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Hoernschemeyer DG, Hawkins SD, Tweedy NM, Boeyer ME. Anterior Vertebral Body Tethering: A Single-Center Cohort with 4.3 to 7.4 Years of Follow-up. J Bone Joint Surg Am 2024:00004623-990000000-01152. [PMID: 38968364 DOI: 10.2106/jbjs.23.01229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/07/2024]
Abstract
BACKGROUND Vertebral body tethering (VBT) is a well-recognized, non-fusion alternative for idiopathic scoliosis in children with growth remaining. To date, there have been almost no published outcome studies with postoperative follow-up of >2 years. We aimed to fill this gap by evaluating mid-term outcomes in our first 31 consecutive patients. METHODS We retrospectively assessed additional clinical and radiographic data (mean, 5.7 ± 0.7 years) from our first 31 consecutive patients. Assessments included standard deformity measures, skeletal maturity status, and any additional complications (e.g., suspected broken tethers or surgical revisions). Using the same definition of success (i.e., all residual deformities, instrumented or uninstrumented, ≤30° at maturity; no posterior spinal fusion), we revisited the success rate, revision rate, and suspected broken tether rate. RESULTS Of our first 31 patients treated with VBT, 29 (of whom 28 were non-Hispanic White and 1 was non-Hispanic Asian; 27 were female and 2 were male) returned for additional follow-up. The success rate dropped to 64% with longer follow-up as deformity measures increased, and the revision rate increased to 24% following 2 additional surgical revisions. Four additional suspected broken tethers were identified, for a rate of 55%, with only 1 occurring beyond 4 years. No additional patients had conversion to a posterior spinal fusion. We observed a mean increase of 4° (range, 2° to 8°) in main thoracic deformity measures and 8° (range, 6° to 12°) in thoracolumbar deformity measures. CONCLUSIONS With >5 years of follow-up, we observed a decrease in postoperative success, as progression of the deformity was observed in most subgroups, and an increase in the revision and suspected broken tether rates. No additional patients had conversion to a posterior spinal fusion, which may indicate long-term survivorship. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | | | - Nicole M Tweedy
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - Melanie E Boeyer
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
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Speirs JN, Parent S, Kelly M, Upasani VV, Petcharaporn M, Bryan TP, Newton PO. Three-dimensional vertebral shape changes confirm growth modulation after anterior vertebral body tethering for idiopathic scoliosis. Spine Deform 2024; 12:1017-1024. [PMID: 38578599 DOI: 10.1007/s43390-024-00856-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 02/26/2024] [Indexed: 04/06/2024]
Abstract
PURPOSE To evaluate three-dimensional (3D) vertebra and disk shape changes over 2 years following anterior vertebral body tether (AVBT) placement in patients with idiopathic scoliosis (IS). METHODS Patients with right thoracic IS treated with AVBT were retrospectively evaluated. 3D reconstructions were created from biplanar radiographs. Vertebral body and disk height (anterior, posterior, left and right) and shape (wedging angle) were recorded over the three apical segments in the local vertebral reference planes. Changes in height and wedging were measured through 2 years postoperatively. Change in patient height was correlated with changes in the spine dimensions. RESULTS Forty-nine patients (Risser 0-3, Sanders 2-4) were included. The mean age was 12.2 ± 1.4 years (range 8-14). The mean coronal curve was 51 ± 10° preoperatively, 31 ± 9° at first postoperative time point and 27 ± 11° at 2-year follow-up (p < 0.001). The mean patient height increased 8 cm by 2 years (p < 0.001). The left side of the spine (vertebra + disc) grew in height by 2.2 mm/level versus 0.7 mm/level on the right side (p < 0.001). This differential growth was composed of 0.5 mm/vertebral level and 1.0 mm/disk level. Evaluation of the change in disk heights showed significantly decreased height anteriorly (- 0.4 mm), posteriorly (- 0.3 mm) and on the right (- 0.5 mm) from FE to 2 years. Coronal wedging reduced 2.3°/level with 1.1°/vertebral level change and 1.2°/disk level. There was no differential growth in the sagittal plane (anterior/posterior height). Patient height change moderately correlated with 3D measures of vertebra + disk shape changes. CONCLUSIONS Three-dimensional analysis confirms AVBT in skeletally immature patients results in asymmetric growth of the apical spine segments. The left (untethered) side length increased more than 3 × than the right (tethered) side length with differential effects observed within the vertebral bodies and disks, each correlating with overall patient height change.
