- Email: [email protected]
Reply to the letter by J. L. Heemskerk, et al.
G Model OTSR-1732; No. of Pages 1
ARTICLE IN PRESS Orthopaedics & Traumatology: Surgery & Research xxx (2017) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
Letter to the editor Reply to the letter by J. L. Heemskerk, et al. We are clearly aware that we included patients with a small risk of progression. We stressed this point in the discussion. However, we only treated patients with progressive curves, despite a Cobb angle below 25◦ . We understand your concern about overtreating patients not at risk of progression toward a severe curve. But one must agree that all severe curves had a 15◦ curve one day. It would indeed be fantastic to identify the risk of progression at 15◦ . This is why we previously worked on predictive factors of progression. It would definitely improve the selection of patients that need to be braced. Since these predictive factors are not available in routine, our philosophy is to start the treatment as early as possible. I agree that bracing is difficult when you start at 25◦ –30◦ , but for very small curves the treatment is easier and the psychological negative impact of a nighttime brace is honestly very small. Yes, we certainly overtreat patients not at risk of progression, but we think it is a better option than to wait 25◦ which is also an arbitrary threshold to start bracing. Another benefit of starting a brace early is that it is possible to make a break when there is clinically and radiologically a complete regression of the scoliosis.
We agree with your conclusion. Maybe we indeed overestimated the effect of nighttime bracing including low progressive curves in our study. Once again, we clearly prefer being almost certain to stop the progression than “running” after the curve progression once the vicious circle has started. Finally, this debate will be closed once we obtain true effective progression predictive factors. Our experience shows anyway that nighttime bracing will be in the first row of possible treatment for early-detected (below 20◦ – Risser 0) patients with potential progressive curves. This paper is also a plea for a specific management of patients with small scoliosis. We still see too many patients with neglected scoliosis that were diagnosed at an early stage and not referred to a specific institution. Disclosure of interest The author declares that he has no competing interest. A. Courvoisier Pediactric Orthopedic Department, Grenoble Alpes University Hospital, BP 217, 38043 Grenoble cedex 09, France E-mail address: [email protected]
DOIs of original articles: http://dx.doi.org/10.1016/j.otsr.2016.10.022, http://dx.doi.org/10.1016/j.otsr.2017.03.009 http://dx.doi.org/10.1016/j.otsr.2017.03.012 1877-0568/© 2017 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Courvoisier A. Reply to the letter by J. L. Heemskerk, et al. Orthop Traumatol Surg Res (2017), http://dx.doi.org/10.1016/j.otsr.2017.03.012
ARTICLE IN PRESS Orthopaedics & Traumatology: Surgery & Research xxx (2017) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
Letter to the editor Reply to the letter by J. L. Heemskerk, et al. We are clearly aware that we included patients with a small risk of progression. We stressed this point in the discussion. However, we only treated patients with progressive curves, despite a Cobb angle below 25◦ . We understand your concern about overtreating patients not at risk of progression toward a severe curve. But one must agree that all severe curves had a 15◦ curve one day. It would indeed be fantastic to identify the risk of progression at 15◦ . This is why we previously worked on predictive factors of progression. It would definitely improve the selection of patients that need to be braced. Since these predictive factors are not available in routine, our philosophy is to start the treatment as early as possible. I agree that bracing is difficult when you start at 25◦ –30◦ , but for very small curves the treatment is easier and the psychological negative impact of a nighttime brace is honestly very small. Yes, we certainly overtreat patients not at risk of progression, but we think it is a better option than to wait 25◦ which is also an arbitrary threshold to start bracing. Another benefit of starting a brace early is that it is possible to make a break when there is clinically and radiologically a complete regression of the scoliosis.
We agree with your conclusion. Maybe we indeed overestimated the effect of nighttime bracing including low progressive curves in our study. Once again, we clearly prefer being almost certain to stop the progression than “running” after the curve progression once the vicious circle has started. Finally, this debate will be closed once we obtain true effective progression predictive factors. Our experience shows anyway that nighttime bracing will be in the first row of possible treatment for early-detected (below 20◦ – Risser 0) patients with potential progressive curves. This paper is also a plea for a specific management of patients with small scoliosis. We still see too many patients with neglected scoliosis that were diagnosed at an early stage and not referred to a specific institution. Disclosure of interest The author declares that he has no competing interest. A. Courvoisier Pediactric Orthopedic Department, Grenoble Alpes University Hospital, BP 217, 38043 Grenoble cedex 09, France E-mail address: [email protected]
DOIs of original articles: http://dx.doi.org/10.1016/j.otsr.2016.10.022, http://dx.doi.org/10.1016/j.otsr.2017.03.009 http://dx.doi.org/10.1016/j.otsr.2017.03.012 1877-0568/© 2017 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Courvoisier A. Reply to the letter by J. L. Heemskerk, et al. Orthop Traumatol Surg Res (2017), http://dx.doi.org/10.1016/j.otsr.2017.03.012