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Ribesse A, Ismail K, Croonenborghs M, Irda N, Miladi L, Jacques PJ, Mousny M, Pardoen T. Fracture mechanisms in Ti and Co-Cr growing rods and impact on clinical practice. J Mech Behav Biomed Mater 2021; 121:104620. [PMID: 34119814 DOI: 10.1016/j.jmbbm.2021.104620] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 04/15/2021] [Accepted: 05/28/2021] [Indexed: 12/29/2022]
Abstract
The widely used treatment of early onset scoliosis based on fusionless spinal instrumentation with growing rods suffers from severe complications due to premature rod failure. Only few studies have explored the fracture mechanisms in single rod constructs, while clinical practice urgently needs guidance. The objectives of this study are (i) to determine the failure mechanisms in Ti-6Al-4V alloy, Ti Cp 2 and Co-Cr alloy rods, and (ii) to propose strategies to reduce the risk of rod fracture. For this purpose, seven rods from three patients treated for early onset scoliosis were characterized by preoperative, pre-fracture X-rays and after-fracture X-rays. Fracture surface analysis, performed using scanning electron microscopy, revealed similar failure mechanisms for all rods, independent of composition and diameter. Fracture is caused by fatigue, associated to repeated bending action in the anteroposterior direction. Cracking initiates at multiple sites. Three-point bending fatigue tests on Ti-6Al-4V bent rods confirmed the fracture scenario. A beam bending model indicates that the failure process is controlled by the combination of cyclic vertical and horizontal forces with amplitudes from 200 N to 400 N and from 70 N to 150 N, respectively. Strategies to minimize fracture involve adaptations of material properties and rod geometry to scoliosis characteristics, including sagittal alignment, and spine behavior.
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Affiliation(s)
- Arnaud Ribesse
- Institute of Mechanics, Materials and Civil Engineering, UCLouvain, Place Sainte Barbe 2 L5.02.02, 1348, Louvain-la-Neuve, Belgium.
| | - Karim Ismail
- Institute of Mechanics, Materials and Civil Engineering, UCLouvain, Place Sainte Barbe 2 L5.02.02, 1348, Louvain-la-Neuve, Belgium.
| | - Maïté Croonenborghs
- Institute of Mechanics, Materials and Civil Engineering, UCLouvain, Place Sainte Barbe 2 L5.02.02, 1348, Louvain-la-Neuve, Belgium.
| | - Nadia Irda
- Department of Orthopedics, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Bruxelles, Belgium.
| | - Lotfi Miladi
- Hôpital Necker, Service d'Orthopédie, 149 Rue de Sèvres, 75 015, Paris, France.
| | - Pascal J Jacques
- Institute of Mechanics, Materials and Civil Engineering, UCLouvain, Place Sainte Barbe 2 L5.02.02, 1348, Louvain-la-Neuve, Belgium.
| | - Maryline Mousny
- Centre Plurisanté, 11 avenue de l'Andalousie, 1140, Bruxelles, Belgium.
| | - Thomas Pardoen
- Institute of Mechanics, Materials and Civil Engineering, UCLouvain, Place Sainte Barbe 2 L5.02.02, 1348, Louvain-la-Neuve, Belgium.
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Miladi L, Khouri N, Pradon J, Elie C, Treluyer JM. One-way self-expanding rod for early-onset scoliosis: early results of a clinical trial of 20 patients. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:749-758. [PMID: 33486593 DOI: 10.1007/s00586-021-06732-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 11/26/2020] [Accepted: 01/11/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Progressive early-onset scoliosis raises major challenges for surgeons, as growth must be preserved. With traditional growing rods, the need for repeated surgery is associated with numerous complications, high costs, and heavy psychosocial burden on the patient and family. We assessed the safety and efficacy of a new one-way self-expanding rod (OWSER). METHODS This prospective single-centre phase 2 study included two groups of children with progressive EOS treated by the OWSER in 2016-2017: Ten received a unilateral construct to treat progressive non-neuromuscular curves and 10 others a bilateral construct for neuromuscular scoliosis. Clinical and radiological data were assessed at surgery and 3, 6, 12, 18 months later. The primary endpoint was success defined as the absence of repeated surgery at 12 months. RESULTS In the non-neuromuscular group, rod expansion occurred in 5 of 10 patients [95% CI 19-81]; in the five other patients, rotational conflict inside the domino prevented rod expansion, four of them required surgery within the first 12 months. Rod expansion occurred spontaneously and during monthly traction sessions in all 10 neuromuscular patients [95% CI 69-100], without mechanical or device-related complications. Residual pelvic obliquity was improved by -3° [- 6.0 to 9.5] at 18 months. Lung function improved in the non-neuromuscular group. CONCLUSION In neuromuscular diseases, the OWSER bilateral construct seems to be safe and less aggressive. Used as unilateral construct in non-neuromuscular group, it was less effective. Accordingly, we recommend the bilateral construct for all aetiologies. That device could avoid further surgery and reduce the rate of complications after long follow-up.
