649 C OPYRIGHT Ó 2014

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T HE J OURNAL

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B ONE

AND J OINT

S URGERY, I NCORPORATED

Bracing for Idiopathic Scoliosis: How Many Patients Require Treatment to Prevent One Surgery? James O. Sanders, MD, Peter O. Newton, MD, Richard H. Browne, PhD, Donald E. Katz, MHA, CO, John G. Birch, MD, and J. Anthony Herring, MD Investigation performed at Texas Scottish Rite Hospital for Children, Dallas, Texas

Background: Although the efficacy of bracing for adolescent idiopathic scoliosis has been debated, recent evidence indicates a strong dose-response effect with respect to preventing curve progression of ‡6°. The purpose of this study was to investigate whether bracing, prescribed with use of current criteria, prevents surgery and how many patients must be treated with bracing to prevent one surgery. Methods: Of 126 patients with adolescent idiopathic scoliosis measuring between 25° and 45° and with a Risser sign of £2, 100 completed a prospective study in which they were managed with a Boston brace fitted with a heat sensor that measured brace wear. Noncompliant patients were compared both with highly compliant patients and with the entire cohort, with the end point of progression to surgery. The absolute risk reduction (ARR) was calculated and used to calculate the number needed to treat (NNT) to prevent one surgery. Results: Bracing was not effective in preventing surgery unless the patient was highly compliant with brace wear. For patients who were considered to be highly compliant, based on the hours per day that they wore the brace, the NNT was 3 (95% confidence interval [CI], 2 to 7). Conclusions: Within the limitations of a nonrandomized prospective study design, bracing for adolescent idiopathic scoliosis was found to substantially decrease the risk of curve progression to a range requiring surgery when patients were highly compliant with brace wear. Since many patients avoid surgery without wearing a brace, current indications appear to lead to marked overtreatment. Bracing appears to decrease the risk of curve progression to a magnitude requiring surgery, but current bracing indications include many curves that would not have progressed to a magnitude requiring surgery even if the patient had not worn the brace, and overall compliance with brace wear is low. Identifying these lower-risk patients and improving the compliance of those likely to have curve progression could substantially improve bracing results. Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. It was also reviewed by an expert in methodology and statistics. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.

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espite regular and continued clinical use of bracing, its actual clinical effectiveness in terms of preventing the need for surgery in patients with adolescent idiopathic scoliosis has not been well demonstrated. Prior studies have been hampered by inadequate controls or have used end points of doubtful clinical relevance. In a multicenter controlled study, Nachemson and Peterson1 found bracing to have a significant

effect with respect to preventing curve progression of ‡6° as compared with observation only and with low-dose electrical stimulation; 74% of those treated with a brace did not have progression of ‡6°, whereas only 34% of those observed or treated with electrical stimulation did not have such progression. In 2010, Katz et al. reported the results of an investigation in which 100 patients had a monitor placed into their brace to

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

J Bone Joint Surg Am. 2014;96:649-53

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http://dx.doi.org/10.2106/JBJS.M.00290

650 TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O LU M E 96-A N U M B E R 8 A P R I L 16, 2 014 d

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B R A C I N G F O R I D I O PAT H I C S C O L I O S I S : H O W M A N Y P AT I E N T S R E Q U I R E T R E AT M E N T T O P R E V E N T O N E S U R G E R Y ?

TABLE I Calculation of NNTs for Comparison of All Subjects Prescribed a Brace with Those Wearing the Brace for Less Than Two Hours per Day Compliance

Total Number

Number Requiring Surgery

Risk of Surgery

95% CI

Bracing for idiopathic scoliosis: how many patients require treatment to prevent one surgery?

Although the efficacy of bracing for adolescent idiopathic scoliosis has been debated, recent evidence indicates a strong dose-response effect with re...
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