Idiopathic Early-onset Scoliosis: Growing Rods Versus Vertically Expandable Prosthetic Titanium Ribs at 5-year Follow-up

Instrumentation failure following pediatric spine deformity growth-sparing surgery using traditional growing rods or vertical expandable prosthetic titanium ribs

BACKGROUND

Instrumentation failure (IF) is a major complication associated with growth-sparing surgery for pediatric spinal deformities; however, studies focusing on IF following each surgical procedure are lacking. We aimed to evaluate the incidence, timing, and rates of unplanned return to the operating room (UPROR) associated with IF following each surgical procedure in growth-sparing surgeries using traditional growing rods (TGRs) and vertical expandable prosthetic titanium ribs (VEPTRs).

METHODS

We reviewed 1,139 surgical procedures documented in a Japanese multicenter database from 2015 to 2017. Of these, 544 TGR and 455 VEPTR procedures were included for evaluation on a per-surgery basis. IF was defined as the occurrence of an implant-related complication requiring revision surgery.

RESULTS

The surgery-based incidences of IF requiring revision surgery in the TGR and VEPTR groups were 4.3% and 4.0%, respectively, with no significant intergroup difference. Remarkably, there was a negative correlation between IF incidence per surgical procedure and the number of lengthening surgeries in both groups. In addition, rod breakage in the TGR group and anchor-related complications in the VEPTR group tended to occur relatively early in the treatment course. The surgery-based rates of UPROR due to IF in the TGR and VEPTR groups were 2.0% and 1.5%, respectively, showing no statistically significant difference.

CONCLUSIONS

We found that IF, such as anchor related-complications and rod breakage, occurs more frequently earlier in the course of lengthening surgeries. This finding may help in patient counseling and highlights the importance of close postoperative follow-up to detect IF and improve outcomes.

Radiographic and clinical outcomes after definitive spine fusion for skeletally immature patients with idiopathic scoliosis

PURPOSE

To assess the intermediate-term radiographic and clinical outcomes of skeletally immature idiopathic scoliosis (IS) patients that underwent definitive fusion (DF).

METHODS

A retrospective review of patients with IS who were Risser 0 with open tri-radiate cartilages at the time of DF with minimum 5-year follow-up. Outcomes included Scoliosis Research Society (SRS)-30 scores, major Cobb angle, pulmonary function tests (PFTs), and unplanned returns to the operating room (UPROR). Adding-on was defined as progression of the major Cobb angle > 5° or tilt of the lowest instrumented vertebra > 5°.

RESULTS

Thirty-two patients (78% female, mean age 12.2 ± 1.3 years old, mean preoperative major Cobb 64.8° ± 15.9) were included. Of these patients, 20 (62.5%) experienced adding-on and 6 (18.8%) required a revision surgery to correct their progressive spinal deformity. Adding-on was associated with lower 5-year postoperative SRS scores for appearance (3.7 ± 0.7 vs 4.4 ± 0.3, p = 0.0126), mental health (4.2 ± 0.6 vs 4.6 ± 0.3, p = 0.0464), satisfaction with treatment (4.0 ± 0.8 vs 4.7 ± 0.4, p = 0.0140), and total score (4.0 ± 0.4 vs 4.4 ± 0.2, p = 0.0035). The results of the PFTs did not differ between groups. Patients experienced an average of 0.53 UPROR/patient.

CONCLUSION

DF in skeletally immature patients results in a high rate of adding-on, which adversely affects Health-Related Quality of Life. However, reoperation rates, both planned and unplanned, remain lower when compared to patients undergoing growth-friendly treatment.

Update on the Diagnosis and Management of Early-onset Scoliosis

PURPOSE OF REVIEW

In this article, we review the most recent advancements in the approaches to EOS diagnosis and assessment, surgical indications and options, and basic science innovation in the space of early-onset scoliosis research.

