John H. Moe (1905-) of Minneapolis has been among the leaders in this generation of orthopaedic surgeons especially in his interest and contributions to the study of scoliosis. Among his many hospital affiliations he holds the titles of Professor Emeritus of Orthopaedic Surgery at the University of Minnesota and Director of the “Twin Cities Scoliosis Center.” E.M.B. The evolution of spine fusion has been well described by Howorth. The following is a brief review of the development of the Hibbs fusion. The first spine-fusion procedure was reported by Hibbs in 1911. He reported three patients with Pott's disease treated by spine fusion and suggested that the procedure might well be used in scoliosis. Hibbs, in 1924, reported a study of 59 patients with scoliosis treated by fusion, in some of whom there was correction and in some there was not. He stated that the first fusion for scoliosis was done in 1914. The technique described by Hibbs in 1911 was quite different from that described in 1924. In 1911 the procedure consisted in partially shearing off the base of the spinous processes and breaking them down to bridge the interlaminar spaces. In 1924 he described the technique which has remained the classic Hibbs method of spine fusion. It must be conceded that any method of spine fusion in which fragments or leaves of bone are elevated from the laminae and spinous processes and are turned up and down in a transposed manner is a modification of the Hibbs technique. However, as is so clearly pointed out in Hibbs' own text, the subperiosteal exposure is meticulous and wide, and the elevation of the bone fragments is done in a specific way and in a specific region. One must question the amount of bone-to-bone contact obtained by the Hibbs technique of curettement of the inferior margins of the vertebral articulations. In the classification of the methods of fusion to be described, it should be emphasized that no inference should be drawn that any new method of fusion is being described. The author‘s early type of fusion differed from the other methods in that exposure was mostly not subperiosteal, nor was it very wide. The Cobb method was a Hibbs subperiosteal exposure, and a slightly modified Hibs fusion, but did not specifically include curettage of the articular facets. Both the early method and the Cobb method differed from the Hibbs technique in that bone was added throughout the fusion area. The technique of articular-facet fusion is also a Hibbs subperiosteal exposure; the joint-fusion technique is a combination of methods described by Howorth and McBride. The method of decor-tication of the spinous processes and laminae and bridging of the interlaminar spaces is similar to that described by Howorth. The stressing of the bridging of the transverse processes laterally has been called to the author's attention by Blount. It is perhaps regrettable that at no time in this series was the classic technique of Hibbs followed. MATERIALS AND METHODS The data presented in this follow-up study of scoliosis have been obtained by the author‘s personal evaluation of patients treated privately and at the Gillette State Hospital for Crippled Children in St. Paul, Minnesota. Patients treated between the years 1947 and 1956 are included. A majority were followed for from 2 to 8 years postoperatively. Relatively few patients are included who were followed for only 14 to 18 months. In these it was the author's opinion that the fusion was solid beyond question and that the spine was remaining stable after a period of 5 months or longer without external support. (In the months following completion of this survey, these patients have been carefully re-examined. No further loss of correction has been noted.) The study is based upon an analysis of 266 patients having curvatures classified as idiopathic and paralytic scoliosis. The total number of patients treated since 1947 is 381. Only 1 patient in the entire group has been lost to follow-up analysis. As one observes and studies numbers of patients with scoliosis, it becomes obvious that roentgenographic evidence of corrected curvature is only one criterion by which the end result should be judged. As Schmidt has pointed out, a fused spinal column is easier to maintain in balance than a flexible one. The regaining of compensation and the improved appearance resulting from it can sometimes be obtained with little or even no roentgenographic evidence of correction of the curvature. The author has tried to evaluate the cosmetic appearance of the patients fairly, using not only his own repeated observations on each patient, but also the patient's opinion and that of the parents. An excellent and good result is apparent to everyone; a fair result indicates improvement in appearance and reasonable satisfaction; a poor result indicates general dissatisfaction on the part of all concerned. The turnbuckle cast of Risser, as modified by Cobb, was used between the years 1948 to 1953. During this period, the Milwaukee brace of Blount and Schmidt was also used in a number of patients. Beginning in 1953 the Risser localizer cast was tried. With increasing experience in its application, this type of cast was found to be equally as efficient as the turnbuckle cast and was far better tolerated by the patient. Since 1954, the localizer cast has been used almost routinely. During the past year most of the difficulties previously encountered in obtaining a well fitting Milwaukee brace have been overcome. This brace, when well fitted, provided excellent correction and was well tolerated by the patient. IDIOPATHIC SCOLIOSIS There is general agreement that the clinical entity known as idiopathic scoliosis does exist and that its clinical course and pattern will usually differ from that of scoliosis following poliomyelitis. The borderlines of differentiation are, however, often indistinct. For purposes of this study, no curvature was termed idiopathic when there was a definite history of poliomyelitis, even in the absence of demonstrable muscle weakness. No