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Affiliation(s)
- Lotfi Miladi
- Paediatric Orthopaedics Surgery Department, Necker Hospital, Université de Paris, Assistance Publique Hôpitaux de Paris, 149, Rue de Sevres, 75015, Paris, France.
| | - Nejib Khouri
- Paediatric Orthopaedics Surgery Department, Necker Hospital, Université de Paris, Assistance Publique Hôpitaux de Paris, 149, Rue de Sevres, 75015, Paris, France
| | - Jerome Pradon
- Clinical Research Unit, Necker Hospital, Université de Paris, Assistance Publique Hôpitaux de Paris, 149, Rue de Sevres, Paris, 75015, France
| | - Caroline Elie
- Clinical Research Unit, Necker Hospital, Université de Paris, Assistance Publique Hôpitaux de Paris, 149, Rue de Sevres, Paris, 75015, France
| | - Jean-Marc Treluyer
- Clinical Research Unit, Necker Hospital, Université de Paris, Assistance Publique Hôpitaux de Paris, 149, Rue de Sevres, Paris, 75015, France
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Nazareth A, Skaggs DL, Illingworth KD, Parent S, Shah SA, Sanders JO, Andras LM. Growth guidance constructs with apical fusion and sliding pedicle screws (SHILLA) results in approximately 1/3rd of normal T1-S1 growth. Spine Deform 2020; 8:531-535. [PMID: 32096132 DOI: 10.1007/s43390-020-00076-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 12/21/2019] [Indexed: 12/23/2022]
Abstract
STUDY DESIGN Retrospective, multicenter. OBJECTIVE To investigate clinical outcomes in particular T1-S1 growth in patients with SHILLA instrumentation independent of inventor's reports. Guided growth with apical fusion and sliding pedicle screws (GGC/SHILLA) is an alternative to distraction-based growing rods for the treatment of EOS. A recent report of patients treated with GGC primarily at the center where the procedure was invented reported surprisingly good spinal growth similar to normal growth. METHODS Retrospective review of EOS patients treated with GGC between 2007 and 2013 was performed from a multicenter database prior to final fusion. Inclusion criteria were < 10 years at index surgery and minimum 2-year follow-up. Patients with GGC performed at the inventor's institution or prior spinal instrumentation were excluded. Predicted normal T1-S1 change during the growth period was calculated for each patient based on Dimeglio's growth rates. RESULTS 20 patients (mean age at surgery: 5.7 years) with the following diagnoses met inclusion criteria: syndromic (N = 9), neuromuscular (N = 5), idiopathic (N = 3) and congenital (N = 3). Preoperative mean Cobb was 77° (range 33°-111°). Mean increase in T1-S1 length from preoperative to postoperative was 51.5 mm, and change from postoperative to final follow-up was 21.8 mm (4.2 mm/year) which was 36% of predicted growth. 15/20 (75%) patients underwent 21 revision surgeries most commonly for implant complications (N = 26) and 8/20 (40%) underwent definitive fusion at a mean of 5.1 ± 1.2 years after guided growth surgery. CONCLUSION This study constitutes the largest case series of patients with EOS treated with GGC outside of the inventor's institution. The change in T1-S1 observed through the follow-up period in EOS patients treated with GGC was approximately 1/3rd of predicted normal growth, and less than 1/3rd of growth reported in previous reports. Similar curve correction and complication rates but less T1-S1 growth during the growth period were found compared to prior GGC (SHILLA) series.
