The usefulness of VEPTR in the older child with complex spine and chest deformity

Assessment of Regional Functional Effects of Surgical Treatment in Thoracic Insufficiency Syndrome via Dynamic Magnetic Resonance Imaging

BACKGROUND

Quantitative regional assessment of thoracic function would enable clinicians to better understand the regional effects of therapy and the degree of deviation from normality in patients with thoracic insufficiency syndrome (TIS). The purpose of this study was to determine the regional functional effects of surgical treatment in TIS via quantitative dynamic magnetic resonance imaging (MRI) in comparison with healthy children.

METHODS

Volumetric parameters were derived via 129 dynamic MRI scans from 51 normal children (November 2017 to March 2019) and 39 patients with TIS (preoperatively and postoperatively, July 2009 to May 2018) for the left and right lungs, the left and right hemi-diaphragms, and the left and right hemi-chest walls during tidal breathing. Paired t testing was performed to compare the parameters from patients with TIS preoperatively and postoperatively. Mahalanobis distances between parameters of patients with TIS and age-matched normal children were assessed to evaluate the closeness of patient lung function to normality. Linear regression functions were utilized to estimate volume deviations of patients with TIS from normality, taking into account the growth of the subjects.

RESULTS

The mean Mahalanobis distances for the right hemi-diaphragm tidal volume (RDtv) were -1.32 ± 1.04 preoperatively and -0.05 ± 1.11 postoperatively (p = 0.001). Similarly, the mean Mahalanobis distances for the right lung tidal volume (RLtv) were -1.12 ± 1.04 preoperatively and -0.10 ± 1.26 postoperatively (p = 0.01). The mean Mahalanobis distances for the ratio of bilateral hemi-diaphragm tidal volume to bilateral lung tidal volume (BDtv/BLtv) were -1.68 ± 1.21 preoperatively and -0.04 ± 1.10 postoperatively (p = 0.003). Mahalanobis distances decreased after treatment, suggesting reduced deviations from normality. Regression results showed that all volumes and tidal volumes significantly increased after treatment (p < 0.001), and the tidal volume increases were significantly greater than those expected from normal growth for RDtv, RLtv, BDtv, and BLtv (p < 0.05).

CONCLUSIONS

Postoperative tidal volumes of bilateral lungs and bilateral hemi-diaphragms of patients with TIS came closer to those of normal children, indicating positive treatment effects from the surgical procedure. Quantitative dynamic MRI facilitates the assessment of regional effects of a surgical procedure to treat TIS.

LEVEL OF EVIDENCE

Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Minimum 5-Year Follow-up on Graduates of Growing Spine Surgery for Early Onset Scoliosis

INTRODUCTION

After discontinuation of growth friendly (GF) surgery for early onset scoliosis, patients undergo spinal fusion or continued observation. This last planned treatment is colloquially called "definitive" treatment, conferring these patients as "graduates" of a growing program. The 5-year radiographic and clinical outcomes of this cohort are unknown.

METHODS

An international pediatric spine database was queried for patients from a GF program (spine or rib-based) with minimum 5-year follow-up from last planned surgery (GF or spinal fusion). Radiographs and charts were reviewed for main coronal curve angle and maximum kyphosis as well as occurrence of secondary surgery.

