Initial Surgical Management Research Articles

Ailing and failing oral implants: initial therapy and surgical management

The distinction between ailing and failing implants is clinically important. Changes in the peri-implant soft or hard tissues will indicate whether the implant is ailing, failing, or has failed. This article discusses these clinical situations and provides an overview and description of peri-implant diseases and their treatment alternatives.

Management of Posttraumatic Radioulnar Synostosis

Posttraumatic radioulnar synostosis is a rare complication following fracture of the forearm and elbow. Risk factors for synostosis are related to the initial injury and surgical management of the fracture. Typically, patients present with complete loss of active and passive forearm pronation and supination. Evidence of bridging heterotopic bone between the radius and ulna can be seen on plain radiographs. Although nonsurgical management is sufficient in some cases, surgical excision is typically required. The timing of surgical intervention remains controversial. However, early resection between 6 and 12 months after the initial injury can be performed safely in patients with radiographic evidence of bony maturation. Surgical management consists of complete resection of the synostosis with optional interposition of biologic or synthetic materials to restore forearm rotation. A low recurrence rate can be achieved following primary radioulnar synostosis excision without the need for routine adjuvant prophylaxis.

Successful Limb-sparing Treatment Strategy for Diabetic Foot Osteomyelitis

Diabetic foot osteomyelitis is common and causes substantial morbidity, including major amputations, yet the optimal treatment approach is unclear. We evaluated an approach to limb salvage that combines early surgical debridement or limited amputation with antimicrobial therapy. We conducted a retrospective cohort study of patients treated between May 1, 2005, and May 31, 2007. The primary end point was cure, defined as not requiring further treatment for osteomyelitis of the affected limb. The secondary end point was limb salvage, defined as not requiring a below-the-knee amputation or a more proximal amputation. Fifty patients with diabetic foot osteomyelitis met the study criteria. Initial surgical management included local amputation in 43 patients (86%) and debridement without amputation in seven (14%). Most infections (n = 30; 60%) were polymicrobial, and Staphylococcus aureus was the most common pathogen (n = 23; 46%). Parenteral antibiotics were used in 45 patients (90%). Patients who had pathologic evidence of osteomyelitis at the surgical margin received therapy for a median of 43 days (interquartile range [IQR], 36-56 days), whereas those without evidence of residual osteomyelitis received therapy for a median of 19 days (IQR, 13-40 days). Overall, 32 patients (64%) were considered cured after a median follow-up of 26 months (IQR, 12-38 months). Fifteen of 18 patients (83%) who failed initial therapy were treated again with limb-sparing surgery. Limb salvage was achieved in 47 patients (94%), with only three patients (6%) requiring below-the-knee amputation. In patients with diabetic foot osteomyelitis, surgical debridement or limited amputation plus antimicrobial therapy is effective at achieving clinical cure and limb salvage.

Noncontact electrosurgical grounding – A useful and safe tool in the initial surgical management of thermal injuries

BackgroundElectrosurgical instruments – one of the useful and most-used instruments within the surgeon's armamentarium – are potentially dangerous by causing unanticipated direct burns; fire occurring as a result of electrosurgical instruments and electromagnetic interference with a pacemaker, defibrillator, or cardiac monitoring device. MethodsThe Mega 2000 Patient Return Electrode System produced by Megadyne Medical Products is a noncontact electrode designed to provide adequate electrical return to facilitate function of electrocautery devices. We used this noncontact device in 67 patients (28 women, 39 men) with large burns during their stay in our burn unit and in 11 of these patients (4 women, 7 men) for escharotomies during admission in our burn care. ResultsThe device functioned well in all cases, no additional cutaneous burns on the patients’ body were noticed. ConclusionThis paper is a review of our experience with this noncontact electrosurgical grounding in burn surgery highlighting its advantages comparing with the conventional electrosurgical instruments.