RECENT FINDINGS

Early-onset scoliosis (EOS) covers a diverse, heterogeneous range of spinal and chest wall deformities that affect children under 10 years old. Recent efforts have sought to examine the validity and reliability of a recently developed classification system to better standardize the presentation of EOS. There has also been focused attention on developing safer, informative, and readily available imaging and clinical assessment tools, from reduced micro-dose radiographs, quantitative dynamic MRIs, and pulmonary function tests. Basic science innovation in EOS has centered on developing large animal models capable of replicating scoliotic deformity to better evaluate corrective technologies. And given the increased variety in approaches to managing EOS in recent years, there exist few clear guidelines around surgical indications across EOS etiologies. Despite this, over the past two decades, there has been a considerable shift in the spinal implant landscape toward growth-friendly instrumentation, particularly the utilization of MCGR implants. With the advent of new biological and basic science treatments and therapies extending survivorship for disease etiologies associated with EOS, the treatment for EOS has steadily evolved in recent years. With this has come a rising volume and variation in management options for EOS, as well as the need for multidisciplinary and creative approaches to treating patients with these complex and heterogeneous disorders.

Modified Clavien-Dindo-Sink system is reliable for classifying complications following surgical treatment of early-onset scoliosis

PURPOSE

Appropriately measuring and classifying surgical complications is a critical component of research in vulnerable populations, including children with early-onset scoliosis (EOS). The purpose of this study was to assess the inter- and intra-rater reliability of a modified Clavien-Dindo-Sink system (CDS) classification system for EOS patients among a group of pediatric spinal deformity surgeons.

METHODS

Thirty case scenarios were developed and presented to experienced surgeons in an international spine study group. For each case, surgeons were asked to select a level of severity based on the modified CDS system to assess inter-rater reliability. The survey was administered on two occasions to allow for assessment of intra-rater reliability. Weighted Kappa values were calculated, with 0.61 to 0.80 considered substantial agreement and 0.81 to 1.00 considered nearly perfect agreement.

RESULTS

11/12 (91.7%) surgeons completed the first-round survey and 8/12 (66.7%) completed the second. Inter-observer weighted kappa values for the first and second survey were 0.75 [95% CI 0.56-0.94], indicating substantial agreement, and 0.84 [95% CI 0.70-0.98], indicating nearly perfect agreement, respectively. Intra-observer reliability was 0.86 (range 0.74-0.95) between the first and second surveys, indicating nearly perfect agreement .

CONCLUSION

The modified CDS classification system demonstrated substantial to nearly perfect agreement between and within observers for the evaluation of complications following the surgical treatment of EOS patients. Adoption of this reliable classification system as a standard for reporting complications in EOS patients can be a valuable tool for future research endeavors, as we seek to ultimately improve surgical practices and patient outcomes.

LEVEL OF EVIDENCE

Level V.

Re-evaluating consensus and uncertainty among treatment options for early onset scoliosis: a 10-year update

PURPOSE

Consensus and uncertainty in early onset scoliosis (EOS) treatment were evaluated in 2010. It is currently unknown how treatment preferences have evolved over the past decade. The purpose of this study was to re-evaluate consensus and uncertainty among treatment options for EOS patients to understand how they compare to 10 years ago.

METHODS

11 pediatric spinal surgeons (similar participants as in 2010) were invited to complete a survey of 315 idiopathic and neuromuscular EOS cases (same cases as in 2010). Treatment options included the following: conservative management, distraction-based methods, growth guidance/modulation, and arthrodesis. Consensus was defined as ≥ 70% agreement, and uncertainty was < 70%. Associations between case characteristics and consensus for treatments were assessed via chi-squared and multiple regression analyses. Case characteristics associated with uncertainty were described.

RESULTS

Eleven surgeons [31.7 ± 7.8 years of experience] in the original 2010 cohort completed the survey. Consensus for conservative management was found in idiopathic patients aged ≤ 3, whereas in 2010, some of these cases were selected for surgery. There is currently consensus for casting idiopathic patients aged 1 or 2 with moderate curves, whereas in 2010, there was uncertainty between casting and bracing. Among neuromuscular cases with consensus for surgery, arthrodesis was chosen for patients aged 9 with larger curves.

CONCLUSION

Presently, preferences for conservative management have increased in comparison to 2010, and casting appears to be preferred over bracing in select infantile cases. Future research efforts with higher levels-of-evidence should be devoted to elucidate the areas of uncertainty to improve care in the EOS population.

LEVEL OF EVIDENCE

Level V.

