of the lumbar curve, were subsequently treated with a lumbar brace. Radiographs taken in the thoracic brace patients showed a mean decrease of the thoracic curve of 9 degrees (27%) and a mean decrease of the lumbar curve of 5 degrees (16%). In the lumbar brace group the mean decrease of the thoracic curve was 7 degrees (21%) and the mean decrease of the lumbar curve was 12 degrees (38%). Brace treatment was successful (<6 degrees progression of the major curve) in 13 patients (70%). In this selection of patients with thoracic and double thoracic lumbar scoliosis a lumbar brace clearly led to a better initial correction of the lumbar curve; follow-up results seem to be comparable to those in literature.     

Physical properties of autoclaved bone: Torsion test of rabbit diaphyseal bone

Structural properties of autoclaved diaphyseal bone in the rabbit were investigated by torsional test. Heat propagation into the bone was studied by means of thermocouples. The torsional test included 54 pairs of diaphyseal bones. Autoclaving was performed to the same degree of sterilization, although with variations of time and temperature. Standard autoclaving at 121°C for 20 min was found to cause a moderate decrease (23 per cent) in torsional strength. The decrease was more pronounced (35 per cent) for bones autoclaved at 110°C for 255 min and less (9 per cent) for those autoclaved at 131°C for 2 min. Heat propagation into bone during autoclaving proved to be rapid at both 121°C and 131°C., indicating that complete, uniform sterilization of diaphyseal bone may be performed to an accurate, predetermined degree. Diaphyseal bone subjected to standard autoclaving remains mechanically adequate for skeletal substitution. Reimplantation of autoclaved tumorous bone might provide a simple combined means for tumor devitalization and subsequent reconstruction.     

Evolution of the curve patterns during brace treatment for adolescent idiopathic scoliosis

Summary of background data

The curve pattern of idiopathic scoliosis is important for making decisions concerning bracing. However, whether the curve pattern changes during brace treatment have not been fully documented. The aim of this study was to investigate the changes of curve pattern during brace treatment in skeletally immature patients with adolescent idiopathic scoliosis (AIS).

Methods

From January 2002 to January 2011, AIS patients treated with a Boston or Milwaukee brace were recruited after meeting the following inclusion criteria: older than 10 years of age at initiation of bracing; having a Cobb angle of 25°–40°; with a Risser sign 0–2; being regularly followed until the weaning of brace or the necessity of surgical treatment; and without history of previous treatment. A total of 130 female and 11 male AIS patients were included. The mean age was 12.9 years at initiation of bracing, and the female patients were, on average, 2.7 months past menarche. The mean follow-up period was 2.6 years (range 1.0–5.5 years). The definitions of changes in curve patterns were divided into four categories as follows: (1) shift of the apex of the main curve; (2) change in the curve span of more than two vertebrae; (3) change in the main curve type with regard to the apex location; and (4) change of curve direction. The patients were divided into two groups. Group A was comprised of patients who had experienced one or more categories of curve pattern changes, and Group B was comprised of those who had not.

Results

Of these 39 patients, 14 had apex shifting, 2 underwent curve span changes, 22 experienced changes in the main curve type, and one female had both changes in the apex and curve span. At the initiation of bracing, patients in Group A demonstrated significantly lower menarchal status (P = 0.018) and lower Risser grade (P = 0.025) than those in Group B. The difference in the percentage of patients who underwent Boston bracing between the two groups was statistically significant (41.5 % for Group A vs. 24.0 % for Group B, P = 0.023).

Conclusion

Changes in curve pattern can occur during brace treatment. Patients with less skeletal maturity and those treated with a Boston brace are more susceptible to this phenomenon.     

Hand burns in children under 5 years of age

In order to evaluate the epidemiology and functional results of hand burns in young children, 92 consecutive patients (126 hand burns) under age 5 years admitted to a Burn Center were reviewed. Scald burns (49 per cent) were most common, followed by flame (34 per cent), contact (14 per cent) and electrical burns (3 per cent). The child was left unattended by an adult in 53 per cent of cases and documented abuse was present in 6 per cent. The mean total body surface area (TBSA) burned was 17 per cent, and 77 patients (85 per cent) had additional burns in other areas (arms 34 per cent, legs 31 per cent, chest 29 per cent and face 27 per cent).

