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Reliability of radiographic assessment of growth modulation from anterior vertebral body tethering surgery in pediatric scoliosis

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Abstract

Purpose

To assess the reliability of vertebral height and angular measurements for anterior vertebral body tethering (AVBT).

Methods

Eight observers measured PA radiographs of 15 idiopathic scoliosis patients treated with AVBT, pre-operative and 4-year follow-up. Vertebral wedging, disc wedging, convex vertebral body heights, and concave vertebral body heights of the 3 apical vertebrae were measured. For each observer, there were a total of 90 measurements for vertebral body height and 75 measurements for all wedging types At least 14 days elapsed between first and second round measurements.

Results

From the pre-operative to the 4-year follow-up time-point, the total wedging angle over the 3 peri-apical levels fell from 30 ± 7° to 16 ± 6° (p < 0.001) and the difference between the convex and concave vertebral heights decreased from 9 ± 4 to 6 ± 3 mm (p < 0.001). Interobserver agreement for pre-operative vertebral body heights was good [ICC = 0.80; 95% CI (0.74–0.85)]. At 4-year follow-up there was a moderate agreement [ICC = 0.67 (0.59–0.74)]. There was a poor interobserver agreement for pre-operative wedging angle measurements [ICC = 0.41 (0.32–0.52)] and 4-year follow-up [ICC = 0.45 (0.36–0.56)]. The Limits of Agreement with the Mean (LOAM) for pre-op heights was ± 2.4 mm, similar to the follow-up ± 2.6 mm. When raters are averaged in random groups of two the agreement limits decrease to ± 1.8 mm pre-op and ± 1.6 mm at follow-up. Similarly for wedging angles, LOAM values among the 8 observers of ± 4.6° pre-op and ± 4.2° dropped to ± 2.7° for both pre-op and follow-up when random groups of two raters were averaged together. Intraobserver agreement ranged from good to excellent per individual (ICC = 0.84–0.94) for pre-operative vertebral body heights, but this decreased at 4-year follow-up (ICC = 0.52–0.88). Intraobserver agreement was low overall for wedging (pre-operative ICC = 0.41–0.71; 4-year follow-up ICC = 0.41–0.76).

Conclusion

Based on 8 individual observers, interobserver agreement ranged from good (pre-operative vertebral body heights) to moderate (4-year follow-up vertebral body heights) to poor (all wedging angles). To improve the reliability of the measurement of wedging angles, we recommend averaging the measurements of at least two observers.

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Data availability

Registry data is available to member institutions. Measurements and analysis done at the IWK Health Centre are on a password protected server. Access may be arranged through application to the REB.

Code availability

Statistical analysis was conducted using Excel version 2002 (Microsoft Corporation, Redmond, Washington, USA) and SPSS version 27.0 (IBM Corp, Armonk, NY, USA).

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Funding

Funding was received for this study from the Dalhousie University Medical Research Foundation W. Alan Curry Studentship.

Author information

Authors and Affiliations

  1. Faculty of Medicine, Dalhousie University, Halifax, NS, Canada

    Gregory Photopoulos & Ron El-Hawary

  2. Division of Orthopedic Surgery, IWK Health Centre, 5850 University Avenue, P.O. Box 9700, Halifax, NS, B3K6R8, Canada

    Gregory Photopoulos, Jennifer Hurry & Ron El-Hawary

  3. Department of Orthopaedic Surgery, Children’s Healthcare of Atlanta, Atlanta, GA, USA

    Joshua Murphy & Kenneth Shaw

  4. Department of Orthopaedic Surgery, Scottish Rite for Children Hospital, Dallas, TX, USA

    Jaysson Brooks

  5. Department of Pediatric Orthopedics and Sports Medicine, Riley Children’s Hospital, Indianapolis, IN, USA

    Ryan Fitzgerald

  6. Division of Pediatric Orthopaedics, Vanderbilt University Medical Center, Nashville, TN, USA

    Craig Louer

  7. Division of Pediatric Orthopaedic Surgery, CHEO Research Institute, Ottawa, ON, Canada

    Kevin Smit

  8. Department of Orthopaedics, British Columbia Children’s Hospital, Vancouver, BC, Canada

    Firoz Miyanji

  9. Department of Orthopaedics, Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC, Canada

    Stefan Parent

Authors
  1. Gregory Photopoulos
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Consortia