Reduced complication rate with simultaneous detethering and spinal deformity correction surgery compared to staged surgeries in patients with early onset scoliosis

PURPOSE

In patients with early onset scoliosis (EOS) and intraspinal anomalies, surgery may be necessary for both the tethered spinal cord (TSC) and spinal deformity. The purpose of this study was to determine if there is a difference in complications when TSC release and surgery for spinal deformity correction (SDC) are performed separately compared simultaneously.

METHODS

EOS patients with TSC who underwent detethering and SDC surgeries were identified through a multicenter registry. Patients were stratified into two groups. The simultaneous cohort consisted of patients receiving both detethering and SDC surgeries in a single anesthetic event on the same day, and the staged cohort consisted of patients undergoing detethering and SDC on two separate occasions. Postoperative complications up to 180 days for either surgery were assessed.

RESULTS

Twenty five (65.8%) patients were staged and 13 (34.2%) underwent a simultaneous approach. Percent curve correction following SDC surgery did not significantly differ between the groups (p = 0.36). Within 90 days postoperatively, 16 complications in 11 patients (44.0%) occurred in the staged group, whereas no complications occurred in the simultaneous cohort (p = 0.006). From 90-days to 180-days postoperatively, 4 additional complications in 3 patients (12.0%) occurred in the staged group, with no complications reported in the same timeframe for the simultaneous cohort.

CONCLUSION

To our knowledge, this is the largest multicenter comparative study to date, and it suggests that a simultaneous approach can be performed safely for EOS patients undergoing detethering and SDC surgeries, with a potentially lower risk profile than the traditional staged approach to these pathologies.

LEVEL OF EVIDENCE

Level III.

Comparison of surgical interventions for the treatment of early-onset scoliosis: a systematic review and meta-analysis

OBJECTIVE

Several growth-preserving surgical techniques are employed in the management of early-onset scoliosis (EOS). The authors' objective was to compare the use of traditional growing rods (TGRs), magnetically controlled growing rods (MCGRs), Shilla growth guidance techniques, and vertically expanding prosthetic titanium ribs (VEPTRs) for the management of EOS.

METHODS

A systematic review of electronic databases, including Ovid MEDLINE and Cochrane, was performed. Outcomes of interest included correction of Cobb angle, T1-S1 distance, and complication rate, including alignment, hardware failure and infection, and planned and unplanned reoperation rates. The percent changes and 95% CIs were pooled across studies using random-effects meta-analysis.

RESULTS

A total of 67 studies were identified, which included 2021 patients. Of these, 1169 (57.8%) patients underwent operations with TGR, 178 (8.8%) Shilla growth guidance system, 448 (22.2%) MCGR, and 226 (11.1%) VEPTR system. The mean ± SD age of the cohort was 6.9 ± 1.2 years. The authors found that the Shilla technique provided the most significant improvement in coronal Cobb angle immediately after surgery (mean [95% CI] 64.3% [61.4%-67.2%]), whereas VEPTR (27.6% [22.7%-33.6%]) performed significantly worse. VEPTR also performed significantly worse than the other techniques at final follow-up. The techniques also provided comparable gains in T1-S1 height immediately postoperatively (mean [95% CI] 10.7% [8.4%-13.0%]); however, TGR performed better at final follow-up (21.4% [18.7%-24.1%]). Complications were not significantly different among the patients who underwent the Shilla, TGR, MCGR, and VEPTR techniques, except for the rate of infections. The TGR technique had the lowest rate of unplanned reoperations (mean [95% CI] 15% [10%-23%] vs 24% [19%-29%]) but the highest number of planned reoperations per patient (5.31 [4.83-5.82]). The overall certainty was also low, with a high risk of bias across studies.

CONCLUSIONS

This analysis suggested that the Shilla technique was associated with a greater early coronal Cobb angle correction, whereas use of VEPTR was associated with a lower correction rate at any time point. TGR offered the most significant height gain at final follow-up. The complication rates were comparable across all surgical techniques. The optimal surgical approach should be tailored to individual patients, taking into consideration the strengths and limitations of each option.