Palmar burns occurred in 24 hands (19 per cent), dorsal in 41 (33 per cent), while both surfaces were burned in 61 (48 per cent). Joints involved included the MP in 96 (76 per cent). PIP in 87 (69 per cent) and DIP in 80 (63 per cent). The depth was superficial partial thickness in 53 (47 per cent), deep partial in 55 (44 per cent), and full thickness in 18 hands (14 per cent); a total of 29 hands were grafted (15 deep partial and 14 full thickness). Escharotomies were required in 12 hands (9 per cent) (9 flame and 3 scald) and partial amputation of digits was required in 3 (2 per cent).

Follow-up was available in 46 hands from 7 to 120 months (mean 39 months). Partial thickness burns (34) healed with normal (32) or near-normal (2) hand function and developmental delay occurred in one patient. Hand function in 12 full thickness burns was normal in 9, decreased in 3 with developmental delay in 2 patients. The number of reoperations required per hand burned after hospital discharge varied with age (2 years and under 1.2 vs. over 2 years 0.6), depth (deep partial 0.4 vs. full thickness 1·6) and surface involved (palmar 1.3 vs. dorsal 0.1 vs. both 1.5), indicating that children under 2 years with full thickness palmar burns are at increased risk of developing burn scar deformities requiring surgical correction. Although 24 total reoperations were required in 25 deep partial and full thickness hand burns, residual burn scar deformities were present in only 2 hands at follow-up (1 boutonniere and I web space contacture).

It is concluded that the overall outcome of hand burns in this age-group is good and developmental delay is rare with proper acute management and prompt surgical correction of burn scar deformities.     

Clinical experience with biobrane® biosynthetic dressing in the treatment of partial thickness burns

Biobrane®, a synthetic, bicomposite wound dressing, has been used to treat 17 patients with partial thickness burn wounds covering 0·5–12·5 per cent of the total body surface area (mean 4·4 per cent). In 16 patients we found complete healing of the wound after removal of the dressing, 6–15 days after the injury. In one patient, the wounds were determined on the third day post-injury to be deeper than initially suspected, and she was taken to the operating room for surgical debridement and grafting. Biobrane is an effective wound covering for clean, superficial partial thickness burns of limited extent; the simultaneous use of topical antimicrobial agents for such wounds is not necessary.     

Management of pseudarthrosis after arthrodesis of the spine for idiopathic scoliosis

Sixty-three first, second, or third-time repairs of one or more pseudarthroses were done in fifty-one patients who had had an arthrodesis for idiopathic scoliosis. Forty-five of the patients were female and six were male. The average age was 30.2 years. The indications for the sixty-three repairs were pain (twenty-five repairs), progression of the curve (sixteen), both pain and progression of the curve (twelve), and radiographic changes only (ten). Failure of the implant was identified before 27 per cent of the sixty-three procedures. The pseudarthroses were diagnosed an average of 2.8 years after the initial arthrodeses. Sixty-eight per cent of the defects were visible on plain radiographs preoperatively and 32 per cent were identified at operation. During the time between the original arthrodeses and the repairs of the pseudarthroses, the scolioses increased by a mean of 7 degrees and the kyphoses, by a mean of 10 degrees. Harrington distraction was the most commonly used instrumentation (twenty-six [41 per cent] of the sixty-three procedures), and autogenous iliac bone was the most commonly used material for the graft (thirty-three [52 per cent] of the procedures).     