RESULTS

Of 580 graduates, 170 (29%) had minimum 5-year follow-up (37% male). Scoliosis etiology was congenital in 41 (24%), idiopathic 36 (21%), neuromuscular 51 (30%), and syndromic 42 (25%). Index surgery consisted of spine-based growing rods in 122 (71%) and rib-based distraction in 48 (29%). Mean age at index surgery was 6.8 years, and patients underwent an average of 5.4 lengthenings over an average of 4.9 years (range, 6 mo to 11 y). Last planned treatment was at an average age of 11.8 years (range, 7 to 17 years). Last planned treatment consisted of spinal fusion in 114 patients, 47 had growing implants maintained, 9 had implants removed. Average follow-up was 7.3 years (range, 5 to 13 y).When compared from postdefinitive treatment to 2-year follow-up, there was noted progression of the coronal curve angle (46±19 to 51±21 degrees, P=0.046) and kyphosis (48±20 to 57±25 degrees, P=0.03). However, between 2 and 5 years, no further progression occurred in the coronal (51±21 to 53±21 degrees, P=0.26) or sagittal (57±25 to 54±28 degrees, P=0.93) planes. When stratified based on etiology, there was no significant coronal curve progression between 2- and 5-year follow-up. When comparing spinal fusion patients to those who had maintenance of their growing construct, there was also no significant curve progression.Thirty-seven (21%) underwent at least 1 (average, 1.7; range, 1 to 7) revision surgery following graduation, and 15 of 37 (41%) underwent 2 or more revision surgeries. Reason for revision was implant revision (either GF or spinal fusion) in 34 patients, and implant removal in 3. On an average, the first revision was 2.5 years after the definitive treatment plan (range, 0.02 to 7.4 y). In total, 15 of 37 (41%) revisions occurred over 2 years following the final decision for treatment plan, and 7 of 37 (19%) occurred 5 or more years after the definitive treatment.Patients who underwent spinal fusion as a definitive treatment strategy were more likely to undergo revision surgery (27%) than patients who had their GF implants maintained (11%) (P=0.04).

CONCLUSIONS

Five years following "graduation" from growing surgery for early onset scoliosis, there is progression of curve magnitude in both the coronal and sagittal planes up to 2 years, with no further progression at 5 years. A total of 21% of patients undergo at least 1 revision surgery, and average time to revision surgery is over 2 years from last planned surgery. Risk of revision surgery was higher in patients who underwent a spinal fusion as their definitive treatment strategy.

LEVEL EVIDENCE

Level III-retrospective comparative.

TYPE OF EVIDENCE

Therapeutic.

Early Childhood Scoliosis Management by Vertical Expandable Prosthetic Titanium Rib (VEPTR): Experience of Royal Medical Services (RMS)

Introduction:

Scoliosis could develop at the childhood age and progress beyond skeletal maturity. An early spinal fusion arrests growth of the spine and thorax, risking the development of secondary thoracic insufficiency syndrome. Vertical expandable prosthetic titanium rib (VEPTR) is a fusionless technique aiming to correct the deformity with preservation of growth potential.

Aim:

To show our experience and results regarding the use of VEPTR in children with scoliosis in regard to coronal profiles(length and deformity angle), spinal growth, and the complications we faced during the follow-up of two years after the index procedure.

Methods:

A retrospective analysis of prospectively collected data of a case series. Forty child with scoliosis of different etiologies. Their primary diagnoses were neuromuscular scoliosis in 13, Juvenile idiopathic scoliosis in12, Congenital Scoliosis in 8, syndromatic patients 5 and 2 with Arthrogryposis. All 40 patients received percutaneous rib-to-pelvis or rib to vertebra or rib to rib VEPTR implantation between January 2016 and January 2018. None of them needed blood transfusion. They underwent 56 primary implantation, 16(40%) bilateral system and 24(60%) unilateral followed by lengthening procedure in a period of 4-6 months. The patients were assessed based on mechanical measures, that is, the radiographic improvement of their scoliosis, spinal height, and sagittal and coronal correction, which are measured and compared preoperatively, immediately postoperatively and at two years follow up, complication encountered during this period are also counted.

Results:

The average initial correction in Cobb angle immediately after the index surgery was 14.4° (5°-26°) and the average final correction of Cobb which is measured after the last expansion procedure (Cobb angle of the major curve measured after last expansion minus initial preoperative Cobb angle of the major curve) was 7.3° (12%). The average of preoperative coronal T1-S1 length was 25.6 cm with an average initial correction achieved immediately after implantation of VEPTR of2.8 cm (1.2-5.1cm) which is 10.9%, and the average coronal length gain at 2 years follow up was 5.7 cm (3.7-9.8cm) that is 22.2%. Complication occurred in 18 of our patients (45%).

Conclusion:

Early results of VEPTR for childhood scoliosis are encouraging. Follow-up till skeletal maturity will best determine future indications.

Comprehensive Wound Risk Stratification of Rib-Based Distraction Instrumentation Procedures

STUDY DESIGN

Single-center retrospective analysis of a prospectively collected registry.

OBJECTIVES

Identify factors predictive of rib-based distraction (RBD) instrumentation wound complication. Create a risk stratification model for RBD instrumentation wound complication.

