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Mainard N, Saghbini E, Pesenti S, Gouron R, Ilharreborde B, Lefevre Y, Haumont T, Sales de Gauzy J, Canavese F. Is posterior vertebral arthrodesis at the end of the electromagnetic rod lengthening program necessary for all patients? Comparative analysis of sixty six patients who underwent definitive spinal arthrodesis and twenty four patients with in situ lengthening rods. INTERNATIONAL ORTHOPAEDICS 2024; 48:1599-1609. [PMID: 38421434 DOI: 10.1007/s00264-024-06121-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 02/12/2024] [Indexed: 03/02/2024]
Abstract
PURPOSE Magnetically controlled growing rods (MCGR) should be removed or changed at most two years after their implantation in the treatment of patients with early-onset scoliosis (EOS) (Safety notice July 2021). However, in the face of patients at high risk of intraoperative complications and relying on the principle of auto-fusion of the spine, some surgeons would prefer a more wait-and-see attitude. The aim of this study was to report on patients who did not undergo final fusion at the end of the lengthening program with MCGR and to compare them with those who did. METHODS This was a multicenter study with ten centres. We collected all graduate patients with EOS who had received MCGR between 2011 and 2022. RESULTS A total of 66 patients had final fusion at the end of the lengthening program and 24 patients kept MCGRs in situ. The mean total follow-up time was 66 months (range, 25.3-109), and the mean follow-up time after final lengthening was 24.9 months (range, 3-67.7). Regarding the main curve and thoracic height, there was no significant difference in the percentage of correction over the whole follow-up between the two groups (p = 0.099, p = 0.176) although there was a significant difference between the end of lengthening and the last follow-up (p < 0.001). After completion of the lengthening program, 18 patients who had final fusion developed 24 of the 26 recorded complications (92.3%). CONCLUSION Contrary to the manufacturer's published safety notice, not all patients systematically benefited from the removal of the MCGRs. Although arthrodesis significantly improved the scoliotic deformity, no significant difference was found in terms of radiographic outcome between patients who underwent spinal fusion and those who kept the MCGRs in situ.
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Affiliation(s)
- Nicolas Mainard
- Department of Pediatric Surgery, Jeanne de Flandre Hospital, CHU Lille, Avenue Eugène Avinée, 59000, Lille, France.
| | - Elie Saghbini
- Orthopaedic and Reconstructive Surgery in Children, Hôpital Armand-Trousseau - AP-HP Is, 26 Avenue du Docteur Arnold Netter, 75012, Paris, France
| | - Sebastien Pesenti
- Pediatric Orthopedic Surgery, Hôpital de La Timone Enfants, 264 Rue Saint-Pierre, 13005, Marseille, France
| | - Richard Gouron
- Child Surgery, CHU Amiens-Picardie, 1 Rond-Point du Professeur Christian Cabrol, 80000, Amiens, France
| | - Brice Ilharreborde
- Department of Pediatric Orthopedic Surgery, Hôpital Robert-Debré, 48 Boulevard Sérurier, 75019, Paris, France
| | - Yan Lefevre
- Children's Surgery - Children's Hospital - Pellegrin Hospital Group, Place Amélie Raba-Léon, 33076, Bordeaux Cedex, France
| | - Thierry Haumont
- Department of Orthopedic, Trauma and Plastic Surgery, Hospital Mère Enfant, 59 Boulevard Pinel, 69500, Hospices Civils de LyonBron, France
| | - Jerome Sales de Gauzy
- Paediatrics - Orthopaedic, Traumatological And Plastic Surgery, Children's Hospital, 330, Avenue de Grande Bretagne - TSA, 70034 - 31059, Toulouse, France
| | - Federico Canavese
- Department of Pediatric Surgery, Jeanne de Flandre Hospital, CHU Lille, Avenue Eugène Avinée, 59000, Lille, France
- Faculty of Medicineof the , University of Lille Henri Warembourg, 2 Av Eugène Avinée, 59120, Loos, France
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Grabala P. Minimally Invasive Controlled Growing Rods for the Surgical Treatment of Early-Onset Scoliosis-A Surgical Technique Video. J Pers Med 2024; 14:548. [PMID: 38929769 PMCID: PMC11205236 DOI: 10.3390/jpm14060548] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Revised: 05/17/2024] [Accepted: 05/20/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND Spinal deformities in children and adolescents can be easily divided into those occurring and diagnosed before the age of 10-early-onset scoliosis-and those occurring and diagnosed after the age of 10-late-onset scoliosis. When the curvature continues to progress and exceeds a Cobb angle of more than 60-65 degrees, surgical treatment should be considered. The