Diagnosis and surgical treatment of an intracranial cyst in an alpaca cria

A 7-day-old female alpaca was examined because of an acute onset of diffuse central neurologic deficits. Diagnostic imaging with CT and MRI identified an intracranial cyst occupying approximately one-third to one-half of the dorsal portion of the cranial cavity, markedly displacing the cerebral hemispheres bilaterally. Initial surgical management via trephination and needle drainage was only transiently effective at resolving the neurologic signs. Craniotomy and drainage and removal of the cyst lining resulted in a sustained improvement in neurologic status, and the cria remained clinically normal and well grown at follow-up 5 months after surgery. This report represented the first description of the successful treatment of an intracranial cyst in a New World camelid.

Management of empyema in children: a clinical audit

<h3>Aim</h3> National guidelines for the management of paediatric pleural infections (empyema) were introduced by the British Thoracic Society in 2005, and our institution implemented a trust guideline in 2008. We reviewed the management of empyema in our children9s hospital in accordance with both guidelines. <h3>Methods</h3> Cases of empyema admitted April 2005-March 2011 were identified through clinical coding, surgical, radiological and microbiological databases. Management and clinical course were extracted onto a proforma, following an initial pilot. Findings were presented at the paediatric clinical governance meeting. <h3>Results</h3> 101 children, median age 5.3 (range 0.6 to 16.3) years, were admitted for median 8 (range 2 to 28) days. 23 children (23%), with ultrasound median effusion depth 1.6 cm, were managed conservatively with IV antibiotics alone. Initial surgical management (77%) included 51% closed chest drainage, 23% video-assisted thoracoscopic surgery (VATS) and 3% open thoracotomy. Intrapleural urokinase was used in 89% of the 78 patients surgically managed: 87% with closed chest drain, 70% of VATS and 67% of open thoracotomy procedures. A quarter (24%) of all chest drains dislodged accidentally at a median 3 (range 1 to 6) days after surgery. 13% of those surgically managed required a second procedure. 92 (91%) patients did not have an anti-streptolysin O-titre (ASOT), nor 27 (27%) a blood culture sent. Pleural fluid was sent for culture in 76 (97%) of surgically managed patients, 13 (16%) of these having differential count/cell cytology. There was limited use of pneumococcal PCR in culture negative patients. Initial IV antibiotic use was with Co-Amoxiclav (46%) or Cephalosporins (52%), either alone or in combination with other antibiotics. Total duration antibiotic therapy was median 21 (range 7-40) days, with variation in intravenous and oral course length. <h3>Conclusion</h3> The majority of children were managed according to guidelines. Almost a quarter were managed conservatively. Urokinase use was varied, with shortened courses, and a number of cases of VATS or thoracotomy receiving urokinase. The high rate of drain dislodgement is of concern, and will be addressed by the introduction of pig tail catheters. Trust guidance regarding appropriate investigations have been modified.

Cancer de la vulve : enquête de pratique de la prise en charge chirurgicale en France. Faut-il se diriger vers des centres de références ?

Vulvar cancer is rare. In France, surgical management of this cancer is codified by national guidelines. The aim of this survey was to evaluate its surgical management regards to the French guidelines. Six hundred questionnaires were given to surgeons during two French congress in 2009. They focused on the surgeon (age, sex, occupation, center of work, practice of vulvar surgery, number of cancers treated individually and in the center), and the disease (initial work-up, surgical management and adjuvant therapy). Three case reports were also proposed, related to vulvar cancer management. Seventeen percent of surgeons (n=102) answered the questionnaire. Only half of them (52.9%) managed vulvar cancer. Of them, 83.2% reported treated less than five cancers per year; 87.4% of centers treated less than 10 vulvar cancers per year. Only 8.7% of surgeons respected the guidelines for the three case reports. The compliance rate was 80.5% for case A; 63.7% for case B and 22.5% for case C. No difference in answers' conformity to the guidelines was found according to age of surgeons, experience, workplace, number of cancers treated per year and centers. Despite some limits of our study, it appears that vulvar cancer management is often not conform to the French guidelines raising concerns on their insufficient diffusion and creation of expert centers.