The state of leucocyte adhesiveness/aggregation (LAA) in the peripheral blood of burned mice: an early and sensitive inflammatory indicator and a marker of pulmonary leukostasis

The inflammatory response during thermal injury increases the adhesiveness of white blood cells. A direct slide test was used to compare the state of leucocyte adhesiveness/aggregation (LAA) in the peripheral blood of mice subjected to a thermal injury with the findings in control animals. The state of LAA in the peripheral blood increased from baseline values of 1.1 ± 1.1 per cent to 6.5 ± 1.3 per cent within 1 h and to 11.0 ± 1.2 per cent and 14.8 ± 4 per cent after 3 and 6 h respectively following thermal injury. The respective leucocyte counts were 3075 ± 277/mm³ (baseline), 3871 ± 359, 3840 ± 687 and 6395 ± 1152 cells/mm³. The LAA values had subsided by 5 days following burning and correlated with the degree of pulmonary leukostasis. Our study suggests that the LAA is an early and sensitive marker of inflammation and that it can be used as a marker for the presence of pulmonary leukostasis during thermal injury.     

Interface corrective force measurements in Boston brace treatment

Brace application has been reported to be effective in treating idiopathic adolescent scoliosis. The exact working mechanism of a thoracolumbo spinal orthosis is a result of different mechanisms and is not completely understood. One of the supposed working mechanisms is a direct compressive force working through the brace upon the body and thereby correcting the scoliotic deformity, achieving optimal fit of the individual orthosis. In this study we measured these direct forces exerted by the pads in a Boston brace in 16 patients with idiopathic adolescent scoliosis, using the electronic PEDAR measuring device (Novel, Munich, Germany). This is designed as an in-shoe measuring system consisting of two shoe insoles (size 8 1/2), wired to a computer, recording static and dynamic pressure distribution under the plantar surface of the foot. After positioning the inserts between the lumbar and thoracic pads and the body, we measured the forces acting upon the body in eight different postures. In all positions the mean corrective force through the lumbar brace pad was larger than the mean corrective force over the thoracic brace pad. Some changes in body posture resulted in statistically significant alterations in the exerted forces. There was no significant correlation between the magnitude of the compressive force over the lumbar and thoracic brace-pad and the degree of correction of the major curve. Comparing the corrective forces in a relatively new (<6 months) and old (>6 months) brace, there was no statistically relevant difference, although the corrective force was slightly larger in the new braces. We think that the use of this pressure measurement device is practicable and of value for studies of the working mechanism of brace treatment, and in the future it might be of help in achieving optimal fit of the individual orthosis.     

Effectiveness of the Providence nighttime bracing in adolescent idiopathic scoliosis: a comparative study of 36 female patients

The aim of the study was to assess the results of treatment of adolescent idiopathic scoliosis (AIS) with the Providence nighttime brace at 1.8 years after discontinuation of bracing. A total of 36 consecutive female patients with an average Cobb angle of 28.4° and an apex below T 10 were studied prospectively. For comparisons, 36 matched patients treated with the Boston full-time brace were studied retrospectively. With the Providence night brace an average of 92% for brace correction of the primary curve was achieved and during follow-up progression of the curve >5° occurred in 27% of the patients. In the control group of the Boston full-time brace patients, brace correction was 50% and the progression of the major curve occurred in 22% of the patients. We conclude that the Providence night brace may be recommended for the treatment of AIS with curves less than 35° in lumbar and thoracolumbar cases.     

Indications and results of surgical treatment of neuromuscular scoliosis]

The results of the operative treatment of 44 patients suffering from a neuromuscular scoliosis are presented. Only multisegmental procedures - also in combination with anterior methods - should be used to avoid a postoperative care with cast or brace. By means of the operation an average correction of the curves of 50.7% was achieved. The preoperative mean angle was 75.1 degrees, postoperatively a mean angle of 37.0 degrees (mean correction of 38.1 degrees) was determined. The preoperative angle, the duration of the operations, the blood loss and the quantity of the complications are higher than in idiopathic scolioses. As a result of the known tendency of deterioration in neuromuscular scolioses, the members of the Arbeitskreis Skoliose of the German Orthopaedic Society (DGOT) recommend an early operation (in progressing curves over 20 degrees) in patients suffering from a muscular dystrophy Duchenne.