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Affiliation(s)
- Alexander Nazareth
- Keck School of Medicine, University of Southern California, Los Angeles, USA.,Children's Orthopaedic Center, Children's Hospital Los Angeles, 4650 Sunset Blvd., M/S 69, Los Angeles, CA, 90027, USA
| | - David L Skaggs
- Keck School of Medicine, University of Southern California, Los Angeles, USA. .,Children's Orthopaedic Center, Children's Hospital Los Angeles, 4650 Sunset Blvd., M/S 69, Los Angeles, CA, 90027, USA.
| | - Kenneth D Illingworth
- Keck School of Medicine, University of Southern California, Los Angeles, USA.,Children's Orthopaedic Center, Children's Hospital Los Angeles, 4650 Sunset Blvd., M/S 69, Los Angeles, CA, 90027, USA
| | - Stefan Parent
- Department of Surgery, Université de Montréal, Montreal, USA
| | - Suken A Shah
- Department of Orthopaedics, Nemours/Alfred I, DuPont Hospital for Children, Wilmington, USA
| | - James O Sanders
- Department of Orthopaedics, University of North Carolina Orthopaedics, Chapel Hill, USA
| | - Lindsay M Andras
- Keck School of Medicine, University of Southern California, Los Angeles, USA.,Children's Orthopaedic Center, Children's Hospital Los Angeles, 4650 Sunset Blvd., M/S 69, Los Angeles, CA, 90027, USA
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Outcomes at Skeletal Maturity of 34 Children With Scoliosis Treated With a Traditional Single Growing Rod. Spine (Phila Pa 1976) 2019; 44:1630-1637. [PMID: 31725685 DOI: 10.1097/brs.0000000000003148] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective case series. OBJECTIVES To analyze the outcomes at skeletal maturity of patients treated with a single traditional growing rod (GR). To compare results of patients according to whether posterior spinal fusion (PSF) was performed at treatment completion. SUMMARY OF BACKGROUND DATA Few studies examined the end results of GRs at skeletal maturity. There is no agreement on requirement of PSF at GR treatment completion. METHODS Clinical and radiological analysis of consecutive patients with severe and/or progressive scoliosis treated initially with traditional single GR. Group comparisons of patients with PSF and without fusion surgery at treatment completion. RESULTS Thirty-four patients underwent traditional single GR implantation at a median age of 11.7 years. Median follow-up was 6.5 years. At last follow-up, T1-S1 distance was increased by a median 116 mm (P < 0.001) and median major curve Cobb angle was changed from 55° preoperatively to 30° (P < 0.001). Complications included 26 rod fractures, 1 implant prominence, 4 proximal junctional kyphosis, 2 proximal hook dislodgments, and 2 wound infections. At the beginning our experience, PSF was performed systematically in 17 patients. Relying on spinal ankylosis, 17 patients were subsequently not fused at GR treatment completion (single GR removed N = 2, single GR retained N = 7, dual GR surgery N = 8). There were no statistical differences between groups in improvements of radiological parameters from preoperative GR insertion to last follow-up. No GR fracture occurred after dual GR surgery. CONCLUSION Single GR allows curve control and promotes spinal growth. Dual GR is, however, recommended for rod fracture prevention and better correction maintenance. In patients with satisfactory deformity correction at skeletal maturity, one may consider retaining dual GR instead of performing PSF. LEVEL OF EVIDENCE 4.
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Wijdicks SPJ, Tromp IN, Yazici M, Kempen DHR, Castelein RM, Kruyt MC. A comparison of growth among growth-friendly systems for scoliosis: a systematic review. Spine J 2019; 19:789-799. [PMID: 30290228 DOI: 10.1016/j.spinee.2018.08.017] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 08/28/2018] [Accepted: 08/28/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The optimal method for surgical treatment of early onset scoliosis is currently unknown. Although the aim of growth-friendly systems is to reduce the curve and maintain growth, there is no consensus on how to measure spinal growth during and after the treatment. Different measurements of different segments (T1-S1, T1-T12, instrumented length) are used for different time points to evaluate growth. The aim of this review is to assess what measurements are used and to compare the growth-friendly systems based on spinal growth during treatment. METHODS The electronic MEDLINE, EMBASE, and Cochrane databases were systematically searched for original articles that reported growth for traditional growing rods (TGR), vertical expandable prosthetic titanium rib expansion technique (VEPTR), Shilla, magnetically controlled growing rods (MCGR), and Luque-trolley systems. All measurements were recorded, and weighted averages calculated in centimeter per year were compared. RESULTS We included 52 studies (26 TGR, 12 MCGR, 6 VEPTR, 4 Luque trolley, 1 Shilla, and 3 mixed). Often only one segment was reported (T1-S1 length in 22 studies, T1-T12 length in two studies, and instrumented length in five studies). The remaining 22 studies reported T1-S1 length in combination with T1-T12 length (15 studies) or instrumented length (eight studies). Spinalgrowth achieved by initial correction only was a considerable 3.9 cm (based on 34 studies) as well as the spinal growth achieved by the final fusion surgery (2.3 cm in four studies). To specifically assess growth achieved with the system, length gain after initial surgery and before final fusion in growth system graduates was considered. Only four TGR studies reported on this "true" spinal growth with 0.6 and 0.3 cm/y in the T1-S1 and T1-T12 segment, respectively. CONCLUSIONS Reporting on spinal growth is currently inadequate and does not allow a good comparison of different techniques. However, all systems often report growth similar to Dimeglio's T1-S1 spinal growth of 1 cm/y. It should be recognized though that a considerable portion of the reported spinal growth is the result of the initial and final surgical correction and not due to the growth-friendly implant.