Reoperative Lymph Node Dissection for Recurrent Papillary Thyroid Cancer and Effect on Serum Thyroglobulin

Papillary thyroid cancer (PTC) has an excellent prognosis with current treatment methods. However, the rates of locoregional recurrence after initial surgical management remain significant. This study evaluates the effect of reoperative neck dissection for locoregional recurrence of PTC after initial total thyroidectomy and radioiodine therapy on the incidence of cervical recurrence and postoperative serum thyroglobulin (Tg) levels. This is a retrospective cohort study conducted in a single academic medical center of patients with recurrent or persistent PTC isolated to the neck after previous total thyroidectomy with or without lymph node dissection and adjuvant I(131) therapy who were treated with reoperative lymph node dissection. Outcomes including operative complications, pathologic findings, and effect of surgery on Tg levels and rates of recurrent disease were analyzed. From 2001 to 2010, a total of 61 patients had reoperative neck dissections for recurrent cervical PTC with a complication rate of 5 %. Seventy-two percent of patients were clinically free of detectable disease, and 28 % of patients had recurrent, persistent, or newly metastatic disease detected during the follow-up period. All patients had significant decreases in Tg levels, with a median 98 % reduction in preoperative levels. However, only 21 % of patients had an undetectable stimulated Tg (<0.5 ng/mL) during the follow-up period of 15.5 months. Reoperative treatment of recurrent or persistent PTC can be performed with low complication rates, and Tg levels greatly decrease in most patients; however, few achieve undetectable stimulated Tg.

Can preoperative urodynamic investigation be omitted in women with stress urinary incontinence? A non‐inferiority randomized controlled trial

To assess in women with stress urinary incontinence (SUI) the value of urodynamics prior to treatment. We performed a multicenter non-inferiority randomized controlled trial. Women with SUI were randomly allocated to management based on a workup with or without urodynamics. The primary outcome was clinical reduction of complaints as measured with the Urogenital Distress Inventory urinary incontinence subscale (UDI-UI) at 12 months after the onset of treatment. A mean difference in improvement of less than 8 was considered non-inferior. The study was analyzed according to intention-to-treat. The trial was stopped prematurely because of slow recruitment. We randomly allocated 59 women to a strategy with (N = 31) or without (N = 28) urodynamics. The mean difference in improvement on the UDI-UI was 14 in favor of the group without urodynamics (48 SD ± 22 vs. 34 SD ± 22, 95% CI: -28 to -0.26), confirming non-inferiority. Addition of urodynamics did not result in a lower occurrence of de novo overactive bladder complaints compared to a workup without urodynamics (6/31 vs. 1/28; RR 5.4, 95% CI: 0.70-42). In the group allocated to urodynamics, initial surgical management was more often abandoned compared to the group not allocated to urodynamics (5/31 vs. 1/28; RR 4.5, 95% CI: 0.56-36). In this relatively small study, the omission of urodynamics was not inferior to the use of urodynamics in the preoperative workup of women with SUI. Women with SUI undergoing urodynamics had the risk of a choice for more prudent treatment, which seemed to result in a delay until effective treatment.

Suspicious Ultrasound Characteristics Predict BRAFV600E-Positive Papillary Thyroid Carcinoma