curvatures with vertebral anomalies, whether congenital or associated with neurofibromatosis, were included. However, the presence of café-aulait marking on the skin in the presence of a typical idiopathic-curve pattern was not felt to be of significance. Likewise, the presence of congenital anomalies elsewhere in the body such as ectopic liver, congenital heart lesions, congenital hip dislocation, or congenital anomalies in the extremities was not felt to be significant if the curvature was typically idiopathic in pattern and appearance. There were 130 patients with scoliosis classified as idiopathic, 98 of whom were treated at Gillette Hospital and 32 privately. There were 116 females (89%) and 14 males (11%). The average age at the time of fusion was 13.8 years, the youngest being 9 years, the oldest 40. Evaluation of Correction The percentage of correction gained was calculated by subtracting the final degree of curvature from the maximum curvature as shown in a roentgenogram made with the patient standing previous to correction. This difference was then divided by the degree of the original curvature. A roentgenogram made with the patient either standing or sitting when he was last seen was used for the final evaluation. The average gain in this series was 40%. Patients with solid fusion in whom no pseudarthroses developed gained an average of 43%. Those patients with pseudarthroses gained on an average of 22% while in those in whom pseudarthroses persisted there was only a 13% average gain. When the average percentage gain was correlated with the cosmetic evaluation, it was found that 101 patients rated as having good cosmetic results showed an average gain of 45%, 20 patients rated as having fair results gained 24% and 8 with poor results showed only a 5% gain. In this series, 78% of the total number of patients were rated as having good cosmetic results. When solid fusions were present with no evidence of graft at any good results. With pseudarthroses present in the were as having good cosmetic and with the graft only were so of The total number of patients with idiopathic scoliosis was In this there were spine-fusion The total number of for of was The methods of spine fusion can be divided three general When the scoliosis was in 1948 at Gillette a method of fusion then in this hospital was In this analysis this is termed the early method of fusion. to some there was from spinous processes and laminae with a The were not and a good of of The exposure was not beyond the base of the transverse processes in the and the were and of or of the bone was not of bone were turned down and bone in the of or bone was added to the area. Cobb In following an of the technique of spine fusion of Cobb, the author his method of fusion in an to technique and to this method to his The fusions done in this series and 1953 were done or to this It is conceded that the technique that so done by The Cobb fusion consisted in meticulous subperiosteal of muscle and all from the spinous and transverse of with Cobb were the end of each was a of bone from a of the laminae or transverse processes of the In this there was of the bone and the final was made up of these the transverse processes as well as the laminae and spinous of bone were then The were not In following an of the Hibbs fusion technique of Risser, the author's technique was modified to include and of bone the articular facets. It was felt that a of bone the articular which did not the a for the of the articular and a which of bone from the be the with the of the Cobb was used for a The or Risser technique of the articular was used in the area. For a time no bone was During the last 2 years the author has this technique by of and bone the articular in the and these the articular as in the technique of in his fusion. The are from the transverse or spinous processes or from a of of the Cobb technique with that of articular-facet fusion indicates in idiopathic scoliosis, the of bone results in the percentage of with either Cobb that fusion of the articular is provided that a meticulous fusion is The data presented to this opinion when a spine with an idiopathic curvature is A of patients treated at Gillette a majority of the were by the with those patients treated in the author's indicates that a result might be when the fusions are by one SCOLIOSIS There were patients with scoliosis to poliomyelitis. There were females and males The youngest patient at time of fusion was three years of the 20 of the were or Evaluation of Correction The average gain in patients with paralytic scoliosis was Those patients with fusions solid without evidence of pseudarthroses at any time gained Patients with graft gained while in those with in the the average gain was patients of and were in the percentage of gain and the cosmetic patients for were also Patients rated as having good cosmetic results showed an average gain of Those with fair results gained while those with poor results showed an average gain of In the group of patients with paralytic scoliosis who were 78% were rated as having a good evidence of a at any good results. With graft present there were good while of those in whom the fusion there were 13% rated as having good cosmetic results. of Correction During The average loss of correction in the series was With pseudarthroses there was an average loss of of There were patients with paralytic scoliosis on whom spine fusions were There were for In the early type of fusion, the of bone in a of graft the patients in this group of early fusion, the percentage of graft was The percentage of excellent results from solid fusions obtained by the Cobb technique in the patients with idiopathic scoliosis was not found in those with paralytic scoliosis. With bone was found in the patients in this in the graft developed in There were patients in whom articular-facet fusion was of there was in the patients in whom bone was developed in the patients in whom no bone was developed in of the patients with those treated at Gillette Hospital is of little in