Wound-Related Complication in Growth-Friendly Spinal Surgeries for Early-Onset Scoliosis-Literature Review

Background: The treatment for early-onset scoliosis (EOS) is one of the most challenging for pediatric orthopedics. Surgical treatment is often necessary, and wound problems and surgical site infections (SSIs) are common, with potentially severe complications in these patients. The aim of the study was to review current literature according to this complication. Methods: PubMed, Cochrane Library, and Embase were systematically searched for relevant articles by two independent reviewers in January 2022. Every step of the review was done according to PRISMA guidelines. Results: A total of 3579 articles were found. Twenty four articles were included in this systematic review after applying our inclusion and exclusion criteria. EOS surgery has a varying but high rate of wound-related problems (on average, 15.5%). Conclusion: The literature concerning the definitions, collection, and interpretation of data regarding EOS wound-related complications is often difficult to interpret. This causes problems in the comparison and analysis. Additionally, this observation indicates that data on the incidence of SSI may be underestimated. Awareness of the high rate of SSI of EOS surgery is crucial, and an optimal strategy for prevention should become a priority.

The complication trends of pediatric spinal deformity surgery in Japan - The Japanese Scoliosis Society Morbidity and Mortality survey from 2012 to 2017

BACKGROUND

The Japanese Scoliosis Society Morbidity & Mortality Committee performed a longitudinal nationwide complication survey of spinal deformity surgery from 2012 to 2017. The present study aimed to analyze the survey results and report the complication trends of pediatric spinal deformity surgery in Japan.

METHODS

All Japanese Scoliosis Society members were invited to participate in the survey. Diagnoses were grouped into idiopathic scoliosis, congenital scoliosis, neuromuscular scoliosis, other types of scoliosis, and pediatric kyphosis. Complications were grouped into death, blindness, neurological deficits (motor/sensory), infection, massive bleeding, hematoma, pneumonia, cardiac failure, deep vein thrombosis/pulmonary embolism, gastrointestinal perforation, and instrumentation failure.

RESULTS

The surveys were performed in 2012, 2014, and 2017. The overall complication rate decreased from 10.7% in 2012 to 8.1% in 2017. In particular, the complication rate in patients with idiopathic scoliosis decreased from 8.8% in 2012 to 4.0% in 2017. The complication rate of patients with neuromuscular scoliosis and kyphosis remained high. The rate of neurological deficits, especially in motor deficits, significantly decreased from 2.0% in 2012 to 0.7% in 2017, and tended to be highest in patients with kyphosis. The rate of massive bleeding was significantly decreased from 3.3% in 2012 to 0.8% in 2017, especially in patients with neuromuscular scoliosis (12.2-4.4%). However, patients with neuromuscular scoliosis had a high rate of postoperative pneumonia (3.7%, 2.6%, and 5.1%, respectively). The rate of instrumentation failure was also high (2.1%, 1.5%, and 2.2%, respectively), especially in patients with early onset idiopathic, congenital and other types of scoliosis.

CONCLUSIONS

The overall surgical complication rates in pediatric patients decreased due to decreased rates of neurological deficits and massive bleeding, especially in patients with idiopathic scoliosis. However, the complication rates remain high in patients with neuromuscular scoliosis and kyphosis.

Complications in growth-friendly spinal surgeries for early-onset scoliosis: Literature review

BACKGROUND

The treatments for early-onset scoliosis (EOS), defined as curvature of the spine with onset before 10 years of age, continue to pose a great challenge for pediatric orthopedics. The treatment goals for EOS include minimizing spinal deformity while maximizing thoracic volume and pulmonary function. Different surgical techniques have different advantages and drawbacks; however, the two major concerns in the management of EOS are repeated surgeries and complications.

AIM

To review the current literature to assess the safety of EOS surgical treatment in terms of the rate of complications and unplanned surgeries.

METHODS

In January 2021 two independent reviewers systematically searched three electronic medical databases (PubMed, the Cochrane Library, and Embase) for relevant articles. Every step of the review was done according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Due to the heterogeneity of articles and topics after data analysis, a descriptive (synthetic) analysis was performed.

RESULTS

A total of 2136 articles were found. Forty articles were included in this systematic review, after applying our inclusion and exclusion criteria. EOS surgery has a varying but high rate of complications. The most frequent complications were categorized as implant (54%), general (17%), wound (15%) and alignment (12%). The rate of complications might have been even higher than reported, as some authors do not report all types of complications. About 54% of patients required unplanned surgeries due to complications, which comprised 15% of all surgeries.