Current American Thyroid Association (ATA) guidelines recommend routine cervical ultrasound (US) in thyroid nodule evaluation. Specific US characteristics can help diagnose papillary thyroid carcinoma (PTC). The aim of this blinded cohort study was to determine whether these specific US characteristics can also reliably detect the more aggressive variants of PTC that are often associated with the BRAF(V600E) mutation. After Institutional Review Board approval, we identified a cohort of patients from January 2007 to December 2009 with histologic PTC≥1 cm who had cervical US, initial thyroid surgery, and molecular testing for BRAF(V600E) on fine-needle aspiration biopsy or histology. Preoperative US images were evaluated by a single radiologist, who was blinded to BRAF status, for nodule size and the presence or absence of the following suspicious US features: taller-than-wide shape, ill-defined margins, hypoechogenicity, calcifications, noncystic composition, and absent halo. BRAF-positivity was associated with most known suspicious US findings, including taller-than-wide shape (47% vs. 7%, p<0.001), ill-defined margins (42% vs. 9%, p<0.001), hypoechogenicity (83% vs. 36%, p<0.001), micro/macrocalcifications (87% vs. 24%, p<0.001), and absent halo (85% vs. 27%, p<0.001) but was not associated with noncystic composition. When ≥3 suspicious US features were present, BRAF-positivity was predicted with a positive predictive value of 82%. The absence of suspicious US features together with negative BRAF testing predicted PTC without extrathyroidal extension or lymph node metastasis (negative predictive value 88%). With routine preoperative cervical US and molecular testing, a trained radiologist or surgeon can improve the preoperative characterization of PTC, potentially impacting risk stratification and initial surgical management.

Preoperative basal calcitonin and tumor stage correlate with postoperative calcitonin normalization in patients undergoing initial surgical management of medullary thyroid carcinoma

The optimal initial operative management of medullary thyroid cancer (MTC) and the use of biomarkers to guide the extent of operation remain controversial. We hypothesized that preoperative serum levels of calcitonin and carcinoembryonic antigen (CEA) correlate with extent of disease and postoperative levels reflect the extent of operation performed. We assessed retrospectively clinical and pathologic factors among patients with MTC undergoing at least total thyroidectomy; these factors were correlated with biomarkers using regression analyses. Data were obtained from 104 patients, 28% with hereditary MTC. Preoperative calcitonin correlated with tumor size (P < .001) and postoperative serum calcitonin levels (P = .01) after multivariable adjustment for lymph node positivity, extent of operation, and hereditary MTC. No patient with a preoperative calcitonin level of <53 pg/mL (n = 20) had lymph node metastases. TNM stage (P = .001) and preoperative calcitonin levels (P = .04), but not extent of operation, independently correlated with the failure to normalize postoperative calcitonin. Postoperative CEA correlated with positive margins (adjusted P = 04). Neither preoperative nor postoperative CEA was correlated with lymph node positivity or extent of surgery. Preoperative serum calcitonin and TMN stage, but not extent of operation, were independent predictors of postoperative normalization of serum calcitonin levels. Future studies should evaluate preoperative serum calcitonin levels as a determinate of the extent of initial operation.

Comparison of plasma and peritoneal indices of fibrinolysis between foals and adult horses with and without colic

To identify hemostatic imbalances indicative of an increased risk of intra-abdominal adhesion formation in foals versus adult horses. Horses with colic undergoing exploratory laparotomy or abdominocentesis as part of a clinical examination (n = 16 foals ≤ 6 months of age and 19 adults ≥ 5 years of age) and horses without colic undergoing herniorrhaphy (15 foals) or euthanasia for noninflammatory and nongastrointestinal disease (10 foals and 20 adults). Paired abdominal fluid and blood samples were collected from each horse into buffered sodium citrate and centrifuged immediately after collection. Supernatants were stored at -80°C, then thawed for measurement of fibrinogen concentration, plasminogen activity, antiplasmin activity, and D-dimer concentration. Supernatant analyte concentrations or activities were compared within age group (foals with and without colic vs adults with and without colic) and within disease status (foals and adults without colic vs foals and adults with colic). All analyte concentrations or activities in abdominal fluid samples were significantly lower in the noncolic groups than in the colic groups, and none differed between foal and adult groups. Several plasma analyte values differed by disease status and age. The risk of intra-abdominal adhesion formation in the foals in this study did not appear to be attributable to differences in intra-abdominal hemostasis between adult horses and foals. Strategies for initial medical and surgical management of colic in adult horses may be applicable to foals with similar disorders.

