The new Lyon ARTbrace versus the historical Lyon brace: a prospective case series of 148 consecutive scoliosis with short time results after 1 year compared with a historical retrospective case series of 100 consecutive scoliosis; SOSORT award 2015 winner
© de Mauroy et al. 2015
Received: 5 June 2015
Accepted: 25 July 2015
Published: 19 August 2015
Adolescent idiopathic scoliosis (AIS) is a four dimensional deformity of the spine arising in otherwise healthy children during puberty. The fourth dimension is time. This dimension is the characteristic of our database created in 1998 with systematic reconvening of our patients at regular intervals which increases the level of scientific evidence . The use of a brace in the conservative treatment for AIS plays an important role and has the aim to stop the evolution of the deformity in immature adolescents in order to prevent problems during adulthood [2, 3]. Long-term follow-ups indicate that patients with scoliosis may have a higher prevalence of back pain and of worsening pulmonary function if the curve becomes extremely severe . A randomized control trial BRAIST study conducted by Weinstein showed that bracing is significantly effective in reducing the progression of AIS . Previously, a Cochrane review  also demonstrated the effectiveness of bracing in the treatment of AIS.
To measure the effectiveness of a brace two main factors can be involved: 1. the immediate in-brace reduction depending how to get the three-dimensional correction and its reproducibility; 2. the patient’s adherence which depends on aesthetics and tolerance [7, 8]. Different types of braces are used in the treatment of AIS but almost all are created on the multiple three points system principle of applying external corrective forces across the curve in order to stop deformity progression, produce an acceptable sagittal and coronal contour, and delay or avoid surgical treatment [9–12]. The main biomechanical concepts are based on: elongation along the vertical axis, lateral inflexion in the frontal plane and derotation of the spine in order to obtain a correction of the scoliotic curve. Derotation is the main movement along the vertical axis. The correction in the sagittal plane is problematic because many scoliosis are accompanied by a change in the sagittal plane with a flat back in half of the cases. All of the above mechanisms are going in the direction of accentuation of the flat back and require significant and uncertain changes during the manufacture of the brace. This problem has now been finally solved thanks to segmental moulding.
Historically, in the early twentieth century, in the United States, Sayre  was the first to make a plaster cast in a standing posture using this biomechanical concept, even if the first modern brace can be considered the Milwaukee brace, created in 1940 by Blount, which was a brace based on axial elongation between the pelvis and the cervical collar.
Derotation and Detorsion or Untwisting
Cotrel added a fundamental component: the flexion in the frontal plane [14, 15]. The acronym ‘EDF’ stands for: Elongation, Derotation, Flexion. He created a framework for three-dimensional scoliosis correction in the supine position with spine untwisting. At the end of plaster cast weaning, the plaster mould to build the Lyon brace reproduces the overcorrection obtained [14, 16].
Even if the old Lyon brace in polymethacrylate was very rigid, the credit for HIGH RIGIDITY goes to the Italian team of ISICO with the Sforzesco brace, which has proven to be effective by avoiding plaster casts for scoliosis over 45° . The acronym ARTbrace (Asymmetrical Rigid Torsion brace) was created by Stefano Negrini. The merit of the ARTbrace is the addition of overcorrection to the high rigidity with a global detorsion. It is this overcorrection for small curvatures which explains the average improvement of the in-brace correction.
Since May 2013, all patients of JCdM were treated with the ARTbrace instead of a plaster cast which showed good initial results. Indeed, the first immediate results of the ARTbrace have demonstrated that the in-brace correction of the Cobb angle in the first 225 cohort of patients was 70 %, a correction which is 40 % higher than with the former Lyon brace or historical Lyon brace. The value of this correction was even higher than for other braces published in the literature, including retrospective studies [21, 22, 8, 23, 24].
Like the historical Lyon brace, the ARTbrace is ADJUSTABLE. Both axillary and pelvic clamps are adjustable with a precise wrench and a bolt system and an anterior ratcheting buckle.