SUMMARY OF BACKGROUND DATA

RBD instrumentation procedures have a high rate of wound complications, often requiring unplanned operative treatment. Currently, there is a relative lack of understanding of RBD complication risk factors compared with the comprehensive understanding of complication risk factors for other spine surgeries.

METHODS

Between January 2011 and September 2015, patients treated with RBD instrumentation at a single institution were analyzed for risk factors associated with surgical wound complications that resulted in unplanned operative treatment. Univariate logistic regression determined predictors of wound complication and multivariate regression determined independent predictive factors; α = 0.10.

RESULTS

A total of 122 patients aged 0-18 years underwent 140 implant surgeries in which 22 resulted in complications: 18 (82%) infectious and 4 (18%) noninfectious. Mean age at surgery was 5.2 years. Univariate analysis showed a correlation between wound complication rates and the following: male gender (p = .097), diapered patient with lower back incision (p = .004), bilateral procedure (p = .008), more than three incisions (p = .011), left iliac incision (p = .097), right iliac incision (p = .009), patient age ≤4 years (p = .10), and operative time >150 minutes (p = .079). Multivariate analysis identified the following independent predictors: age ≤ 4 years (p = .002), male gender (p = .04), number of skin incisions (p = .001), left iliac incision (p = .018), and nutritionally challenged (p = .044). The multivariate model predicted wound complications with an area under the receiver operating characteristic curve of 0.88.

CONCLUSIONS

Knowledge of risk factors for RBD instrumentation wound complications can be used to construct patient risk models. This can identify patients at higher risk for complications and influence clinical decision making.

LEVEL OF EVIDENCE

Level II.

Experience with definitive instrumented final fusion after posterior-based distraction lengthening in patients with early-onset spinal deformity: single center results

Limited reports exist with regard to clinical and radiographic details of patients with early-onset spinal deformity (EOSD) undergoing definitive instrumented final fusion (FF) following implantation of a growing construct. Charts and radiographs were queried for all patients who underwent FF after management of EOSD with a distraction-based posterior construct at a single institution from 2006 to 2017. Patients managed during the growth modulation period with either proximal rib or spinal fixation were included. Thirteen patients qualified for inclusion. Spinal deformity etiologies were varied (neuromuscular: 5, idiopathic: 4, congenital: 4). Average age at implantation was 6.5 years, and patients underwent an average of 8.15 lengthening procedures over an average of 69 months. After the growing program, modest correction in main coronal Cobb was obtained at FF (average 52.4° before FF, 37.6° following FF, P<0.001; average percent improvement of 27%). Five patients required posterior column osteotomies. Using criteria proposed by Flynn and colleagues, 'minimal' coronal correction was achieved in 23% of patients and 'moderate' in 77%. No patient achieved 'substantial' (>50%) correction. Subjective poor bone quality was appreciated in 67% of patients, and 85% were noted to have areas of autofusion over previously spanned levels. Two (15%) patients sustained a total of four complications. After growth modulation procedures, EOSD deformities are generally stiff, bone quality is often subjectively poor, and autofusion is common, even after use of proximally rib-based systems. Modestly improved coronal Cobb correction can be obtained at FF but may require single or multiple posterior osteotomies. Intraoperative difficulties can be expected, and clinicians should be alert for intraoperative and postoperative complications.

Use of a Vertical Expandable Prosthetic Titanium Rib in Children With Thoracic Insufficiency Syndrome and Scoliosis

Thoracic insufficiency syndrome is the inability of the thorax to support normal respiration or lung growth. One treatment to address the thoracic deformities associated with the syndrome is placement of a vertical expandable prosthetic titanium rib. The goal is to restore thoracic volume, symmetry, and function and to allow for growth of the thorax in skeletally immature children. The main topics include indications for placement of a titanium rib, postoperative nursing care, potential complications, long-term follow-up, quality-of-life issues, and implications for critical care nurses and advanced practice nurses.

Growing rod erosion through the lamina causing spinal cord compression in an 8-year-old girl with early-onset scoliosis

BACKGROUND CONTEXT

Early-onset scoliosis often occurs by the age of 5 years and is attributed to many structural abnormalities. Syndromic early-onset scoliosis is considered one of the most aggressive types of early-onset scoliosis. Treatment starts with serial casting and bracing, but eventually most of these patients undergo growth-sparing procedures, such as a single growing rod, dual growing rods, or a vertical expandable titanium prosthetic rib.