Routine Hysterectomy in the Surgical Management of Ovarian Cancer: A Retrospective Case Series, Physician Opinion Survey, and Review of the Literature

Current international guidelines recommend routine hysterectomy in the initial surgical management of epithelial ovarian cancer. However, there seems to be limited evidence to support these recommendations. We examined the data for a series of women undergoing hysterectomy as part of surgical management of ovarian cancer. Most of the women who underwent hysterectomy had no macroscopic uterine involvement in the ovarian cancer. However, almost half of them had macroscopic residual disease at completion of cytoreductive surgery. The incidence of synchronous primary endometrial cancers was 5%, and preoperative ultrasound had a sensitivity of 82% for predicting endometrial pathology. We also surveyed the members of the Australian Society of Gynaecological Oncologists (ASGO) regarding the role of hysterectomy in the management of ovarian cancer. Most of the respondents indicated that they believe hysterectomy should be routinely performed in the management of ovarian cancer but acknowledge that there is a lack of evidence to support the practice.

Compartment syndrome in dislocation and non-dislocation type proximal tibia fractures: analysis of 356 consecutive cases

Dislocation type proximal tibia fractures are associated with the major soft tissue injuries. The main purpose of this study was to analyze the incidence of compartment syndrome (CS) in proximal tibia fractures in relation to the fracture type, i.e., dislocation versus non-dislocation type. We further analyzed CS within the non-dislocation type injuries, initial treatment modality as well as infection rate relative to the treatment policies (one- or two-staged procedures). Over an 8.5-year period, prospectively, acquired data of 356 proximal tibia fractures were evaluated. All fractures were classified either according to the AO/OTA or to the Moore (fracture dislocation type) classification system respectively. The appearance of CS in dislocation and non-dislocation type injuries as well as treatment modality, i.e., one- or two-staged procedures was analyzed. 307 (86%) fractures were classified as non-dislocation type and 49 (14%) as fracture dislocation type injuries. Overall 31 (8.7%) CS occurred. All were diagnosed and treated within the initial surgical management. CS was equally distributed in non-dislocation type fractures (24/307) and Moore type fractures (7/49) (Chi-square test, p = 0.4). But a significant difference in the non-dislocation type injuries was observed between AO/OTA B-type (0/166) and non-B type fractures (24/117) (Chi-square test, p < 0.001). 104 fractures were treated in a two-staged procedure with definitive reconstruction after an average of 6.0 days. Initial postoperative surgical site infection remained very low with 0.5%, and did not seem to be related to operative treatment variables including single-stage versus two-stage reconstruction, temporary external fixation and/or compartment fasciotomies. The incidence for CS did not differ between the dislocation and non-dislocation type group, but a significant difference was found comparing the incidence for CS only in the non-dislocation type group.

Preventive Scleral Buckling and Silicone Oil Tamponade Are Important for Posttraumatic Endophthalmitis Successfully Managed with Vitrectomy

Aims: Posttraumatic endophthalmitis (PTE) managed with pars plana vitrectomy (PPV) and a variety of other methods often resulted in retinal detachment (RD), which deteriorates postoperative visual acuity (VA). We investigated initial ocular conditions, surgical management and outcomes of PTE patients and analyzed their relationship in order to find the necessary management for different patients’ conditions. Methods: Retrospective study. Medical records of 62 consecutive patients who were diagnosed with PTE and managed with PPV were retrospectively analyzed. The included patients were divided into two groups depending on their initial VA, with light perception (LP) as borderline: group A (12 cases; VA = LP) and group B (50 cases; VA > LP). Specific variables related to surgical outcomes were analyzed, including: initial VA; intraocular foreign body; location and length of the wound; microbiologic test; cataract extraction; scleral buckling; silicon oil tamponade; gas tamponade, and retinal restoration. Data were statistically analyzed by the χ² test, by univariate analysis for predictors and by multivariate logistic regression analysis. Results: RD happened in 19 (30.6%) of the 62 cases included. There were 6 cases (50%) in group A and 13 cases (26%) in group B which resulted in RD. Statistical analysis demonstrated that none of the related factors were correlated to the occurrence of RD (all factors: p > 0.05) in group A, but in group B, scleral buckling (with: 2/22, 9%; without: 11/28, 39%; p < 0.05) and silicone oil tamponade (with: 0/6; without: 13/44, 30%; p < 0.05) were statistically significantly correlated to the occurrence of RD. Conclusions: Preventive scleral buckling and silicone oil tamponade are important for patients with good initial VA (VA > LP) to be successfully managed by PPV.