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Affiliation(s)
- Sebastiaan P J Wijdicks
- Department of Orthopaedic Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands.
| | - Isabel N Tromp
- Department of Orthopaedic Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Muharrem Yazici
- Faculty of Medicine, Department of Orthopaedics, Sihhiye, Ankara, 06100 Turkey
| | - Diederik H R Kempen
- Surgery, Onze Lieve Vrouwe Gasthuis, P.O. Box 95500, 1090 HM, Amsterdam, The Netherlands
| | - René M Castelein
- Department of Orthopaedic Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Moyo C Kruyt
- Department of Orthopaedic Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
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Mackel CE, Jada A, Samdani AF, Stephen JH, Bennett JT, Baaj AA, Hwang SW. A comprehensive review of the diagnosis and management of congenital scoliosis. Childs Nerv Syst 2018; 34:2155-2171. [PMID: 30078055 DOI: 10.1007/s00381-018-3915-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 07/11/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE To provide the reader with a comprehensive but concise understanding of congenital scoliosis METHODS: We have undertaken to summarize available literature on the pathophysiology, epidemiology, and management of congenital scoliosis. RESULTS Congenital scoliosis represents 10% of pediatric spine deformity and is a developmental error in segmentation, formation, or a combination of both leading to curvature of the spine. Treatment options are complicated by balancing growth potential with curve severity. Often associated abnormalities of cardiac, genitourinary, or intraspinal systems are concurrent and should be evaluated as part of the diagnostic work-up. Management balances the risk of progression, growth potential, lung development/function, and associated risks. Surgical treatment options involve growth-permitting systems or fusions. CONCLUSION Congenital scoliosis is a complex spinal problem associated with many other anomalous findings. Treatment options are diverse but enable optimization of management and care of these children.
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Affiliation(s)
- Charles E Mackel
- Department of Neurosurgery, Tufts Medical Center and Floating Hospital for Children, 800 Washington St, Boston, 02111, MA, USA
| | - Ajit Jada
- Department of Neurological Surgery, Weill Cornell Medical College, Box 99, 525 E 68th St, New York, 10065, NY, USA
| | - Amer F Samdani
- Shriners Hospitals for Children-Philadelphia, 3551 N Broad Street, Philadelphia, PA, 19140, USA
| | - James H Stephen
- Department of Neurosurgery, University of Pennsylvania, 3400 Spruce St, Philadelphia, 19104, PA, USA
| | - James T Bennett
- Department of Orthopaedic Surgery, Lewis Katz School of Medicine at Temple University, 3500 N Broad St, Philadelphia, 19140, PA, USA
| | - Ali A Baaj
- Department of Neurological Surgery, Weill Cornell Medical College, Box 99, 525 E 68th St, New York, 10065, NY, USA
| | - Steven W Hwang
- Shriners Hospitals for Children-Philadelphia, 3551 N Broad Street, Philadelphia, PA, 19140, USA.
