Is it ever too late to brace? ART brace outcomes in adolescent idiopathic scoliosis across skeletal maturity levels and a range of curve magnitudes

In the United States, many orthopedic clinicians only consider candidacy for conservative treatment of Adolescent Idiopathic Scoliosis (AIS) when a patient presents at a skeletally immature stage and with a small curve magnitude. This is in contrast to the European approach where conservative treatment is more widely utilized. This longitudinal clinical audit evaluated the ART brace combined with a Lyon physical therapy program as a conservative treatment option for AIS with an emphasis on the outcomes across varying stages of skeletal maturity and varying initial curve magnitudes. The ART brace is a rigid asymmetric brace, and an evolution of the well-known Lyon brace that has been used to treat scoliosis since the late 1940’s. In a regional European scoliosis clinic, the charts of 720 consecutive adolescents (age 10–18) with AIS who were treated with the ART brace between 2013 and 2018 by a single clinician were audited. Skeletal maturity and curve magnitude were measured at the initiation of bracing treatment by the Risser Sign and Cobb angle, respectively. Patients were grouped two ways: based on Risser stages 0 through 5 and initial curve magnitude above and below 40 degrees. Brace success was assessed via the avoidance of the surgical threshold of 50 degrees, curve progression ≤ 5° and ≥ 6°, and percent change and degrees of change between pre-treatment, at brace termination, and 2-year follow-up Cobb angles. Two years following brace termination, patients showed a 23% thoracic curve improvement ( p < 0.001) and 38% lumbar improvement ( p < 0.001) as compared to the initial, pre-treatment Cobb angles. Furthermore, 98% and 99% of patients avoided the surgical threshold of 50° for thoracic and lumbar curvatures, respectively. Bracing was also successful at all skeletal maturity stages with all Risser stages demonstrating significant curve improvements. Similarly, bracing was successful for curves initially above 40 degrees, demonstrated by high rates of avoidance of the surgical threshold and significant curve improvements. Adolescents who began treatment in all six Risser stages had successful outcomes. At all skeletal maturity stages, the ART brace outcomes showed not simply controlling curves but improving them. Curve magnitude groups further illustrate that conservative treatment can indeed be successful, even in cases with large initial Cobb angles. In all, this analysis provides evidence in contrary to the theory that only adolescents with immature spines and small curves will benefit from brace treatment.