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Affiliation(s)
- Joshua N Speirs
- Department of Orthopedics, University of Utah, Salt Lake City, UT, USA
| | - Stefan Parent
- Department of Orthopaedics, CHU Sainte-Justine, Montreal, QC, Canada
- Department of Surgery, University of Montreal, Montréal, QC, Canada
| | - Michael Kelly
- Division of Orthopedics and Scoliosis, Rady Children's Hospital, 3020 Children's Way, San Diego, CA, 92123, USA
- Department of Orthopaedics, University of California, San Diego, CA, USA
| | - Vidyadhar V Upasani
- Division of Orthopedics and Scoliosis, Rady Children's Hospital, 3020 Children's Way, San Diego, CA, 92123, USA
- Department of Orthopaedics, University of California, San Diego, CA, USA
| | | | - Tracey P Bryan
- Division of Orthopedics and Scoliosis, Rady Children's Hospital, 3020 Children's Way, San Diego, CA, 92123, USA
| | - Peter O Newton
- Division of Orthopedics and Scoliosis, Rady Children's Hospital, 3020 Children's Way, San Diego, CA, 92123, USA.
- Department of Orthopaedics, University of California, San Diego, CA, USA.
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Trobisch PD, Kim HJ, Da Paz S, Chang DG. The efficacy of anterior vertebral body tethering in lenke type 6 curves for adolescent idiopathic scoliosis. 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 2024; 33:2696-2703. [PMID: 38753189 DOI: 10.1007/s00586-024-08300-y] [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: 12/02/2023] [Revised: 04/08/2024] [Accepted: 05/02/2024] [Indexed: 07/25/2024]
Abstract
PURPOSE Spinal fusion is the standard treatment for severe forms of adolescent idiopathic scoliosis (AIS). However, with the lowest instrumented vertebra that is usually located at L3 or L4, patients are prone to develop adjacent segment degeneration in the long term. Vertebral body tethering (VBT) as motion preserving technique has become an alternative for select patients with AIS. Several studies have presented the outcome after thoracic VBT but no study has analyzed the outcome after VBT for Lenke type 6 curves. METHODS This is a retrospective single center data analysis of patients who have had bilateral VBT for Lenke type 6 curves and a minimum follow up of 24 months. Radiographic analysis was performed on several time points. Suspected tether breakages were additionally analyzed with respect to location and time at occurrence. RESULTS 25 patients were included. Immediate thoracic curve correction was 55.4% and 71.7% for TL/L curves. Loss of correction was higher for TL/L curves and resulted in a correction rate of 48.3% for thoracic curves and 48.9% for TL/L curves at 24 months post-operatively. 22 patients were suspected to have at least one segment with a tether breakage. Three patients required a re-VBT but no patient received posterior spinal fusion. CONCLUSION Bilateral VBT for Lenke type 6 curves is feasible and shows a significant curve correction for thoracic and TL/L curves at a minimum of 24 months post-operatively. Tether breakage rate and loss of correction remain an unfavorable observation that needs to be improved in the future.
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Affiliation(s)
- Per D Trobisch
- Department of Spine Surgery, Eifelklinik St. Brigida, Simmerath, Germany.