most common treatment procedure for EOS is the surgical correction of the deformity using standard growing rods (SGRs), and in the case of congenital defects with additional hemivertebrae, it is the resection of the hemivertebra and short fusion. Minimally invasive controlled growing rods (MICGRs) need to be distracted every 6-9 months through a minimally invasive approach that involves sedation and neuromonitoring to obtain the best possible correction while minimizing complications. The aim of our study is to present a less-invasive surgical technique for MICGR implantation based on a two-case presentation-early-onset idiopathic scoliosis and congenital kyphosis. The surgical technique is the less-invasive percutaneous and subfascial implantation of MICGRs without long incisions in the back. CONCLUSIONS The use of MICGRs is an alternative and safe surgical technique for patients undergoing surgical treatment for EOS. Without the risk of metallosis, like in other implant systems, and the need for replacement after 2 years of use, like in using magnetically controlled growing rods (MCGRs), the MICGR system can be used as a less-invasive procedure, allowing for the avoidance of many periodic invasive procedures in children with a wider opening of the spine (like in using standard growing rods), minimizing the number of planned hospitalizations, reducing the length of hospital stays, and reducing the physical and mental burdens on young patients, parents, and families.
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Affiliation(s)
- Pawel Grabala
- Department of Pediatric Orthopedic Surgery and Traumatology, Medical University of Bialystok, Medical University of Bialystok Children’s Clinical Hospital, ul. Waszyngtona 17, 15-274 Bialystok, Poland;
- Paley European Institute, Al. Rzeczypospolitej 1, 02-972 Warsaw, Poland
- Department of Neurosurgery with Department of Interventional Neurology, Medical University of Bialystok, Medical University of Bialystok Clinical Hospital, ul. M. Sklodowskiej-Curie 24A, 15-276 Balystok, Poland
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Alberghina F, McManus R, Keogh C, Turner H, Moore D, Noël J, Kennedy J, Kiely P. The Evaluation of Serum Metal Ion Levels and Metallosis in Graduated Patients With Magnetically Controlled Growing Rods. J Pediatr Orthop 2024; 44:43-48. [PMID: 37779282 DOI: 10.1097/bpo.0000000000002526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
BACKGROUND Magnetically controlled growing rods (MCGR) aim to control curve progression while limiting surgical burden in children with early-onset scoliosis. Systemic and local distribution of metal debris has been documented in children with spinal implants. The aim of the study was to assess serum metal ion levels and local metal debris-related changes at the conclusion of MCGR treatment. METHODS Between February 2019 and September 2022, all patients who had a conversion to definitive fusion at the completion of MCGR treatment in our institution were invited to participate in this study. Consenting patients had serum metal ion levels drawn (titanium, cobalt, and chromium) and histologic analyses of peri-implant tissue samples. RESULTS We enrolled 24 children who underwent definitive fusion post-MCGR treatment for early-onset scoliosis. The average age at definitive fusion was 13.3 years (range: 11 to 17 y). The average length of MCGR treatment was 4.8 years (range: 1.5 to 6.8 y). At the end of the MCGR treatment, 23 (96%) patients had elevated serum metal ion levels. Mean serum titanium levels were 165.4 nmol/L (range: 30 to 390 nmol/L), mean serum cobalt levels were 4.6 nmol/L (range: 1.2 to 14 nmol/L), and mean serum chromium levels were 14 nmol/L (range: 2.4 to 30 nmol/L). Peri-implant soft tissue histologic analysis demonstrated local metal debris and foreign body reactions in all patients. CONCLUSIONS At the completion of MCGR treatment, the majority of patients demonstrate elevated serum metal ion levels and local metal debris-related peri-implant soft tissue changes. Although there is no current literature to suggest these findings are harmful, further research as to the clinical significance is required. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Flavia Alberghina
- Department of Orthopaedics, Children's Health Ireland (CHI) at Crumlin, Crumlin, Dublin, Ireland
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Grabala P, Helenius IJ, Chamberlin K, Galgano M. Less-Invasive Approach to Early-Onset Scoliosis—Surgical Technique for Magnetically Controlled Growing Rod (MCGR) Based on Treatment of 2-Year-Old Child with Severe Scoliosis. CHILDREN 2023; 10:children10030555. [PMID: 36980113 PMCID: PMC10047795 DOI: 10.3390/children10030555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/12/2023] [Accepted: 03/14/2023] [Indexed: 03/17/2023]