PURPOSE

This case report aimed to describe an unusual complication of erosion of a growing rod through the lamina that caused spinal cord compression in an 8-year-old girl with early-onset scoliosis.

STUDY DESIGN

This is a case report.

METHODS

A retrospective chart review was used to describe the clinical course and radiographic findings of this case after rod erosion into the spinal canal.

RESULTS

The patient underwent successful revision surgery removing the rod without neurologic complications.

CONCLUSIONS

Patients with syndromic early-onset scoliosis are more prone to progressive curves and severe rotational deformity. We believe that the severe kyphotic deformity in addition to the dysplastic nature of the deformity in this population may predispose them to this unusual complication.

Congenital scoliosis: an up-to-date

Congenital scoliosis represents a spinal malformation due to defects of formation, segmentation or mixed ones. It is characterized by a longitudinal and rotational imbalance. 54 patients were analyzed and 39 out of them were operated by various approaches with anterior and posterior instrumentations during 2000 and 2012. The impossibility to appoint some patients encountered in the daily practice into the known classifications, allowed us to purpose two categories of congenital scoliosis related to the predominance of spinal deviances in the coronal and transversal views. No certain etiology of congenital scoliosis has been identified until today. The susceptibility of some polygenic defects is obvious due to the presence of a sum of defects associated to most of the congenital scoliosis cases and the rarity of the presence of a unique defect. The diagnosis requires a thorough clinical and imaging examination in order to establish an individualized therapeutic strategy. The treatment of congenital scoliosis is different from the adolescent idiopathic one. Therapeutic criteria are significantly different. It is essential to assess the difference in growth of the concavity related to the convexity when choosing a particular procedure. The magnitude of the curve and the progressive rate are fundamental issues to the surgeon.

[Non-fusion techniques for treatment of pediatric scoliosis]

The primary goal of treatment in children with early onset scoliosis (EOS) is to control the deformity and to allow spinal and chest wall growth to continue and improve pulmonary function. In skeletally immature children spondylodesis leads to fusion of the instrumented segments with associated nonsymmetrical growth and pulmonary insufficiency. Non-fusion, techniques such as growing rods, vertical expandable prosthetic titanium rib® (VEPTR) and staples have evolved over the past years. Each technique has its different spectrum of indications which the surgeon has to follow accurately to prevent the patient from developing complications. A new trend started by using magnetically controlled growing rods to avoid the need for anesthesia and open surgery during adaptive growth. The intention of this article is to give the reader a synopsis about the three most important non-fusion techniques based on own experience and the current literature.

Recent advances in the management of early onset scoliosis

As the undesired results of early spinal fusion have become apparent, "growth-friendly" management methods for early onset scoliosis have been increasing during recent years. Current literature supports the use of repeated corrective cast applications as the initial management for most early onset progressive spinal deformities as either definitive treatment or as a temporizing measure. If casting is not an option or the deformity cannot be controlled via casting, one of the growth-friendly instrumentation techniques is chosen. Growth-friendly surgical methods and implants have been evolving as understanding of the disease improves.

Pulmonary and Radiographic Outcomes of VEPTR (Vertical Expandable Prosthetic Titanium Rib) Treatment in Early-Onset Scoliosis

BACKGROUND

VEPTR (vertical expandable prosthetic titanium rib) expansion thoracoplasty is used to manage thoracic insufficiency syndrome in early-onset scoliosis. Literature regarding the effects of this technique on pulmonary function is scarce. The aim of this study was to report the intermediate-term results of VEPTR expansion thoracoplasty.

METHODS

Twenty-one children with thoracic insufficiency syndrome underwent VEPTR expansion thoracoplasty from 2002 to 2012 and had complete chart data, preoperative and follow-up radiographs, and pulmonary function tests performed at the index implantation, first expansion, and last expansion. Pulmonary function tests with forced and passive deflation techniques developed for children under general anesthesia were performed prior to the index implantation and each expansion surgery under the same anesthetic conditions. Pulmonary and radiographic parameters were analyzed longitudinally.