| | - Hong Jin Kim
- Department of Orthopedic Surgery, College of Medicine, Inje University Sanggye Paik Hospital, Inje University, Seoul, Korea
| | - Stephanie Da Paz
- Department of Spine Surgery, Eifelklinik St. Brigida, Simmerath, Germany
| | - Dong-Gune Chang
- Department of Orthopedic Surgery, College of Medicine, Inje University Sanggye Paik Hospital, Inje University, Seoul, Korea
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Hori Y, Kaymaz B, Almeida da Silva LC, Rogers KJ, Yorgova P, Gabos PG, Shah SA. Subclassification of Sanders Maturation Stage 3 Demonstrates Differences in Spine and Total Height Velocity Between 3A and 3B in Patients With Idiopathic Scoliosis. Spine (Phila Pa 1976) 2024; 49:902-908. [PMID: 37417724 DOI: 10.1097/brs.0000000000004772] [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] [Received: 03/30/2023] [Accepted: 06/18/2023] [Indexed: 07/08/2023]
Abstract
STUDY DESIGN A single-center retrospective case-control study. OBJECTIVE To compare the spine and total height velocity between Sanders maturation stage (SMS) 3A and 3B. SUMMARY OF BACKGROUND DATA Identifying SMS 3 is critical for treating growing children because it represents the early phase of rapid adolescent growth. However, there is limited literature available that clearly describes the growth differences between 3A and 3B. MATERIALS AND METHODS The current study included consecutive patients with idiopathic scoliosis staged SMS 3 from January 2012 to December 2021. T1-S1 spine height, total body height, and curve magnitude were measured at the initial and follow-up visits. In addition to the spine and total height velocity calculated per month, corrected height velocity was estimated for curve magnitude using a validated formula. Mann-Whitney U test was used to compare SMS 3A and 3B outcomes, followed by a multiple linear regression model to evaluate the association of the SMS subclassifications to growth velocity adjusted for confounding factors. RESULTS A total of 204 patients (66% girls, mean age: 12.3±1.3 y) met the inclusion criteria. Patients staged SMS 3A had higher spine height velocity (mm/month) in both girls (2.3 vs. 1.5, P <0.001) and boys (2.6 vs. 1.7, P <0.001), as well as total height velocity [mm/month; (5.8 vs. 4.3, P <0.001 for girls; 6.6 vs. 4.5, P <0.001 for boys]. Corrected velocity showed similar results with greater spine and total height velocity in SMS 3A. Multivariate analysis indicated a significant association of the SMS subclassification to the spine and total height velocity. The scoliosis curve progression was comparable between SMS 3A and 3B. CONCLUSIONS SMS 3A and 3B had differential growth velocity in the spine and total body height. These results indicate the importance of the SMS 3 subclassification for managing scoliosis treatment, including observation, bracing, and surgical interventions with fusion and growth modulation. LEVEL OF EVIDENCE Level III-case-control study.
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Affiliation(s)
- Yusuke Hori
- Department of Orthopaedic Surgery, Nemours Children's Health, Wilmington, DE
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Trobisch PD, Kim HJ, Da Paz S, Alkharsawi M, Castelein R, Chang DG. Early-term outcome of apical fusion with vertebral body tethering for thoracolumbar curves in adolescent idiopathic scoliosis: a preliminary study. 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 2024; 33:2530-2535. [PMID: 38615086 DOI: 10.1007/s00586-024-08242-5] [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: 01/23/2024] [Revised: 03/17/2024] [Accepted: 03/27/2024] [Indexed: 04/15/2024]
Abstract
INTRODUCTION Vertebral body tethering (VBT) has become an alternative option for select patients with idiopathic scoliosis. However, studies have shown a high number of tether breakages, specifically after thoracolumbar (TL) VBT, that can have a negative impact on the outcome, when the breakage occurs within the first year after surgery. In order to overcome this problem, we have started to apply an apical fusion (AF) in combination with TL VBT for select patients. This study aims to analyze the outcome after AF plus VBT. METHODS This is a retrospective single surgeon's data analysis. All patients were included who have had TL VBT after January 2022 and a follow-up of 12 months. Patients were grouped based on whether they only had VBT or VBT + AF. RESULTS Twenty-five patients were analyzed (15 VBT, 10 VBT + AF). Both groups showed a significant curve correction for thoracic and TL curves. Minor loss of correction was observed in both groups. A significant difference was seen regarding early tether breakages, which were found in 60% of VBT patients and 10% of VBT + AF patients. CONCLUSION The preliminary data shows a significant reduction of early tether breakages when TL VBT is applied in combination with AF.