Like the historical Lyon brace, the SAGITTAL PLANE is fixed by the posterior bar. But the sagittal plane is determined by the segmental mould and the superposition of the mouldings. In additional it is the lack of support at the sterno-clavicular level and at the abdominal level that avoids lumbar delordosis and thoracic flat back.
In this study, early results of 148 first consecutive scoliosis treated with the ART-brace after 1-year are reported in correlation with a matched pair control of the last 100 patients treated with the old Lyon Brace.
Material and Methods
We performed a prospective case series of 148 scoliosis with short time results after 1 year compared with a historical retrospective case series of 100 scoliosis. Consecutive cases are recruited in both groups. Randomization was not possible due to the administrative impossibility to perform plaster casts after May 2013. All lumbar scoliosis Lenke 5 were eliminated in the two groups as they continue to be treated by the GTB short brace .
Since May 2013, we treated more than 400 patients at the “Clinique du Parc – Lyon” with the new Lyon brace (ARTbrace) instead of the classical EDF plaster cast followed by the historical Lyon brace. The initial aim was to avoid a plaster cast, but very quickly, the ARTbrace appeared to be a much more effective solution compared to the former plaster casts and it was even better tolerated. Following the early successes the whole treatment was continued with the same brace. In this prospective study, only the first 148 of all patients, 17 % of males and 83 % of females with an average age of 13.37, with a follow-up at 1 year, have been included. The patients of this main group presented 35 thoracic primary curves and 28 lumbar or thoraco-lumbar primary curves and 37 double major curves with a Cobb angle ranging from 20° to 53° (average 29.23° and Standard Deviation: 8.14°). These 148 patients are group A. The second matched pair control group consisted of a consecutive series of 100 patients (22 % males 78 % Females) and an average age of 13.6, treated with a plaster cast and the historical Lyon brace, and controlled 1-year after brace fitting, with 41 thoracic primary curves, 23 primary lumbar or thoraco-lumbar curves and 36 double major curves with a Cobb angle ranging from 20° to 52° (average angle Cobb 30.4° and Standard Deviation: 9.61°). These 100 patients are group B.
All treatment parameters like indications, physiotherapy, full or part-time bracing were identical for both groups, according to the experience of Lyon management [14, 16, 17]. The plaster cast time was replaced by an equivalent time of “full time” ARTbrace.
The study of dropouts is fundamental and we expected a high rate because the realization of the plaster cast was a barrier that only 2/3 of children were crossing. Lyon bracing management has always been considered as an elitist treatment. After 1 year the number of dropouts is 14 (162-148) about 10 %. Some patients referred by colleagues from other countries and controlled by them are not considered as dropouts.
All patients were evaluated radiologically before treatment (T0), in-brace (T1), at 6 months without brace (T2) and at 1 year without brace (T3) during treatment. Clinical evaluation at T1 is performed at the end of full time wearing. The clinical parameters were identical for both groups and consisted of measure rib hump in millimetres, and Bunnel ATR by Adam’s posture.
An automated management system control facilitates regularity in follow up meetings. A 3D sterEOS study was carried out every time we had the EOS radiography at T0.
The radiological follow-up of control group B patients was performed without a sagittal view due to radiation saving habits with traditional radiology and probably also because the correction in the sagittal plane was not perfect. The problem of radiation in scoliosis was discussed in the consensus session of the SOSORT 2011 meeting . In fact to avoid excessive radiation, exposition lateral view X-ray was not systematically executed for most patients. On the contrary, thanks to using ultra-low dose EOS system, a systematically sagittal analysis of spine was possible for the patients in the main group A. The sagittal parameters like Sacral Slope (SS), Lumbar Lordosis (LL) and Thoracic Kyphosis (CT) were automatically measured by EOS system.