Surgical management of colorectal injuries: colostomy or primary repair?

Several factors have been considered important for the decision between diversion and primary repair in the surgical management of colorectal injuries. The aim of this study is to clarify whether patients with colorectal injuries need diversion or not. From 2008 to 2010, ten patients with colorectal injuries were surgically treated by primary repair or by a staged repair. The patients were five men and five women, with median age 40 years (20-55). Two men and two women had rectal injuries, while 6 patients had colon injuries. The mechanism of trauma in two patients was firearm injuries, in two patients was a stab injury, in four patients was a motor vehicle accident, in one woman was iatrogenic injury during vaginal delivery, and one case was the transanal foreign body insertion. Primary repair was possible in six patients, while diversion was necessary in four patients. Primary repair should be attempted in the initial surgical management of all penetrating colon and intraperitoneal rectal injuries. Diversion of colonic injuries should only be considered if the colon tissue itself is inappropriate for repair due to severe edema or ischemia. The role of diversion in the management of unrepaired extraperitoneal rectal injuries and in cases with anal sphincter injuries is mandatory.

Prevention of Infections Associated With Combat-Related Thoracic and Abdominal Cavity Injuries

Trauma-associated injuries of the thorax and abdomen account for the majority of combat trauma-associated deaths, and infectious complications are common in those who survive the initial injury. This review focuses on the initial surgical and medical management of torso injuries intended to diminish the occurrence of infection. The evidence for recommendations is drawn from published military and civilian data in case reports, clinical trials, meta-analyses, and previously published guidelines, in the interval since publication of the 2008 guidelines. The emphasis of these recommendations is on actions that can be taken in the forward-deployed setting within hours to days of injury. This evidence-based medicine review was produced to support the Guidelines for the Prevention of Infections Associated With Combat-Related Injuries: 2011 Update contained in this supplement of Journal of Trauma.

Incidence of Oral Cancer Occult Metastasis and Survival of T1-T2N0 Oral Cancer Patients

In head and neck cancer, the most important prognostic factor is the presence or absence of neck metastasis. Although still debated in the published data regarding the "wait and see" policy for Stage T1-T2 oral cancer, a large number of clinicians support the necessity of neck dissection, especially in cases of oral tongue carcinoma, because of the poor prognosis and high risk of recurrence. The aim of the present study was to summarize and quantify the incidence of occult metastasis in oral cancer treatment at the oral and maxillofacial surgery department, Rambam Medical Center, in the past 10 years. A total of 142 neck dissections performed at our department in the past 10 years (1998 to 2009) and a series of 68 patients (44 men and 22 women) treated for Stage T1N0 or T2N0 oral cancer were included in the present retrospective study. All patients underwent surgical resection of the oral cancer and selective neck dissection of the ipsilateral side. Occult lymph node metastases were detected in 11 patients (16% overall, 9 in the tongue, 1 in the buccal mucosa, and 1 in the gingiva of the mandible). The frequency of occult metastasis from tongue carcinoma was 34% (9 of 26 cases). The 5-year survival rate in the present study was 78.9%. In patients who underwent chemotherapy, radiotherapy, brachytherapy, or a combination of the 3 after surgical management, the overall survival rate decreased significantly to 22.5% (P = .006, log-rank test). The incidence of occult metastasis in patients with oral cancer in the present study was 16% overall. In those with tongue carcinoma, a much greater incidence (34%) of occult metastasis was detected. Furthermore, the need for chemoradiotherapy after initial surgical management, mainly because of occult metastasis, was a significant negative predictor of patient outcome. The results of the present study emphasize the need for prophylactic neck dissection in patients with oral cancer diagnosed with Stage T1N0 or T2N0 disease, especially when the primary lesion is localized in the tongue.