RESULTS

Mean follow-up was six years, and mean age at implantation was 4.8 years. The mean number of expansion procedures per patient was eleven, and the mean number of pulmonary function tests was ten. The mean interval between surgical procedures was 6.4 months. Mean forced vital capacity (FVC) increased from 0.65 to 0.96 L (p < 0.0001). However, the percentage of the predicted FVC decreased from 77% to 58%. Respiratory system compliance normalized on the basis of body weight, Crs/kg, decreased by 39%, from 1.4 to 0.86 mL/cm H₂O/kg. The mean Cobb angle before treatment was 80°, and the mean maximum thoracic kyphosis angle was 57° (range, 7° to 107°). The initial coronal correction was maintained at the time of final follow-up (67°); however, there was a trend toward a decrease in the maximum thoracic kyphosis angle (to 66°, p = 0.08). Clinically apparent proximal thoracic kyphosis occurred in four patients, and spinal imbalance occurred in seven. The mean gain in T1-T12 height during the treatment period was 18 mm (2.9 mm/year).

CONCLUSIONS

FVC improved over time; however, this increase in lung volume did not keep up with the growth of the child, as the percentage of the predicted FVC decreased, and the chest wall stiffness increased. Coronal correction was maintained, but the increase in proximal thoracic kyphosis is concerning.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

2014 Update on the 'growing spine surgery' for young children with scoliosis

PURPOSE OF REVIEW

Spinal fusion procedures that are the mainstay of the treatment of progressive or severe curves in adolescents and adults are not suitable for most young children as there is a large magnitude of remaining growth. Early spinal fusion stunts the growth of the thorax and may interfere with the development of the lungs. Therefore, in children with early-onset scoliosis, 'growth friendly' instrumentation systems have been utilized to control the deformity while allowing the growth of the spine and the thoracic cage.

RECENT FINDINGS

The experience with growing rods has been increasing, along with expanding indications. Several self-lengthening instrumentation systems have been introduced aiming for guided spinal growth. There has been considerable progress in the clinical and laboratory studies using magnetically controlled growing rod constructs. Growing rods and vertical expandable prosthetic titanium rib (VEPTR) systems provide deformity control while allowing for spinal growth along with a risk of spontaneous vertebral fusions. VEPTR may cause rib fusions as the implants overlie the thoracic cage and, therefore, the use in pure spinal deformities is controversial.

SUMMARY

There have been exciting recent advances concerning the treatment of spinal deformities in young children. Despite these advances, the surgical treatment of early-onset scoliosis remains far from optimal and more development is on the way.

Complications in pediatric spine surgery using the vertical expandable prosthetic titanium rib: the French experience

STUDY DESIGN

Multicenter retrospective study of 54 children.

OBJECTIVE

To describe the complication rate of the French vertical expandable prosthetic titanium rib (VEPTR) series involving patients treated between August 2005 and January 2012.

SUMMARY OF BACKGROUND DATA

Congenital chest wall and spine deformities in children are complex entities. Most of the affected patients have severe scoliosis often associated with a thoracic deformity. Orthopedic treatment is generally ineffective, and surgical treatment is very challenging. These patients are good candidates for VEPTR expansion thoracoplasty. The aim of this study was to evaluate the potential complications of VEPTR surgery.

METHODS

Of the 58 case files, 54 were available for analysis. The series involved 33 girls and 21 boys with a mean age of 7 years (range, 20 mo-14 yr and 2 mo) at primary VEPTR surgery. During the follow-up period, several complications occurred.

RESULTS

Mean follow-up was 22.5 months (range, 6-64 mo). In total, 184 procedures were performed, including 56 VEPTR implantations, 98 expansions, and 30 nonscheduled procedures for different types of complications: mechanical complications (i.e., fracture, device migration), device-related and infectious complications, neurological disorders, spine statics disturbances. Altogether, there were 74 complications in 54 patients: a complication rate of 137% per patient and 40% per surgery. Comparison of the complications in this series with those reported in the literature led the authors to suggest solutions that should help decrease their incidence.

CONCLUSION

The complication rate is consistent with that reported in the literature. Correct determination of the levels to be instrumented, preoperative improvement of nutritional status, and better evaluation of the preoperative and postoperative respiratory function are important factors in minimizing the potential complications of a technique that is used in weak patients with complex deformities.