the group in which articular-facet fusion was In this group of patients from Gillette there were patients with pseudarthroses In patients treated privately by articular-facet fusion there were 5 patients with pseudarthroses There has been for years among orthopaedic surgeons of experience that the spine in a percentage of patients than the and The of in patients with idiopathic scoliosis is known to be than that in those with paralytic scoliosis. The of to the spine in those with idiopathic scoliosis, in to the of these to the of solid fusion. the other most in scoliosis by a good of the are flexible and and to be The most for fusion in the spine is in the between and In this group of patients with idiopathic and paralytic scoliosis, there were pseudarthroses developed in many patients. In little evidence of the bone graft was found at the time of being found No for this bone has been In the typical there will be a solid graft by which up to the of there is to the area. the will be well and can only be after an of bone pseudarthroses can be by roentgenographic study of the graft 5 or months following fusion. the there were pseudarthroses and the there were the the being found in the between the and first the the of It is reasonable to that this is to some to the number of fused this vertebral AND In the group of 266 patients there were for spine fusion and for of a total of No No of has been The of to to of a in one patient. of the The of the spine to be that with the or can usually be without it be of The of a pattern not The of the 2 of a pattern not The of the 2 of a pattern not The 2 of a pattern not The has the the and the as seen in made with the patient to the In the in idiopathic scoliosis is usually or often and In the is with a In made with the patient or these 2 be from the made with the patient to the that the is flexible than the In this early made when the is to that the is far in of the In the is and made with the patient to the that the is This is an In the 2 are equally from and equally with There are 2 which the of any vertebral and or of the The end can be at a of the those to the margins in to when these the of a and to on the of the It that the spaces a will be to the of a and that will be in the In the fusion must be The of of the the of the not is present in any curvature and can be by the of the to the vertebral the spinous is often to and the are the are most often used in When the of the body beyond the on the of a than it does on the that is to the When the 2 are from the vertebral margins on each that is not and be called The shown on be by having the the patient with and the for an The of the as by the with of that the also be the other it is that the is to the of the and that such for or even beyond the In this the fusion must be beyond the to include all which are so and to include as well the at each end of the This is of the end of a The first in of the fusion to all which are to the of the and to include the and made and after correction must be The of the and the of the not such is a in which the is the or the fusion will not have to include all of the In such a the be the not the be stated that in scoliosis having the in the and having a one this When a is the and a is present that of the spine with the must be fused in part or all of its total if the patient is for it curvature which will the fused of the spine This is in paralytic scoliosis. One the in patients with idiopathic scoliosis, with the being It must be pointed out that early will the first and that while the clinical evidence of being when the patient it becomes as as the and often a degree of in made with the patient to the In such a only the of the spine in the fusion in one must be to to balance curvature be present in the and as shown by made with the patient to the The fusion of 1 and the will that correction will not be lost of the original The to When in a to the fusion area. This is encountered in patients with paralytic scoliosis. the and to be equally these of the spine should be fused in correction. The of idiopathic scoliosis an obvious pattern from its Both are equally and Both of the spine should be fused throughout the of the The of the There is no specific to correction and fusion of the spine in the patient with scoliosis other than the presence of an in the fusion area. fusion does not to a loss of of the spine which is of clinical significance. It is that vertebral in following fusion at the of the to some It is also that some degree of in the fusion provided that the spine is very corrected in its curvature and that a or slightly spine in the fusion to It is to fusion while some correction or at by of a Milwaukee brace or Risser localizer cast in patients with idiopathic scoliosis in whom the roentgenogram a spine with a of the It is also to fusion in the very with paralytic scoliosis the spinal are not have in the author's in of the fusion in the patient have to a of the the of in the fusion area. The to is to to the fusion when in not of Correction has been loss of correction following spine fusion in the patient. In the author's experience such loss of correction has not without There are for such loss in the as well as in the The fusion was not of A in the fusion was not in time to loss of In paralytic scoliosis, muscle and or have persisted and to with upon the fused The author has seen one patient with this combination of in whom the fused spine with it was One might question whether the fusion was in this patient, for that loss of correction not have the fusion down to the also might have been used to loss in such after fusion by the Milwaukee brace or Risser localizer not loss of correction even if The loss of correction can be in most and can be of Correction methods of correction of the has the of time as has the turnbuckle cast of Risser and In of the series of patients presented in this survey, the author used the turnbuckle cast of Risser, as modified by correction was obtained for the most with only the The of time between the cast and