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Dubory A, Bouloussa H, Riouallon G, Wolff S. A computed tomographic anatomical study of the upper sacrum. Application for a user guide of pelvic fixation with iliosacral screws in adult spinal deformity. INTERNATIONAL ORTHOPAEDICS 2017; 41:2543-2553. [PMID: 28791464 DOI: 10.1007/s00264-017-3580-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Accepted: 07/06/2017] [Indexed: 11/25/2022]
Abstract
PURPOSE Widely used in traumatic pelvic ring fractures, the iliosacral (IS) screw technique for spino-pelvic fixation remains anecdotal in adult spinal deformity. The objective of this study was to assess anatomical variability of the adult upper sacrum and to provide a user guide of spino-pelvic fixation with IS screws in adult spinal deformity. METHODS Anatomical variability of the upper sacrum according to age, gender, height and weight was sought on 30 consecutive pelvic CT-scans. Thus, a user guide of spino-pelvic fixation with IS screws was modeled and assessed on ten CT-scans as described below. Two invariable landmarks usable during the surgical procedure were defined: point A (corresponding to the connector binding the IS screw to the spinal rod), equidistant from the first posterior sacral hole and the base of the S1 articular facet and 10 mm-embedded into the sacrum; point B (corresponding to the tip of the IS screw) located at the junction of the anterior third and middle third of the sacral endplate in the sagittal plane and at the middle of the endplate in the coronal plane. Point C corresponded to the intersection between the A-B direction and the external facet of the iliac wing. Three-dimensional reconstructions modeling the IS screw optimal direction according to the A-B-C straight line were assessed. RESULTS Age had no effect on the anatomy of the upper sacrum. The distance between the base of the S1 superior articular facet and the top of the first posterior sacral hole was correlated with weight (r = 0.6; 95% CI [0.6-0.9]); p < 0.001). Sacral end-plate thickness increased for male patients (p < 0.001) and was strongly correlated with height (r = 0.6; 95% CI [0.29-0.75]); p < 0.001) and weight (r = 0.8; 95% CI [0.6-0.9]); p < 0.001). The thickness of the inferior part of the S1 vertebral body increased in male patients (p < 0.001). Other measured parameters slightly varied according to gender, height and weight. Simulating the described technique of pelvic fixation, no misplaced IS screw was found whatever the age, gender and morphologic parameters. CONCLUSION This user guide of spinopelvic fixation with IS screws seems to be reliable and reproducible independently of age, gender and morphologic characteristics but needs clinical assessment. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Arnaud Dubory
- Department of Orthopaedic Surgery, Paris-Saint-Joseph Hospital Group, 185 rue Raymond Losserand, Paris, France.
- Orthopaedic Surgery, Hôpital Henri Mondor, AP-HP Paris, University Paris East (UPEC), 94010, Creteil, France.
| | - Houssam Bouloussa
- Department of Orthopaedic Surgery, Paris-Saint-Joseph Hospital Group, 185 rue Raymond Losserand, Paris, France
- Orthopaedic Department, Tumor and Spine Unit, Bicêtre University hospital, AP-HP Paris, F-94270; JE 2494 Univ Paris-Sud Orsay, F-01405, 78 Rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
| | - Guillaume Riouallon
- Department of Orthopaedic Surgery, Paris-Saint-Joseph Hospital Group, 185 rue Raymond Losserand, Paris, France
| | - Stéphane Wolff
- Department of Orthopaedic Surgery, Paris-Saint-Joseph Hospital Group, 185 rue Raymond Losserand, Paris, France
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Yan C, Li Y, Yu Z. Prevalence and Consequences of the Proximal Junctional Kyphosis After Spinal Deformity Surgery: A Meta-Analysis. Medicine (Baltimore) 2016; 95:e3471. [PMID: 27196453 PMCID: PMC4902395 DOI: 10.1097/md.0000000000003471] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The aim of this study was to estimate the prevalence and patient outcomes of proximal junctional kyphosis (PJK) in pediatric patients and adolescents who received surgical interventions for the treatment of a spinal deformity.Literature was searched in electronic databases, and studies were selected by following précised eligibility criteria. Percent prevalence values of the PJK in individual studies were pooled to achieve a weighted effect size under the random effects model. Subgroup and meta-regression analyses were performed to appraise the factors affecting PJK prevalence.Twenty-six studies (2024 patients) were included in this meta-analysis. Average age of the patients was 13.8 ± 2.75 years of which 32 ± 20 % were males. Average follow-up was 51.6 ± 38.8 (range 17 ± 13 to 218 ± 60) months. Overall, the percent prevalence of PJK (95% confidence interval) was 11.02 (10.5, 11.5) %; P < 0.00001 which was inversely associated with age (meta-regression coefficient: -1.607 [-2.86, -0.36]; 0.014). Revision surgery rate in the patients with PJK was 10%. The prevalence of PJK was positively associated with the proximal junctional angle at last follow-up (coefficient: 2.248; P = 0.012) and the change in the proximal junctional angle from surgery to last follow-up (coefficient: 2.139; P = 0.014) but not with preoperative proximal junctional angle.The prevalence of PJK in the children and adolescent patients is 11%. About 10% of those affected require revision surgery.