[Early onset scoliosis. What are the options?]

The prognosis of children with progressive early onset scoliosis has improved considerably due to recent advances in surgical and non-surgical techniques and the understanding of the importance of preserving the thoracic space. Improvements in existing techniques and development of new methods have considerably improved the management of this condition. Derotational casting can be considered in children with documented progression of a <60° curve without previous surgical treatment. Both single and dual growing rods are effective, but the latter seem to offer better results. Hybrid constructs may be a better option in children who require a low-profile proximal anchor. The vertical expandable prosthetic titanium rib (VEPTR(®)) appears to be beneficial for patients with congenital scoliosis and fused ribs, and thoracic Insufficiency Syndrome. Children with medical comorbidities who may not tolerate repeated lengthenings should be considered for Shilla or Luque Trolley technique. Growth modulation using shape memory alloy staples or other tethers seem promising for mild curves, although more research is required to define their precise indications.

Serial casting as a delay tactic in the treatment of moderate-to-severe early-onset scoliosis

BACKGROUND

Serial casting can cure mild infantile idiopathic scoliosis. Its use in delaying surgery in older children and those with larger curves or syndromes is poorly defined.

METHODS

A review of a single center's experience with casting was performed. Patients were included if they had a syndromic, neuromuscular, or congenital scoliosis or were older than 2.5 years with an idiopathic scoliosis measuring >50 degrees.

RESULTS

A retrospective review was performed on 29 patients meeting all inclusion criteria. Of these, 12 were idiopathic and 17 were nonidiopathic curves. Average age at first cast was 4.4 ± 2.1 years, and 3.0 ± 1.8 cast changes were performed over 1.4 ± 1.1 years. Patients were transitioned to a brace and followed up for 5.5 years (range, 2.2 to 11.4 y). The main thoracic Cobb angle before casting was 68.8 ± 12.3 degrees, which corrected to 39.1 ± 16.4 degrees in a cast. Cobb angle after cast removal was 60.9 ± 18.4 degrees, which increased to 76.3 ± 24.0 degrees at final follow-up. T1-T12 height increased to 1.1 ± 2.6 cm during the treatment period (P=0.05). There were 5 minor complications. Fifteen patients (51.7%) required surgical treatment for their scoliosis at most recent follow-up and an additional 7 patients (24.1%) were delayed until a definitive anterior/posterior spinal fusion could be performed. Surgery was delayed 39 ± 25 months from the first cast. Growing rods were required in 8 patients (27.6%). The patients who ultimately underwent surgical intervention (SG) were more likely to have a larger postcasting residual main thoracic Cobb angle than those who did not require surgery [NS; 69.5 ± 14.6 degrees (SG) vs. 51.6 ± 17.9 degrees (NS), P=0.007] and had a greater progression of their curves after cast removal [20.9 ± 13.5 degrees (SG) vs. 9.4 ± 11.0 degrees (NS), P=0.02].

CONCLUSIONS

Serial casting is a viable alternative to surgical growth sparing techniques in moderate-to-severe early-onset scoliosis and may help delay eventual surgical intervention. Although a cure cannot be expected, an average of 39 months of delay was achieved in this patient cohort and 72.4% have avoided growing spine surgery.

LEVEL OF EVIDENCE

Level IV, case series.

Advances in nonfusion techniques for the treatment of scoliosis in children

Scoliotic deformity in young children is a challenge for the spinal surgeon. Though traditional spinal correction and fusion techniques can improve these deformities, they inhibit growth of the spine. Nonfusion technologies are an effective approach to this problem. They not only correct the spinal deformity, but also allow the spine to keep growing and developing. These techniques include the growing rod, stapling, pedicle screw tethering, the vertical expandable prosthetic titanium rib (VEPTR), and multi-vertebrae wedge osteotomy. This is a review of advances in nonfusion techniques for the treatment of scoliosis in children.