All the data are recorded immediately into a database and a serial number is automatically assigned at T1 about 3 days after bracing. All other statistical tests are done with the package SPSS v20. The first step is to confirm the normality of distribution (Kolmogorov-Smirnov & Shapiro-Wilk) and then use an independent-samples T test to compare Cobb angles T0 (before brace), T1 (in-brace),T2 (at 6 months) and T3 (at 1 year). A p value of less than 0.05 was considered to be significant. A copy of the Excel database can be downloaded to allow any comparisons (Additional file 1).
Average and Standard Deviations of Rib hump and Bunnel ATR before bracing and at 6 months for group A (ARTbrace) and Group B (old Lyon brace)
T – ARTbrace (A)
23.44 ± 9.4
9.75 ± 4.1
10.33 ± 6.6
5.14 ± 3.3
T - Old Lyon (B)
23.56 ± 8.6
10.55 ± 3.9
16.7 ± 8.5
7.95 ± 4.0
L – ARTbrace (A)
17.21 ± 7.8
7.51 ± 3.6
4.65 ± 4.5
2.06 ± 2.4
L – Old Lyon (B)
16.41 ± 7.4
7.47 ± 3.4
9.41 ± 6.3
4.51 ± 3.2
There was not a significant difference in the score of Thoracic rib hump before brace for control group with the old Lyon brace (M = 23.56, SD = 8.61) and the ARTbrace group (M = 23.44, SD = 9.43, t(176) = 0.089, p = 0.929.
There was not a significant difference in the score of Thoracic Bunnel ATR before brace for control group with the old Lyon brace (M = 10.55, SD = 3.85) and the ARTbrace group (M = 9.75, SD = 4.10, t(176) = 1.307, p = 0.193.
There was not also a significant difference in the score of Lumbar rib hump before brace for control group with the old Lyon brace (M = 16.41, SD = 7.36) and the ARTbrace group (M = 17.21, SD = 7.76, t(154) = -0.612, p = 0.541.
There was not also a significant difference in the score of Lumbar Bunnel ATR before brace for control group with the old Lyon brace (M = 7.47, SD = 3.378) and the ARTbrace group (M = 7.51, SD = 3.63, t(154) = -0.072, p = 0.943.
There was a significant difference in the scores for thoracic rib hump and Bunnel ATR and for lumbar rib hump and Bunnel ATR, at 6 months between the two groups.
Thoracic rib hump: t(176) = 5.651, p = 0.00
Thoracic Bunnel ATR: t(176) = 5.104, p = 0.00
Lumbar rib hump: t(155) = 5.459, p = 0.00
Lumbar Bunnel ATR: t(155) = 5.304, p = 0.00
Group A (ARTbrace)
At the thoracic level the percentage improvement is: 57 % for rib hump and 51 % for ATR
At the lumbar level the percentage improvement is: 79 % for rib hump and 86 % for ATR
Group B (Historical Lyon brace)
At the thoracic level the percentage improvement is: 27 % for rib hump and 25 % for ATR
At the lumbar level the percentage improvement is: 53 % for rib hump and 49 % for ATR
The percentage improvement between the old and the new Lyon brace is near 30 % for both rib hump and ATR. It is better for the lumbar area compared with the thoracic one.
The main group A of 148 patients (ARTbrace) had 195 primary curves from 20° to 55°: 63 curve Thoracic, 42 curve lumbar with 45 double major curves. Only primary curves were selected.