Abstract
Background: Spinal deformities in children can be caused by various etiologies, such as congenital, syndromic, neuromuscular, or idiopathic. Early-onset scoliosis (EOS) is diagnosed before the age of ten years, and when the curvature continues to progress and exceeds a Cobb angle of 60–65 degrees, surgical treatment should be considered. Initial minimally invasive surgery and the implantation of magnetically controlled growing rods (MCGRs) allows for the noninvasive distraction of the spine, growing, and avoids multiple operations associated with the classic distractions of standard growing rods. Case presentation: A 2-year-old girl was admitted to our clinic with rapidly progressive thoracic scoliosis. The major curve of the thoracic spine Cobb angle was 122° at 30 months. No congenital deformities were detected. The surgical technique was the less-invasive percutaneous and subfascial implantation of MCGRs, without long incisions on the back and the non-invasive ambulatory lengthening of her spine over the next 4 years. Conclusions: MCGR is a safe procedure for EOS patients. It is extremely effective at correcting spinal deformity; controlling the growth and curvature of the spine as the child develops during growth; reducing the number of hospitalizations and anesthesia; and minimizing the physical and mental burden of young patients, parents, and their families.
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Affiliation(s)
- Pawel Grabala
- Department of Pediatric Orthopedic Surgery and Traumatology, University Children’s Hospital, Medical University of Bialystok, Waszyngtona 17, 15-274 Bialystok, Poland
- Paley European Institute, Al. Rzeczypospolitej 1, 02-972 Warsaw, Poland
- Correspondence:
| | - Ilkka J. Helenius
- Department of Orthopedics and Traumatology, Helsinki University Hospital, 00260 Helsinki, Finland
| | - Kelly Chamberlin
- Department of Neurosurgery, University of North Carolina, Chapel Hill, NC 27516, USA
| | - Michael Galgano
- Department of Neurosurgery, University of North Carolina, Chapel Hill, NC 27516, USA
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Cundy PJ, Antoniou G, Freeman BJC, Cundy WJ. Persistently Raised Serum Titanium Levels After Spinal Instrumentation in Children. Spine (Phila Pa 1976) 2022; 47:1241-1247. [PMID: 35960139 DOI: 10.1097/brs.0000000000004406] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 05/23/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective study of patients undergoing elective spinal deformity surgery with repeated testing for circulating metal ions including preoperative levels acting as controls. OBJECTIVE The aim was to determine if levels of particular circulating metal ions are maintained to two years postsurgery including different implant systems and rods. SUMMARY OF BACKGROUND DATA Adults having hip replacements, especially metal-on-metal bearings, may develop high metal ion levels. Pediatric spinal implants are known to cause circulating metal ions, notably titanium, chromium, cobalt, and nickel. MATERIALS AND METHODS Fifty-six children having spinal deformity surgery were studied with repeated testing for circulating metal ions, using high-resolution inductively coupled plasma mass spectrometry. Linear mixed-effects models adjusting for repeated measurements over time were used to analyze levels of titanium, cobalt, chromium, and nickel. RESULTS Titanium levels showed a rapid increase by seven days and a peak at 30 days that was essentially maintained at the two-year assay. At two years, titanium levels were 5.14 times greater compared with the presurgery control level (P<0.0001). Cobalt levels were shown to gradually rise to a peak at 30 days and then slowly decline but remained 1.74 times above mean baseline level at two years (P=0.0004), with a declining trajectory. Chromium and nickel levels rose immediately postoperatively and then steadily declined to baseline by six months and remained at baseline at two years. The five implant systems tested had generally equivalent results. CONCLUSION The persistent and rising levels of titanium, in a predominantly female population, is concerning. Titanium is known to cross the placental barrier and enter the circulation of the fetus in rodents and humans, and to accumulate in solid organs especially the liver, spleen, heart, and lymph nodes in humans. This potentially exposes the offspring of mothers with spinal implants to titanium, with potential teratogenic effects.