the fusion was usually or A of correction by the method with as the author that most curvatures be corrected to the maximum at the time of cast application, with the out at the of for the patient. correction by and turnbuckle was for those in whom the spine was most The of from the with increasing In the Risser localizer cast the author's method of correction of scoliosis. correction was obtained for the most if further correction were it was obtained of the or by by the of and the of years in this survey, the Milwaukee brace of Schmidt and Blount was used on a number of patients. The encountered was to the for of this In of early poor correction was on the The author is with the of this brace, when in the correction of scoliosis. In to fitting it is for the to with the technique of as by Blount and not be to many orthopaedic and for this it is the author's opinion that the orthopaedic should with the of the Risser localizer cast and the so that he most patients with scoliosis, even a brace in the of the Milwaukee brace not be to patients in this series have by been to many months of be for final correction and fusion. During these most of the patients Risser localizer and a few Milwaukee In the patients with scoliosis such in some to the patient in obtaining maximum correction. In scoliosis and especially in the author‘s experience to that such at correction are and that the correction is obtained with the patient The author with Blount and Schmidt in that correction in the Milwaukee brace can be obtained only with the patient in and Likewise, in all correction in the Risser localizer cast can only be by the patient in for a period of from to months. In this series, only those patients in whom the scoliosis was in the and in whom it was corrected be to be up without loss of correction of or Since loss of correction of in the average patient when the author did not that the of were to an further loss of correction. loss on has in of the most to technique of the of a well and A has developed in the author‘s experience the past years in the and of scoliosis. to the the patient is for of the cast the following further study is The cast is to the patient with his and A maximum is made to the correction or The technique followed in cast is that of the localizer cast as described by The cast is in and The is with to the cast beyond are made with the patient and the is on the correction is than the cast can be or this can be to a upon the patient's to further correction. The fusion is out in 1 or 2 2 The average number of vertebral fused at one time is Since cast usually the cast was not postoperatively. It is so if further correction is usually with The author was not with the of the by the spine fusion and of the localizer cast did not correction further than that obtained by the in the average patient. that the correction has been obtained and that the patient is he is from the hospital a or after is The patient is to but and in at The be elevated to a from the without The are in the of the to be in are In the average the patient for the first cast in months. that time the cast is and the spine is on 14 by in and in the A roentgenogram at this time was not found are carefully for evidence of A new localizer cast is with and are in and to the fusion the patient then be to be up to A roentgenogram with the patient standing is made 2 after is The localizer cast is for months The cast is then and roentgenographic studies the fusion solid and a body cast is and for 2 months. there is no loss of the patient is then to be without external support. in this The of can be by 1 or 2 months if the is the age of 9 years and has no a an it is and without further the patient being down in the localizer are for an which is not In patients with paralytic scoliosis with is made to the of and to the technique. In the localizer cast in these the author has found it to the by a of the if the fusion is not to down to the Patients with paralytic scoliosis of a degree with should have the spine is corrected and In the presence of such must be the spine has been corrected and Patients being treated in the Milwaukee brace a different Since the brace is for fusion, it that correction must be obtained postoperatively. It is to the patient in the hospital for a slightly longer period of the brace, of the spine is obtained for correction. When that correction is the patient be at but should at for brace The patient is the fusion is a period of from 5 to months. The brace is the fusion is a period of from to months. Scoliosis One and patients with idiopathic scoliosis were treated by methods of fusion. The average gain in correction was 40%. In the absence of the average gain was 43%. Patients with pseudarthroses showed an average gain of 22% and those with showed an average gain of Patients rated as having a good cosmetic result showed an average gain of 45%, while those rated as poor gained only in the early years of this series in of bone The Cobb method of fusion in pseudarthroses in only fusions in in but in the group in whom bone was developed in only Scoliosis One and patients with paralytic scoliosis were treated in whom the average gain in correction was With no the average gain was Patients having gain and those with gain in correction. Patients rated as having a good cosmetic result showed an average gain of while those with poor results showed a gain in correction. the patients in whom early fusions were there were pseudarthroses in fusions with bone added in in while in articular-facet there was an of of when bone was Correction and fusion of the spine is of results and provided that the fusion is and the graft becomes solid and is the for loss of correction. pseudarthroses can be and solid without loss of correction. A meticulous fusion with exposure, with all from the of the with carefully and and with articular carefully is of the results.
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JOHN H. MOE (2007) studied this question.
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