Average and Standard Deviation of Cobb angle at T0 (before bracing), T1 (in-brace), T2 (6 months), T3 (1 year), for group A (ARTbrace) and Group B (old Lyon brace)
T2 6 months
T3 1 year
A-Tho ART (n = 108)
30.03 ± 9.6
11.26 ± 8.65
20.25 ± 11
21.47 ± 11
A-Lumb ART (n = 87)
27.83 ± 7.5
6.64 ± 8.8
15.50 ± 9.1
16.40 ± 9.38
B-Tho Hist (n = 76)
31.14 ± 9.6
16.96 ± 9.3
23.96 ± 11
26.95 ± 11.9
B-Lumb Hist (n = 59)
29.69 ± 7.7
12.32 ± 7.9
18.81 ± 9.4
20.41 ± 11
Percentage improvement relative to the initial angle at T1 (in-brace), T2 (6 months), T3 (1 year), for group A (ARTbrace) and Group B (old Lyon brace)
A-Tho ART (n = 108)
A-Lumb ART (n = 87)
B-Tho Hist (n = 76)
B-Lumb Hist (n = 59)
Differential percentage between group A (ARTbrace) and Group B (old Lyon brace) at T1 (in-brace), T2 (6 months), T3 (1 year)
(%A-%B)/%B at T1
(%A-%B)/%B at T2
(%A-%B)/%B at T3
Differential Tho (n = 184)
Differential Lumb (n = 146)
With SPSS we can confirm with two tests: Shapiro-Wilk, and Kolmogorov-Smirnov, that the data comes from a normal distribution (Additional file 2).
We also use SPSS comparison of means tests to compare the two independent groups and answer the following questions (Additional file 3).
There was not a significant difference in the score of Thoracic Cobb angles before brace for control group with the old Lyon brace (M = 31.14, SD = 9.62) and the ARTbrace group (M = 30.03, SD = 8.30, t(182) = 0.834, p = 0.405.
There was not also a significant difference in the score of Lumbar Cobb before brace for control group with the old Lyon brace (M = 26.69, SD = 7.72) and the ARTbrace group (M = 27.82, SD = 7.51, t(144) = -0.884, p = 0.378.
There was a significant difference in the scores for thoracic and lumbar curves: in brace, at 6 months and after 1 year.
Thoracic in-brace: t(182) = 4.254, p = 0.00
Lumbar in-brace: t(144) = 3.993, p = 0.00
Thoracic at 6 months: t(182) = 2.284, p = 0.023
Lumbar at 6 months: t(144) = 2.131, p = 0.035
Thoracic at 1 year: t(182) = 3.205, p = 0.02
Lumbar at 1 year: t(134) = 2.463, p = 0.015
The radiological follow-up of control group patients was performed without lateral X-ray and therefore it is not possible to make a statistical comparison. But thanks to the use of the micro dose EOS system a systematic sagittal analysis was possible for the main group of patients (ARTbrace).
In a previous study, we showed that the average thoracic kyphosis angle with the upper limit T4 was 37° . For this study, we set the cut off at 30° for hypokyphosis or flat back.
73/148 patients (i.e. 49.4 %) had initial thoracic kyphosis below 30° (m = 19.6°, SD = 6.77)
In-brace angulation (m = 28.45°, SD = 5.84°) improvement in ARTbrace is 8.84°, significant (p = 0.000)
- 3.50 patients were monitored with sagittal EOS without brace at the 1 year follow-up (m = 27.3°, SD = 5.40). For this specific group: initial kyphosis (m = 18.58°, SD = 6.63), in-brace kyphosis (m = 28.06°, SD = 5.45) and last follow-up without brace (m = 27.15°, SD = 5.45) were analysed (Fig. 7)
The in-brace improvement rate is 50 % and very significant (p = 0.000), and without brace at the last follow up, the improvement rate is 46 % (p = 0.000). There was no statistical difference between the in-brace group and 1 year after when not wearing a brace (p = 0.289). The in-brace improvement is therefore maintained at the 1 year follow up when the brace is off.
38 % of patients showed an improvement of 10° or more, 36 % of patients showed an improvement between 5° and 9°, 26 % of cases with stability, no back flat worsening.
Comparing plaster cast and ARTbrace
Horizontal plane in-brace correction
Case n° 401
The average for the 15 patients studied was 37 %.