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Affiliation(s)
- Peter J Cundy
- Department of Orthopaedic Surgery, Women's and Children's Hospital, Adelaide, SA, Australia
- Centre for Orthopaedic and Trauma Research, University of Adelaide, SA, Australia
| | - Georgia Antoniou
- Department of Orthopaedic Surgery, Women's and Children's Hospital, Adelaide, SA, Australia
| | - Brian J C Freeman
- Department of Orthopaedic Surgery, Women's and Children's Hospital, Adelaide, SA, Australia
- Centre for Orthopaedic and Trauma Research, University of Adelaide, SA, Australia
| | - William J Cundy
- Department of Orthopaedic Surgery, Women's and Children's Hospital, Adelaide, SA, Australia
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Tognini M, Hothi H, Tucker S, Broomfield E, Shafafy M, Gikas P, Di Laura A, Henckel J, Hart A. Blood titanium levels in patients with large and sliding titanium implants. BMC Musculoskelet Disord 2022; 23:783. [PMID: 35974363 PMCID: PMC9380337 DOI: 10.1186/s12891-022-05717-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 07/29/2022] [Indexed: 11/23/2022] Open
Abstract
Background Titanium, which is known to be a highly biologically inert element, is one of the most commonly used metals in orthopaedic implants. While cobalt and chromium blood metal ion testing is routinely used in the clinical monitoring of patients with metal-on-metal hip implants, much less is known about the levels of titanium in patients with other implant types. The aim of this study was to better understand the normal ranges of blood titanium levels in patients implanted with large and sliding titanium constructs by comparison with reference levels from conventional titanium hips. Methods This study examined data collected from 136 patients. Over a period of 24 months, whole blood samples were collected from 41 patients implanted with large titanium implants: long (range 15 to 30 cm) spine rods with a sliding mechanism (“spine rods”, n = 18), long bone tumour implants (“tumour implants”, n = 13) and 3D-printed customised massive acetabular defect implants (“massive acetabular implants”, n = 10). This data was compared with standard, uncemented primary titanium hip implants (“standard hips”, 15 cm long) (n = 95). Clinical, imaging and blood titanium levels data were collected for all patients and compared statistically between the different groups. Results The median (range) of blood titanium levels of the standard hip, spine rods, femoral tumour implants and massive acetabular implants were 1.2 ppb (0.6–4.9), 9.7 ppb (4.0–25.4), 2.6 ppb (0.4–104.4) and 5.7 ppb (1.6–31.5) respectively. Spine rods and massive acetabular implants had significantly greater blood titanium levels compared to the standard hips group (p < 0.001). Conclusion This study showed that titanium orthopaedic implants that are large and/or have a sliding mechanism have higher blood titanium levels compared to well-functioning, conventionally sized titanium hips. Reassuringly, the increased levels did not appear to induce adverse metal reactions. This study provides useful baseline data for future studies aimed at assessing blood titanium levels as a biomarker for implant function.