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Affiliation(s)
- Chunda Yan
- From the 4th Ward of Orthopedics (CY, ZY), the First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang; and Department of Orthopaedics (YL), Shanxi Province People's Hospital, Xi'an, China
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Odent T, Ilharreborde B, Miladi L, Khouri N, Violas P, Ouellet J, Cunin V, Kieffer J, Kharrat K, Accadbled F. Fusionless surgery in early-onset scoliosis. Orthop Traumatol Surg Res 2015; 101:S281-8. [PMID: 26386889 DOI: 10.1016/j.otsr.2015.07.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 06/17/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Surgical treatment of early-onset scoliosis has greatly developed in recent years. Early-onset scoliosis covers a variety of etiologies (idiopathic, neurologic, dystrophic, malformative, etc.) with onset before the age of 5 years. Progression and severity threaten respiratory development and may result in respiratory failure in adulthood. Many surgical techniques have been developed in recent years, aiming to protect spinal and thoracic development. MATERIAL AND METHODS Present techniques are based on one of two main principles. The first consists in posterior distraction of the spine in its concavity (single growing rod, or vertical expandable prosthetic titanium rib [VEPTR]), or on either side (dual rod); this requires iterative surgery, for lengthening, unless motorized using energy provided by a magnetic system. The second option is to use spinal growth force to lengthen the assembly; these techniques (Luque Trolley, Shilla), using a sliding assembly, are known as growth guidance. RESULTS These techniques are effective in controlling early scoliotic deformity, and to some extent restore spinal growth. However, they show a high rate of complications: infection, rod breakage, spinal fixation pull out and, above all, progressive spinal stiffness, reducing long-term efficacy. Respiratory gain is harder to assess, as thoracic expansion does not systematically improve respiratory function, particularly due to impaired compliance of the thoracic cage.
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Affiliation(s)
- T Odent
- Service de chirurgie orthopédique pédiatrique, CHRU de Tours, université François-Rabelais de Tours, PRES Centre-Val de Loire université, 49, boulevard Béranger, 37044 Tours, France.
| | - B Ilharreborde
- Service de chirurgie orthopédique pédiatrique, hôpital universitaire Robert-Debré, université Paris-Diderot, Assistance publique-Hôpitaux de Paris, 75019 Paris, France
| | - L Miladi
- Service de chirurgie orthopédique pédiatrique, hôpital universitaire Necker-Enfants-Malades, université Paris-Descartes, Sorbonne Paris-Cité, Assistance publique-Hôpitaux de Paris, 149, rue de Sèvres, 75743 Paris cedex 15, France
| | - N Khouri
- Service de chirurgie orthopédique pédiatrique, hôpital universitaire Necker-Enfants-Malades, université Paris-Descartes, Sorbonne Paris-Cité, Assistance publique-Hôpitaux de Paris, 149, rue de Sèvres, 75743 Paris cedex 15, France
| | - P Violas
- Service de chirurgie pédiatrique, hôpital Sud, université Rennes 1, boulevard de Bulgarie, 35000 Rennes, France
| | - J Ouellet
- Shriner's Hospital, McGill University, Montreal, Canada
| | - V Cunin
- Service d'orthopédie pédiatrique, hôpital Femme-Mère-Enfant, université Lyon 1, hospices civils de Lyon, 59, boulevard Pinel, 69677 Bron cedex, France
| | - J Kieffer
- Pediatric clinic, Luxembourg, Luxembourg
| | - K Kharrat
- Hôpital hôtel-Dieu, B.P. 166830, Beirut, Lebanon
| | - F Accadbled
- Service d'orthopédie, hôpital des Enfants, CHU de Toulouse, Toulouse, France
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Hu HM, Hui H, Zhang HP, Huang DG, Liu ZK, Zhao YT, He SM, Zhang XF, He BR, Hao DJ. The impact of posterior temporary internal distraction on stepwise corrective surgery for extremely severe and rigid scoliosis greater than 130°. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015; 25:557-68. [PMID: 26071944 DOI: 10.1007/s00586-015-4013-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Revised: 05/06/2015] [Accepted: 05/06/2015] [Indexed: 11/27/2022]
Abstract
AIM To investigate the efficacy and safety of temporary internal distraction corrective surgery for extremely severe scoliosis. METHODS Eleven scoliosis patients (3 males and 8 females) with curves ≥130° (mean 148.8°; range 130°-157°) who underwent a two-stage surgery, including a posterior temporary internal distraction correction and definitive posterior spinal correction with posterior pedicle screw instrumentation from 2008 to 2011 were retrospectively reviewed. Minimum follow-up was 2-years (mean 41.8 months; range 27.0-63.0 months). The analysis focused on the impact of temporary internal distraction on curve correction, pulmonary function tests (PFTs), complications and surgical outcomes. Neurosurveillance of sensory (somatosensory-evoked potentials) and motor (motor-evoked potentials) potential was performed in all cases. Posterior instrumentation was used in all patients. RESULTS After the use of internal distraction, the preoperative major curve (mean 148.8°; range 130°-157°) was corrected to a mean of 79° (range 63°-87°), the T5-T12 kyphosis Cobb angle (mean 79°; range 30°-97°) was corrected to a mean of 59° (range 20°-75°), the coronal imbalance (mean 0.8 cm; range -3.6 to 2.8 cm) was improved to a mean of 0.6 cm (range -1.5 to 2.0 cm), the forced vital capacity percentage (FVC%) was improved from 59.3 ± 11.6 to 68.7 ± 13.7, and the forced expiratory volume in 1 s (FEV1%) was improved from 61.4 ± 13.6 to 71.3 ± 9.3. The average increase in body height was 6.7 cm, and the dorsum razor was corrected to 3-5 cm. During definitive surgery, the final major curves were corrected to a mean of 55° (range 32°-72°), the T5-T12 kyphosis Cobb was corrected to 35° (range 15°-68°), the coronal imbalance was improved to 0.5 cm (range -1.2 to 1.8 cm), the FVC% was improved to 71.2 ± 8.3, the FEV1% was improved to 76.3 ± 16.7, the increase in body height was 3.1 cm, and the dorsum razor was corrected to 1-3 cm. The mean interval time between the two surgeries was 3.5 months. None of the patients exhibited postoperative neurologic deficits or infections. No instrument complications were found during the final follow-up. CONCLUSIONS Temporary internal distraction in a two-stage corrective surgery provided patients who had extremely severe and rigid scoliosis, an effective and safe solution for scoliosis without significant complications.
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Affiliation(s)
- Hui-Min Hu
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University College of Medicine, No. 76 Nanguo Road, Xi'an, 710054, Shaanxi, People's Republic of China
| | - Hua Hui
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University College of Medicine, No. 76 Nanguo Road, Xi'an, 710054, Shaanxi, People's Republic of China
| | - Hai-Ping Zhang
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University College of Medicine, No. 76 Nanguo Road, Xi'an, 710054, Shaanxi, People's Republic of China
| | - Da-Geng Huang
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University College of Medicine, No. 76 Nanguo Road, Xi'an, 710054, Shaanxi, People's Republic of China
| | - Zhong-Kai Liu
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University College of Medicine, No. 76 Nanguo Road, Xi'an, 710054, Shaanxi, People's Republic of China
| | - Yuan-Ting Zhao
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University College of Medicine, No. 76 Nanguo Road, Xi'an, 710054, Shaanxi, People's Republic of China
| | - Si-Min He
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University College of Medicine, No. 76 Nanguo Road, Xi'an, 710054, Shaanxi, People's Republic of China
| | - Xue-Fang Zhang
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University College of Medicine, No. 76 Nanguo Road, Xi'an, 710054, Shaanxi, People's Republic of China
| | - Bao-Rong He
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University College of Medicine, No. 76 Nanguo Road, Xi'an, 710054, Shaanxi, People's Republic of China.
| | - Ding-Jun Hao
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University College of Medicine, No. 76 Nanguo Road, Xi'an, 710054, Shaanxi, People's Republic of China.
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Cunin V. Early-onset scoliosis: current treatment. Orthop Traumatol Surg Res 2015; 101:S109-18. [PMID: 25623270 DOI: 10.1016/j.otsr.2014.06.032] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2014] [Revised: 05/12/2014] [Accepted: 06/05/2014] [Indexed: 02/02/2023]
Abstract
Early-onset scoliosis, which appears before the age of 10, can be due to congenital vertebral anomalies, neuromuscular diseases, scoliosis-associated syndromes, or idiopathic causes. It can have serious consequences for lung development and significantly reduce the life expectancy compared to adolescent scoliosis. Extended posterior fusion must be avoided to prevent the crankshaft phenomenon, uneven growth of the trunk and especially restrictive lung disease. Conservative (non-surgical) treatment is used first. If this fails, fusionless surgery can be performed to delay the final fusion procedure until the patient is older. The gold standard delaying surgical treatment is the implantation of growing rods as described by Moe and colleagues in the mid-1980s. These rods, which are lengthened during short surgical procedures at regular intervals, curb the scoliosis progression until the patient reaches an age where fusion can be performed. Knowledge of this technique and its complications has led to several mechanical improvements being made, namely use of rods that can be distracted magnetically on an outpatient basis, without the need for anesthesia. Devices based on the same principle have been designed that preferentially attach to the ribs to specifically address chest wall and spine dysplasia. The second category of surgical devices consists of rods used to guide spinal growth that do not require repeated surgical procedures. The third type of fusionless surgical treatment involves slowing the growth of the scoliosis convexity to help reduce the Cobb angle. The indications are constantly changing. Improvements in surgical techniques and greater surgeon experience may help to reduce the number of complications and make this lengthy treatment acceptable to patients and their family. Long-term effects of surgery on the Cobb angle have not been compared to those involving conservative "delaying" treatments. Because the latter has fewer complications associated with it than surgery, it should be the first-line treatment for most cases of early-onset scoliosis.