CONCLUSION

The literature concerning the definitions, collection, and interpretation of data regarding EOS surgery complications is often difficult to interpret. This creates problems in the comparison, analysis, and improvement of spine surgery practice. Additionally, this observation indicates that data on the incidence of complications can be underestimated, and should be interpreted with caution. Awareness of the high rate of complications of EOS surgery is crucial, and an optimal strategy for prevention should become a priority.

Effect of Etiology, Radiographic Severity, and Comorbidities on Baseline Parent-Reported Health Measures for Children with Early-Onset Scoliosis

BACKGROUND

The Classification of Early-Onset Scoliosis (C-EOS) allows providers to differentiate patients, for clinical and research purposes, on the basis of the etiology of their disease as well as radiographic parameters. The Early Onset Scoliosis Questionnaire (EOSQ) is the first disease-specific, parent-reported HRQOL (health-related quality-of-life) outcome measure for this condition. We sought to determine the influence of the C-EOS etiology designation, radiographic parameters, and medical comorbidities on EOSQ scores to differentiate quality of life in this heterogeneous patient population. We hypothesized that baseline EOSQ scores for patients with EOS would be strongly affected by the C-EOS etiology designation.

METHODS

The analysis included prospectively enrolled patients with EOSQ scores recorded in a multicenter EOS database prior to intervention for the EOS. EOSQ scores were compared across C-EOS etiologies, severity of disease based on radiographic measurements, and patient comorbidities prior to scoliosis intervention.

RESULTS

Six hundred and ten patients with EOS were available for analysis; 119 had congenital, 201 had idiopathic, 156 had neuromuscular, and 134 had syndromic EOS. In multivariate analysis, neuromuscular and syndromic etiologies were associated with lower scores than congenital and idiopathic etiologies in many EOSQ domains including general health, transfer, daily living, fatigue/energy level, and emotion. Patients with neuromuscular EOS had the lowest EOSQ scores in general. Congenital and idiopathic EOS did not differ from each other in any EOSQ domain. Coronal Cobb and kyphosis angles had significant inverse but generally weak correlations with EOSQ domains. Individual medical comorbidities had a minor effect on certain domains while American Society of Anesthesiologists (ASA) class and total number of comorbidities had inverse correlations with most domains.

CONCLUSIONS

The underlying etiology of EOS appears to have a significant influence on the parent-reported HRQOL outcomes of the disease. Specifically, syndromic and neuromuscular C-EOS diagnoses are associated with lower EOSQ scores before treatment compared with congenital and idiopathic diagnoses. Radiographic measurements of severity have a relatively small influence on EOSQ scores. These baseline differences in C-EOS-designated etiology should be accounted for in studies comparing outcomes of treatment for this heterogeneous patient population.

LEVEL OF EVIDENCE

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

Outcomes of Vertical Expandable Prosthetic Titanium Ribs in Children With Early-Onset Scoliosis Secondary to Cerebral Palsy

Purpose

Patients who have neuromuscular scoliosis, such as cerebral palsy (CP), often develop spinal deformities that negatively impact quality of life. The vertical expandable prosthetic titanium rib (VEPTR) was designed for thoracic insufficiency syndrome (TIS), but it has also been utilized in patients with CP with restrictive lung disease and spine deformity. Few studies report on VEPTRs in neuromuscular scoliosis; however, none reports on their utilization specifically in patients with CP. Our purpose was to assess if VEPTRs can improve spinal deformity and TIS in these patients.

Methods

A retrospective chart review was performed of all patients with CP and scoliosis treated with a VEPTR between 2008 and 2017. Eight patients were eligible for this study. The mean follow-up was four years. Outcomes evaluated were Cobb angle, pelvic obliquity, space available for lung ratio (SAL), T1-S1 height, and complication rates. A p-value of less than 0.05 was used for statistical significance.

Results

There were significant postoperative improvements in Cobb angle, pelvic obliquity, and T1-S1 height, but no statistical difference in SAL. Prior to final fusion, the mean number of VEPTR lengthening procedures was 3. The mean time from index surgery to final fusion was 3.7 years. The most common complications were infection (62.5%) and wound dehiscence (25%). Only 25% of patients did not have a complication.