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Affiliation(s)
- Martina Tognini
- Institute of Orthopaedics and Musculoskeletal Science, University College London, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, HA7 4LP, UK.
| | - Harry Hothi
- Institute of Orthopaedics and Musculoskeletal Science, University College London, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, HA7 4LP, UK
| | - Stewart Tucker
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Edel Broomfield
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Masood Shafafy
- Department of Trauma and Orthopaedics, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Panos Gikas
- Institute of Orthopaedics and Musculoskeletal Science, University College London, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, HA7 4LP, UK
| | - Anna Di Laura
- Institute of Orthopaedics and Musculoskeletal Science, University College London, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, HA7 4LP, UK
| | - Johann Henckel
- Institute of Orthopaedics and Musculoskeletal Science, University College London, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, HA7 4LP, UK
| | - Alister Hart
- Institute of Orthopaedics and Musculoskeletal Science, University College London, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, HA7 4LP, UK
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Lüders KA, Braunschweig L, Zioła-Frankowska A, Stojek A, Jakkielska D, Wichmann A, Dihazi GH, Streit F, Güsewell SE, Trüe TC, Lüders S, Schlie J, Tsaknakis K, Lorenz HM, Frankowski M, Hell AK. Titanium wear from magnetically controlled growing rods (MCGRs) for the treatment of spinal deformities in children. Sci Rep 2022; 12:10811. [PMID: 35752736 PMCID: PMC9233686 DOI: 10.1038/s41598-022-15057-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 06/17/2022] [Indexed: 11/29/2022] Open
Abstract
Magnetically controlled growing rods (MCGRs) are an effective treatment method for early-onset scoliosis (EOS). In recent years, increasing titanium wear was observed in tissue adjacent to implants and in blood samples of these patients. This study aims to investigate the potential correlation between amount of metal loss and titanium levels in blood during MCGR treatment as well as influencing factors for metal wear. In total, 44 MCGRs (n = 23 patients) were retrieved after an average of 2.6 years of implantation and analyzed using a tactile measurement instrument and subsequent metal loss calculation. Titanium plasma levels (n = 23) were obtained using inductively coupled plasma-mass spectrometry (ICP-MS). The correlation of both parameters as well as influencing factors were analyzed. Titanium abrasion on MCGRs was observed in the majority of implants. There was no correlation of metal implant wear or titanium plasma values to the duration of MCGR implantation time, number of external lengthening procedures, patient’s ambulatory status, gender, weight or height. Material loss on the MCGRs showed a positive correlation to titanium blood plasma values. The present study is one of the first studies to analyze retrieved MCGRs using high-precision metrological techniques and compare these results with ICP-MS analyses determining blood titanium values.
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Affiliation(s)
- K A Lüders
- Pediatric Orthopaedics, Department of Trauma, Orthopaedic and Plastic Surgery, University Medical Center Göttingen, Göttingen, Germany
| | - L Braunschweig
- Pediatric Orthopaedics, Department of Trauma, Orthopaedic and Plastic Surgery, University Medical Center Göttingen, Göttingen, Germany
| | | | - A Stojek
- Faculty of Chemistry, Adam Mickiewicz University, Poznan, Poland
| | - D Jakkielska
- Faculty of Chemistry, Adam Mickiewicz University, Poznan, Poland
| | - A Wichmann
- Pediatric Orthopaedics, Department of Trauma, Orthopaedic and Plastic Surgery, University Medical Center Göttingen, Göttingen, Germany
| | - G H Dihazi
- Clinical Chemistry, University Medical Center Göttingen, Göttingen, Germany
| | - F Streit
- Clinical Chemistry, University Medical Center Göttingen, Göttingen, Germany
| | - S E Güsewell
- Pediatric Orthopaedics, Department of Trauma, Orthopaedic and Plastic Surgery, University Medical Center Göttingen, Göttingen, Germany
| | - T C Trüe
- Pediatric Orthopaedics, Department of Trauma, Orthopaedic and Plastic Surgery, University Medical Center Göttingen, Göttingen, Germany
| | | | | | - K Tsaknakis
- Pediatric Orthopaedics, Department of Trauma, Orthopaedic and Plastic Surgery, University Medical Center Göttingen, Göttingen, Germany
| | - H M Lorenz
- Pediatric Orthopaedics, Department of Trauma, Orthopaedic and Plastic Surgery, University Medical Center Göttingen, Göttingen, Germany
| | - M Frankowski
- Faculty of Chemistry, Adam Mickiewicz University, Poznan, Poland
| | - A K Hell
- Pediatric Orthopaedics, Department of Trauma, Orthopaedic and Plastic Surgery, University Medical Center Göttingen, Göttingen, Germany.
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