Central Neck Dissection for Papillary Thyroid Cancer

Central compartment lymph node dissection is a common adjunct to thyroidectomy in the treatment of papillary thyroid cancer. The indications, surgical technique, potential benefits, and operative risks of this procedure should be clearly defined in order to provide optimal care to these patients. A systematic review of the literature and an analysis of evidence-based recommendations were performed regarding central neck node dissection for patients with papillary thyroid carcinoma. Cervical nodal metastasis in papillary thyroid cancer is a common occurrence. The presence of metastasis is associated with increased recurrence rates and may decrease survival. Detection of central and lateral neck nodal metastasis preoperatively with clinical examination and cervical ultrasound is important in determining the appropriate initial surgical management. Level VI neck dissection and central neck dissection are terms often used interchangeably to describe surgical excision of all lymph nodes from the hyoid bone to the sternal notch between the carotid arteries, but the addition of the superior mediastinal lymph nodes in compartment VII should be included in the central neck dissection. Due to improved recurrence rates and survival, therapeutic central neck dissection is recommended for all patients with nodal involvement detected pre- or intraoperatively. Prophylactic central neck dissection in patients without detectable nodal disease remains a controversial topic due to a lack of definitive evidence of improved recurrence rates or survival and the possibility of higher complication rates compared to total thyroidectomy alone. Reoperative central nodal dissection can be a challenging procedure with increased complication rates but with good outcomes in experienced centers. Central neck lymph node dissection plays an important role in the appropriate treatment of papillary thyroid cancer at initial presentation and in cases of recurrent disease. Surgeons caring for this group of patients should have familiarity and skill with this procedure.

Current Treatment Preferences for Early Onset Scoliosis

Surgical options for the management of idiopathic early onset scoliosis (EOS) have increased over the past decade, perhaps surpassing traditional nonoperative methods. We sought to assess current treatment preferences in the management of EOS among pediatric orthopaedic surgeons. We hypothesized that practitioner access to casting tables and halo traction would be significantly associated with treatment choices. A web-based survey was distributed to the members of the Pediatric Orthopaedic Society of North America. Information with regard to practice type, access to casting tables and halo traction, and management of patients with EOS was obtained. Clinical vignettes were used to assess current physician preferences in the treatment of EOS, including the use of bracing, casting, halo-gravity traction, fusionless spine techniques, definitive fusion, and chest wall devices. Members of Pediatric Orthopaedic Society of North America (19.8%) completed the survey with the vast majority of respondents (93.8%) treating children with EOS. Sixty-six percent of respondents had access to a casting table and 77% reported access to halo-gravity traction. Access to casting tables and access to halo-gravity traction was associated with the use of casting and traction (P<0.0001). Equal numbers of surgeons currently use casting (62%) and growing spine techniques (64.1%). Chest wall expansion was offered as a treatment option by 39.1% of surgeons, and 27% of surgeons reported the use of halo-gravity traction. Ninety-three percent of respondents chose nonoperative management of a 2-year-old child with a 50° progressive scoliosis. In contrast, 63% of surgeons would offer surgery as the initial management to a 5-year-old child with a progressive 70° idiopathic scoliosis. The majority of respondents had access to halo traction and casting tables at their hospitals. There was a statistically significant association between access to equipment and use of casting and halo traction. Nonoperative management was the preferred treatment option in the very young (2 year-old). Two-thirds of surgeons report initial surgical management of the 5-year-old child with a large idiopathic curve.