Pediatric Spine Study Group

Contributions

Design or the acquisition, analysis, or interpretation of data: GP, JH, JM, JB, RF, CL, KS, KS, FM, SP, Pediatric Spine Study Group, RE-H. Drafted the work or revised it critically: GP, JH, JM, JB, RF, CL, KS, KS, FM, SP, Pediatric Spine Study Group, RE-H. Approved: GP, JH, JM, JB, RF, CL, KS, KS, FM, SP, Pediatric Spine Study Group, RE-H. Accountable: GP, JH, JM, JB, RF, CL, KS, KS, FM, SP, Pediatric Spine Study Group, RE-H.

Corresponding author

Correspondence to Ron El-Hawary.

Ethics declarations

Conflict of interest

Gregory Photopoulos received a studentship from Dalhousie University during the conduct of the study. Jennifer Hurry has nothing to disclose. Joshua Murphy—reports personal fees from Depuy Synthes Spine, personal fees from Orthopeditrics, outside the submitted work. Jaysson Brooks—reports working as consultant with Depuy Synthes and OrthoPediatrics, outside the submitted work. Ryan Fitzgerald—reports personal fees from Medtronic, personal fees from Depuy Synthes, personal fees from Orthopediatrics, outside the submitted work. Craig Loeur has nothing to disclose. Kenneth Shaw—Committee member for AAOS and NASS. Kevin Smit—reports grants from Zimmer BioMet, grants from Medtronics, grants from SpinoModulation, outside the submitted work. Firoz Miyanji—DePuy, A Johnson & Johnson Company: Paid consultant; Research support. Orthopediatrics: Paid consultant. Pediatric Orthopaedic Society of North America: Board or committee member. Stryker: Paid consultant. Zimmer: IP royalties; Paid consultant. Stefan Parent—reports personal fees from EOS-imaging, personal fees from Spinologics, personal fees from K2M, personal fees from EOS-imaging, personal fees from DePuy Synthes Spine, other from Academic Research chair in spine deformities of the CHU Sainte-Justine (DePuy), grants from DePuy Synthes Spine, grants from Canadian Institutes of Health Research, grants from Pediatric Orthopaedic Society of North America, grants from Scoliosis Research Society, grants from EOS imaging, grants from Canadian Foundation for Innovation, grants from Setting Scoliosis Straight Foundation, grants from Natural Sciences and Engineering Council of Canada, grants from Fonds de recherche Québec—Santé, grants and other from Orthopaedic Research and Education Foundation, other from DePuy Synthes, other from Medtronic, other from Orthopaediatrics, outside the submitted work. Pediatric Spine Study Group reports grants from DePuy Synthes Spine, grants from Medtronic, grants from NuVasive, grants from Globus Medical Inc., grants from OrthoPediatrics, grants from Zimmer Biomet, grants from Pediatric Spine Foundation, grants from Stryker, outside the submitted work. Ron El-Hawary reports personal fees from Depuy Synthes Spine, personal fees from Medtronic Spine, grants from Depuy Synthes Spine, grants from Medtronic Spine, personal fees from Orthopediatrics, other from Pediatric Spine Foundation, other from Scoliosis Research Society, outside the submitted work.

Ethics approval

This work is a sub-study of the Pediatric Spine Study Group Registry which was approved by the Research Ethics Board at the IWK Health Centre (#1002256) in accordance with the ethical standards outlined in the Tri-Council Policy Statement and the 1964 Declaration of Helsinki and its later amendments.

Consent to participate

All research participants or their legal guardians provided written consent to be a part of the registry and have the data collected be used in ongoing research on scoliosis.

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Not applicable.

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Photopoulos, G., Hurry, J., Murphy, J. et al. Reliability of radiographic assessment of growth modulation from anterior vertebral body tethering surgery in pediatric scoliosis. Spine Deform 11, 115–121 (2023). https://doi.org/10.1007/s43390-022-00570-0

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