Can VEPTR(®) control progression of early-onset kyphoscoliosis? A cohort study of VEPTR(®) patients with severe kyphoscoliosis

BACKGROUND

Kyphoscoliosis is considered a relative contraindication to treatment with the Vertical Expandable Prosthetic Titanium Rib (VEPTR(®); Synthes Inc, Paoli, PA). Nevertheless, patients do present with early-onset kyphoscoliosis and thoracic insufficiency syndrome, and no suitable alternative treatments are currently available. However, it is unclear whether VEPTR(®) is reasonable for treating patients with kyphoscoliosis.

QUESTIONS/PURPOSES

We determined whether VEPTR(®) controls progression in patients with kyphoscoliosis and, if so, what methods might be used to improve control of deformity progression in these patients.

PATIENTS AND METHODS

We retrospectively reviewed 14 patients who had VEPTR(®) treatment of early-onset kyphoscoliosis. Degrees of kyphosis and scoliosis before, during, and after treatment were measured, and levels of instrumentation, thoracic dimensions, and complications were recorded. Minimum followup was 1.7 years (average, 5.8 years; range, 1.7-12.8 years).

RESULTS

While scoliosis was stabilized, kyphosis increased a mean of 22° at last followup. Supple kyphosis became rigid during treatment. Proximal cradle cutout was a recurring problem. Distal anchors placed too proximally had inadequate lever arms to control kyphosis.

CONCLUSIONS

Progression of kyphosis can be minimized during VEPTR(®) treatment by early extension of the construct to the second ribs bilaterally, distal extension of hybrid constructs to the pelvis, use of bilateral hybrid VEPTR(®) implants, and use of redesigned VEPTR(®) constructs that enhance fixation at the upper end. While our early results suggest these devices control progression of kyphosis, longer followup with more patients will be required to confirm the concept in these patients.

Vertical expandable prosthetic titanium rib device insertion: does it improve pulmonary function?

PURPOSE

Vertical expandable prosthetic titanium rib (VEPTR) insertion and expansion has been advocated to increase thoracic volume and pulmonary function in patients with thoracic insufficiency syndrome. We reviewed our experience with VEPTR implantation to determine if lung function and growth is augmented, to determine the children's functional status, and if the scoliosis is controlled.

METHODS

From 2006 to 2010, 29 insertions and 57 expansions were performed in 26 patients at our institution. Demographic data were reviewed in conjunction with complications, scoliosis angles, pulmonary function tests (PFTs), and computed tomography-guided 3D reconstructions to determine lung volumes; and quality of life scores were determined using a modified Scoliosis Research Society (SRS) questionnaire preoperatively and postoperatively. The groups were also stratified by age (because of lung growth potential), disease (congenital or infantile scoliosis, Jeune syndrome, neuromuscular, other structural thoracic disorders), and sex. Analyses using SPSS (SPSS, Chicago, Ill) were performed with P < .05 considered significant.

RESULTS

Each patient underwent 3.03 ± 1.8 surgeries, spending 0.97 ± 1.8 days in the intensive care unit and 4.41 ± 6 days in the hospital for each procedure. Mean age was 90.7 ± 41 months. Of the 36 complications, most were because of infection (12), half requiring operative repair (hardware removal). The average PFT percent predicted values for forced expiratory volume in 1 second, forced vital capacity, and RV were 54.6 ± 22, 58.1 ± 24, and 145.3 ± 112, respectively, preoperatively and 51.8 ± 20, 55.9 ± 20, and 105.6 ± 31, respectively, postoperatively. The lung volumes measured by computed tomography when corrected for age do not increase significantly postoperatively. The mean Cobb measurement for the preoperative major curves was 64.7° and postoperatively was 46.1° for those curves measured preoperatively, for a 29% curve improvement. All postoperative curves had a mean of 56.4° and 58.1° at final follow-up, a 3% curve increase. The SRS scores for patients remained unchanged and no statistical difference was seen from preoperative to postoperative values. No statistically significant difference was seen in complications, PFT (forced expiratory volume in 1 second, forced vital capacity, RV), lung volumes, scoliosis angles, and SRS scores between sex, age, and disease categories.

CONCLUSION

There was mild improvement in scoliosis angles but no improvement in lung function and volume. Scoliosis Research Society scores indicate that the children have near normal function both before and after VEPTR placement. Pulmonary function, lung volume, and patient subjective assessments did not increase dramatically after VEPTR placement, although scoliosis angles improved.