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Affiliation(s)
- V Cunin
- Service D'orthopédie Et Traumatologie Pédiatrique, Hospices Civils de Lyon, Hôpital Femme-Mère-Enfant de Lyon, 59, boulevard Pinel, 69500 Bron, France.
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Jenks M, Craig J, Higgins J, Willits I, Barata T, Wood H, Kimpton C, Sims A. The MAGEC system for spinal lengthening in children with scoliosis: A NICE Medical Technology Guidance. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2014; 12:587-99. [PMID: 25172432 PMCID: PMC4232741 DOI: 10.1007/s40258-014-0127-4] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Scoliosis-structural lateral curvature of the spine-affects around four children per 1,000. The MAGEC system comprises a magnetically distractible spinal rod implant and an external remote controller, which lengthens the rod; this system avoids repeated surgical lengthening. Rod implants brace the spine internally and are lengthened as the child grows, preventing worsening of scoliosis and delaying the need for spinal fusion. The Medical Technologies Advisory Committee at the National Institute for Health and Care Excellence (NICE) selected the MAGEC system for evaluation in a NICE medical technologies guidance. Six studies were identified by the sponsor (Ellipse Technologies Inc.) as being relevant to the decision problem. Meta-analysis was used to compare the clinical evidence results with those of one conventional growth rod study, and equal efficacy of the two devices was concluded. The key weakness was selection of a single comparator study. The External Assessment Centre (EAC) identified 16 conventional growth rod studies and undertook meta-analyses of relevant outcomes. Its critique highlighted limitations around study heterogeneity and variations in baseline characteristics and follow-up duration, precluding the ability to draw firm conclusions. The sponsor constructed a de novo costing model showing that MAGEC rods generated cost savings of £9,946 per patient after 6 years, compared with conventional rods. The EAC critiqued and updated the model structure and inputs, calculating robust cost savings of £12,077 per patient with MAGEC rods compared with conventional rods over 6 years. The year of valuation was 2012. NICE issued a positive recommendation as supported by the evidence (Medical Technologies Guidance 18).
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Affiliation(s)
- Michelle Jenks
- York Health Economics Consortium, University of York, Level 2, Market Square, York, YO10 5NH, UK,
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A novel technique for treatment of progressive scoliosis in young children using a 3-hook and 2-screw construct (H3S2) on a single sub-muscular growing rod: surgical technique. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2014; 23 Suppl 4:S432-7. [PMID: 24811689 DOI: 10.1007/s00586-014-3339-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2014] [Revised: 04/24/2014] [Accepted: 04/24/2014] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Several different growing rod techniques have been described in the literature to treat progressive scoliosis in young children. Nevertheless, none of these techniques has shown a real superiority, and the rate of complications remains high. The purpose of this report is to describe an original fusionless method of treatment for this problem. MATERIALS AND METHODS The 3 hooks-2 screws (H3S2) construct consists of a single 5.5 mm titanium rod with three hooks proximally and two monoaxial pedicle screws distally, and some extra length of rod located distally and/or proximally that can be used for future lengthenings. To date, a total of 103 H3S2 constructs have been performed in our institution. This paper reports the preliminary results on 38 patients, with a minimum follow-up of 2 years. RESULTS This procedure was found to be effective in maintaining scoliosis correction while allowing continued spinal growth and was associated with a low rate of complications. CONCLUSIONS The H3S2 construct was found to have several advantages over the growing rod techniques as previously described in the literature. These include no need for post-operative bracing, fewer lengthening procedures and a lower rate of complications.
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