Adolescent idiopathic scoliosis (AIS) is a structural three-dimensional deformity of the spine arising in otherwise normal children during puberty. The use of brace in the conservative treatment for AIS  plays an important role and is meant to stop the evolution of the deformity in immature adolescents in order to prevent problems during adulthood. Different types of braces have been used in the treatment of AIS. The Lyon brace, created in 1947 by Pierre Stagnara, has been the first 3-points system adjustable brace, used after a plaster cast reduction [14, 16, 17].
Many previous studies support the positive results with the casting and Lyon braces [14, 16, 17]. The serial derotational plaster cast is commonly used for early onset scoliosis to create asymmetrical growth and remodelling . The idea is to recreate, with a removable brace, the same derotational forces. In this study we report short time prospective results after 1 year of 148 scoliosis cases treated with the new Lyon ARTbrace, in correlation with a matched-pair control with the old Lyon Brace.
Segmental moulding with individual correction of the frontal and sagittal plane,
Individual shape superposition
Fixed sagittal plane with simultaneous correction of flat back or hyperkyphosis
Night and day overcorrecting brace
Axilla baby lift concept
Coupled movement with biomechanical helicoidally detorsion of spine,
High rigidity asymmetric polycarbonate with “mayonnaise tube” elongation effect
Soft contact to increase tolerance and compliance
4D action with breathing toward the lateral expansions
One limit of this study was to only value the results of the immediate in-brace reduction of scoliotic curves by the ARTbrace, so in a limited time frame (3 day follow-up). In our study, instead, we report the early clinical and radiological results of group A (of 148 patients) with a follow-up after 1 year, so over a longer period of time, in correlation with a matched-pair control old Lyon brace group B.
T1 initial in-brace correction
For thoracic curves, the percentage improvement between the two groups was 37 %, confirming the initial results.
T2 at 6 months
X-rays at 6 months are conducted without the brace. In both groups we observe an angular recurrence linked to the elasticity of the scoliotic curvature with and without brace, which is normal. Overall, this elasticity is statistically lower for group A, as if a better in-brace correction decreased elasticity of scoliosis i.e. the difference between in-brace angulation without brace. These results confirm the BRAIST study that retains the importance of in-brace correction brace as a fundamental criterion of the final outcome treatment. If we compare the two groups, the percentage of improvement is even slightly higher.
T3 after 1 year
Many authors consider the results at 6 months as an excellent point in time to predict the final outcome [8, 34, 21, 35]. But above all, it is interesting to assess the evolution of the 2 curves that can be parallel, convergent or divergent, which has never been described to date. In our study, we find a divergence between both thoracic curves and lumbar curves in favor of group A, which would tend to prove that the initial efficiency of the brace is continuing with time. The average angular improvement is 5° between the two groups.
Certainly angular reduction after 1 year is not the final treatment outcome (2 years after weaning of brace), but we can identify some trends.
In the sagittal plane, this is the first brace to significantly improve the flat back and delordosis tendency.
This improvement with the ARTbrace can be related to segmental moulding with fixed sagittal correction but above all to the unscrewing or untwisting effect of the spine with translation of the vertebral bodies near the midline. In the literature, studies on improvement to the sagittal plane due to brace effect do not exist. Instead, many authors report accentuating brace effect on the flat back, probably related to axial stretching due to the overcorrection in the frontal plane [36, 37]. Analysing the effect of a brace on 38 patients treated with Chêneau using MR animation, shows a significant reduction of the mean Cobb angle of thoracic curves in-brace in MR animation coronal 0° projection (simulating A-P view in X-ray) but in -90° projection, simulating a lateral X-ray view, reported a reduction Kyphosis Cobb angle in 33/38 patients. So the MRI animation analysis confirms the straightening effect of the brace leading to the flattening of the sagittal spinal profile.
In the horizontal plane, this is the first time we no longer speak of segmental derotation but overall untwisting of scoliosis measured automatically by SterEOS (index of global detorsion).