Conclusion

VEPTRs demonstrated significant improvement in almost all parameters and may be valuable in improving TIS in patients with CP. The complication and reoperation rates were similar to those of VEPTRs used for other pathological conditions.

Growth-friendly Spinal Instrumentation in Marfan Syndrome Achieves Sustained Gains in Thoracic Height Amidst High Rates of Implant Failure

BACKGROUND

There are few reports on the surgical management of early-onset scoliosis (EOS) associated with Marfan syndrome (MFS). Affected patients tend to have more rapid curve progression than those with idiopathic EOS, and their course is further complicated by medical comorbidities. As surgical techniques and implants for growing spines become more widely applied, this study seeks to better delineate the safety and efficacy of growth-friendly spinal instrumentation in treating this population.

METHODS

A prospective registry of children treated for EOS was queried for MFS patients treated between 1996 and 2016. Forty-two patients underwent rib-based or spine-based growing instrumentation and were assessed on preoperative, surgical, and postoperative clinical and radiographic parameters including complications and reoperations. Subgroup analysis was performed based on spine-based versus rib-based fixation.

RESULTS

Patients underwent their index surgery at a mean age of 5.5 years, when the major coronal curve and kyphosis measured 77 and 50 degrees, respectively. Over half were treated with traditional growing rods. Patients underwent 7.2 total surgical procedures-4.7 lengthening and 1.9 revision surgeries not including conversion to fusion-over a follow-up of 6.5 (±4.1) years. Radiographic correction was greatest at index surgery but maintained over time, with a final thoracic height measuring 23.8 cm. Patients experienced a mean of 2.6 complications over the course of the study period; however, a small group of 6 patients experienced ≥6 complications while over half of patients experienced 0 or 1. Implant failures represented 42% of all complications with infection and pulmonary complications following.

CONCLUSIONS

This is the largest report on patients with EOS and MFS. All subtypes of growth-friendly constructs reduced curve progression in this cohort, but complications and reoperations were nearly universal; patients were particularly plagued by implant failure and migration. Further collaborations are needed to enhance understanding of optimal timing and fixation constructs for those with MFS and other connective tissue diseases.

Growth-preserving instrumentation in early-onset scoliosis patients with multi-level congenital anomalies

STUDY DESIGN

Retrospective.

OBJECTIVES

To assess final outcomes in patients with early-onset scoliosis (EOS) who underwent growth-preserving instrumentation (GPI). Various types of growth-preserving instrumentation (GPI) are frequently employed, but until recently had not been utilized long enough to assess final outcomes.

METHODS

GPI "graduates" with multi-level congenital curves were identified. Graduation was defined as a final fusion or 5 years of follow-up without planned future surgeries. Outcomes included radiographic parameters and complications.

RESULTS

26 patients were included. 11 had associated diagnoses; eight had fused ribs. 17 were treated with traditional growing rods, seven with vertically expandable prosthetic ribs, and two with Shilla procedures. The mean GPI spanned 12.3 levels including 10.7 motion segments, age at index surgery was 5.5 years, treatment spanned 7.5 years, and follow-up was 9.2 years. 24 patients underwent final fusion. Mean major curve decreased from 73° to 49° with index surgery (p < 0.01) and remained unchanged through a final follow-up. Final major curve was < 40° in 9 patients (35%), 40°-60° in 11 patients (42%), and > 60° in 6 patients (23%). None worsened throughout treatment. Mean T1-T12 height increased 2.4 cm with index surgery (p = 0.02) and 5.4 cm total (p < 0.01). T1-T12 height increased in all patients and was ultimately < 18 cm in 10 patients (38%), 18-22 cm in 10 patients (38%), and > 22 cm in 6 patients (23%). On average, there were 2.6 complications per patient, including 1.7 implant failures. 12 patients (46%) experienced ≥ 3 complications; four patients (15%) experienced none.

CONCLUSION

We observed successful prevention of deformity progression but substantial residual deformity among GPI graduates with multi-level congenital EOS. Most coronal curve correction was attained during GPI implantation; thoracic height improved throughout treatment. While some favorable results were found, treatment strategies allowing improved deformity correction would be valuable for this challenging population.

LEVEL OF EVIDENCE

Therapeutic-III.

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.