Courtney Toombs1, Baron Lonner2, Akil Fazal3, Oheneba Boachie-Adjei4, Tracey Bastrom5, Ferran Pellise6, Mohamed Ramadan7, Wael Koptan8, Yasser ElMiligui8, Feng Zhu9, Yong Qiu9, Harry Shufflebarger10. 1. Department of Orthopaedics & Rehabilitation, Yale New Haven Hospital, 20 York Street, New Haven, CT 06510, USA. 2. Mount-Sinai Beth Israel Medical Center, Department of Orthopedics, 281 1st Ave, New York, NY 10003, USA. Electronic address: blonner@scoliosisassociates.com. 3. Nairobi Spine and Orthopaedic Centre, Department of Orthopaedics, Fortis Suites, 1st Floor, Hospital Rd, Nairobi, Kenya. 4. FOCOS Orthopaedic Hospital, 8 Teshie Street, Pantang, Kanda, Accra, Ghana. 5. Pediatric Orthopedics & Scoliosis Center, Rady Children's Hospital, 3020 Children's Way, San Diego, CA 92123, USA. 6. Department of Traumatology, Orthopaedic Surgery and Emergency, Hospital Vall d'Hebron, Passeig de la Vall d'Hebron, 119-129, 08035 Barcelona, Spain. 7. Department of Orthopaedics, Tanta University, El-Gaish, Tanta Qism 2, Tanta, Gharbia Governorate, Tanta, Egypt. 8. Department of Orthopaedics and Traumatology, Cairo University, 1 Gamaa Street, P.O. Box 12613, Giza, Cairo, Egypt. 9. Spine Surgery, Nanjing University Drum Tower Hospital, 321 Zhongshan Rd, Gulou Qu, Nanjing Shi, Jiangsu Sheng, China 210008. 10. Division of Pediatric Spinal Surgery, Miami Children's Hospital, 3100 SW 62nd Ave, Miami, FL 33155, USA.
Abstract
BACKGROUND: The prevalence of adolescent idiopathic scoliosis (AIS) in diverse regions of the world has been studied. Access to care varies widely, and differences in disease severity and operative treatment outcomes are not well understood. This study aimed to determine variation in disease presentation and operative complications for AIS patients from an international cohort. METHODS: This is a retrospective study carried out at seven surgical centers in the United States (Manhattan and Miami), Ghana, Pakistan, Spain, Egypt, and China. A total of 541 consecutive patients with AIS were evaluated. Preoperative major curve magnitude, operative parameters, and complications were compared among sites using analysis of variance with post hoc tests and Pearson correlation coefficients. Univariate and multivariate forward stepwise binary logistic regressions determined the variables most predictive of complications. RESULTS: Countries with lowest-access to care (Ghana, Egypt, and Pakistan) displayed larger curves, more levels fused, longer operative time (OT), and greater estimated blood loss (EBL) than the other countries (p ≤ .001). Increasing curve magnitude was correlated with greater levels fused, longer OT, and greater EBL in all groups (p = .01). In the univariate regression analysis, Cobb magnitude, levels fused, EBL, and OT were associated with complication occurrence. Only OT remained significantly associated with complication occurrence after adjusting for Cobb magnitude, levels fused, and site (odds ratio [OR] = 1.005, 95% confidence interval 1.001-1.007, p = .003). Complications were greatest in Pakistan and Ghana (21.7% and 13.5%, respectively) and lowest in Miami (6.5%). CONCLUSIONS: Larger curve magnitudes in the least-access countries correlated with more levels fused, longer OT, and greater EBL, indicating that increased curve magnitude at surgery could explain the difference in operative morbidity between low- and high-access countries. With OT as the prevailing predictive factor of complications, we suggest that increased curve magnitude leads to longer OTs and more complications. A lack of access to orthopedic care may be the largest contributor to the postponement of treatment. LEVEL OF EVIDENCE: Level II.
BACKGROUND: The prevalence of adolescent idiopathic scoliosis (AIS) in diverse regions of the world has been studied. Access to care varies widely, and differences in disease severity and operative treatment outcomes are not well understood. This study aimed to determine variation in disease presentation and operative complications for AISpatients from an international cohort. METHODS: This is a retrospective study carried out at seven surgical centers in the United States (Manhattan and Miami), Ghana, Pakistan, Spain, Egypt, and China. A total of 541 consecutive patients with AIS were evaluated. Preoperative major curve magnitude, operative parameters, and complications were compared among sites using analysis of variance with post hoc tests and Pearson correlation coefficients. Univariate and multivariate forward stepwise binary logistic regressions determined the variables most predictive of complications. RESULTS: Countries with lowest-access to care (Ghana, Egypt, and Pakistan) displayed larger curves, more levels fused, longer operative time (OT), and greater estimated blood loss (EBL) than the other countries (p ≤ .001). Increasing curve magnitude was correlated with greater levels fused, longer OT, and greater EBL in all groups (p = .01). In the univariate regression analysis, Cobb magnitude, levels fused, EBL, and OT were associated with complication occurrence. Only OT remained significantly associated with complication occurrence after adjusting for Cobb magnitude, levels fused, and site (odds ratio [OR] = 1.005, 95% confidence interval 1.001-1.007, p = .003). Complications were greatest in Pakistan and Ghana (21.7% and 13.5%, respectively) and lowest in Miami (6.5%). CONCLUSIONS: Larger curve magnitudes in the least-access countries correlated with more levels fused, longer OT, and greater EBL, indicating that increased curve magnitude at surgery could explain the difference in operative morbidity between low- and high-access countries. With OT as the prevailing predictive factor of complications, we suggest that increased curve magnitude leads to longer OTs and more complications. A lack of access to orthopedic care may be the largest contributor to the postponement of treatment. LEVEL OF EVIDENCE: Level II.