As scoliosis is a structural three-dimensional deformity, the development of the EOS-system has allowed us to study better transverse plane analysis. It is a concept initiated by  his “torsiometer” is still considered the most accurate method of measurement of axial vertebral rotation on 2D A-P radiographs [39, 40]. Then MRI and CT have improved accuracy of vertebral rotations measurements but their clinical relevance is limited by the supine position of the patient for MRI and radiation exposition for CT. Today the development of the EOS-system has allowed us to study better transverse plane analysis and improve our knowledge. Courvoisier, analysing the transverse plane pattern of 111 patients with mild scoliosis in 3D by the EOS-system, combining apical axial rotation, the intervertebral axial rotation at junctions and the torsion index, has demonstrated that it is independent of the scoliotic curve location but above all significant in the determination of the progression risk of mild scoliosis .
Simplicity of classification
The former Lyon brace requires the use of Lenke classification adapted to bracing. The segmental moulding of the new Lyon brace is much simpler and requires only two classes: C and S shaped scoliosis. The overall alignment is provided by the first moulding. For C shaped scoliosis, the thoracic and lumbar shifts will be realized in the same direction, while it will be carried out in opposite directions for the S curves. The lumbar oblique tilt and high curvatures are also much easier to manage.
The interest of overcorrection is not obvious especially for a specialist symmetrical brace such as the historical Lyon brace. However, we were using the night overcorrection for small thoracolumbar curves with good results. The Chêneau brace experience also goes in the direction of overcorrection. The ability to manually perform that overcorrection directly on the child is an advantage. Toru Maruyama showed us the interest of the shift in the scoliosis correction [41, 42] and the patient’s posture during the segmental moulding is very close to some of Schroth’s specific exercises .
Lyon brace Management
The indications are the same with wear time in the day depending on the initial angulation.
The management is the same during treatment with adaptation of wearing time according to the elasticity of the scoliosis (X-ray without brace compared to in-brace X-Ray). Indeed, we believe that the spine is not made to grow properly under a rigid brace, and a very effective brace worn for a shorter period during the day is better than a less effective brace worn 23h/24. Although the consequences of the brace on bone mass is not obvious, the precautionary principle is required .
Physiotherapy has remained the same, but the brace asymmetry and preparation for segmental moulding are closer to asymmetric methods and probably the current protocol will change in the future.
The continuation of sports during treatment is a characteristic of the Lyon bracing treatment because the plaster cast causes a realignment of tension along the spine. The results with the historical Lyon brace were better when the children were practicing at least 5 h of sport each week. The initial full time wearing has the same creep effect. There is also another advantage with increase of skin tolerance (watch effect of Manuel Rigo). However, tolerance is worse in part time wearing.
Compliance is a key element of the final results of the treatment with immediate in-brace reduction. Compliance depends on the child and the family, but also on the brace which should be light, aesthetics and the allowance of normal breathing by expansions. The low dropout rate may also be due to changes in the brace.
This study demonstrates not only good results of the ARTbrace about immediate in-brace reducibility of scoliosis described in previous studies published by the same author, but this trend is maintained further at 6 months and at 1 year. So the new concepts and first results of ARTbrace, defined as a modified or “new” Lyon brace, confirm that it can completely replace the casting and old Lyon brace process.
Finally, angular reduction at 1 year is not certainly the final treatment outcome (2 years after weaning of brace) even if some authors are using the reduction at this point in time as a predictive criterion. So, future studies could confirm if this criterion is valid and consequently the effectiveness of the ARTbrace.
Availability of supporting data
The data set supporting the results and all SPSS statistics results are included within the article.
All patients were informed and have given their consent for this work. This monocentric study was the object of a declaration to the CNIL under the number 1831534 in France and the procedure accepted.
Adolescent idiopathic scoliosis
Bunnel’s Angle of Trunk Rotation
Scoliosis research society
Society on scoliosis orthopedic and rehabilitation treatment
We thank Agnes de Mauroy and Alex Thornton for correcting the English text.
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