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Affiliation(s)
- Per D Trobisch
- Department of Spine Surgery, Eifelklinik St. Brigida, Simmerath, Germany.
| | - Hong-Jin Kim
- Department of Orthopedic Surgery, Inje University Sanggye Paik Hospital, College of Medicine, Inje University, Seoul, Korea
| | - Stephanie Da Paz
- Department of Spine Surgery, Eifelklinik St. Brigida, Simmerath, Germany
| | - Mahmoud Alkharsawi
- Department of Spine Surgery, Eifelklinik St. Brigida, Simmerath, Germany
| | - Rene Castelein
- Dutch Scoliosis Center, University Medical Center Utrecht, Utrecht, Zeist, The Netherlands
| | - Dong-Gune Chang
- Department of Orthopedic Surgery, Inje University Sanggye Paik Hospital, College of Medicine, Inje University, Seoul, Korea
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Lonner B, Eaker L, Hoernschemeyer D, Zhang J, Wilczek A, Elliot P, Boeyer ME, Fletcher ND, Alanay A, Yilgor C, Newton P, Miyanji F. Double major curvature treated with vertebral body tethering of both curves: how do outcomes compare to posterior spinal fusion? Spine Deform 2024; 12:651-662. [PMID: 38285163 DOI: 10.1007/s43390-023-00803-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 12/09/2023] [Indexed: 01/30/2024]
Abstract
PURPOSE Vertebral body tethering (VBT) is a non-fusion alternative to posterior spinal fusion (PSF). There have been few reports on VBT of two curvatures. We aim to compare the radiographic outcomes between VBT and PSF in patients with double curvatures in which both curves were instrumented. METHODS 29 AIS patients matched by Lenke, age (± 2 years), triradiate cartilage closure status, major Cobb angle (± 8°), and T5-T12 kyphosis (± 10°). Variables were compared using Wilcoxon rank-sum tests, Student's t tests, and chi-Square. Clinical success was defined as major curve < 35°. RESULTS Group baseline demographics were similar. Major thoracic (T) curve types had significantly better major (VBT 51.5 ± 7.9° to 31.6 ± 12.0° [40%] vs. PSF 54.3 ± 7.4° to 17.4 ± 6.5° [68%]; p = 0.0002) and secondary curve correction in the PSF group. 71% of major T VBT patients were clinically successful versus 100% of PSF. Major thoracolumbar (TL) curve types experienced comparable major (VBT 52.3 ± 7.0° to 18.3 ± 11.4° (65%) vs. PSF 53.0 ± 5.2° to 23.8 ± 10.9° (56%); p = 0.2397) and secondary curve correction. 92% of major TL VBT patients were clinically successful versus 75% in the PSF group. There was no difference in T5-12 kyphosis or lumbar lordosis between groups for any curve type. There were 4 patients (13.8%) with major complications in the VBT group compared to 0 (0%) in the PSF. CONCLUSION Patients with double major AIS who underwent VBT with major T curve types had less correction than PSF; however, those with major TL curves experienced similar radiographic outcomes regardless of procedure. Complications were greater for VBT.
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Affiliation(s)
- Baron Lonner
- Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, Mount Sinai Spine, 5 E 98th St., New York, NY, 10029, USA.
| | - Lily Eaker
- Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, Mount Sinai Spine, 5 E 98th St., New York, NY, 10029, USA
| | | | - Jessica Zhang
- Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, Mount Sinai Spine, 5 E 98th St., New York, NY, 10029, USA
| | - Ashley Wilczek
- Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, Mount Sinai Spine, 5 E 98th St., New York, NY, 10029, USA
| | - Patrick Elliot
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO, USA
| | - Melanie E Boeyer
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO, USA
| | - Nicholas D Fletcher
- Department of Orthopaedics, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Ahmet Alanay
- Department of Orthopedics and Traumatology, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Caglar Yilgor
- Department of Orthopedics and Traumatology, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Peter Newton
- Department of Orthopaedics, Rady Children's Hospital, San Diego, CA, USA
| | - Firoz Miyanji
- Department of Orthopedics, British Columbia Children's Hospital, Vancouver, BC, Canada
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Alasadi H, Rajjoub R, Alasadi Y, Wilczek A, Lonner BS. Vertebral body tethering for adolescent idiopathic scoliosis: a review. Spine Deform 2024; 12:561-575. [PMID: 38285164 DOI: 10.1007/s43390-023-00806-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 12/09/2023] [Indexed: 01/30/2024]
Abstract
PURPOSE Adolescent Idiopathic Scoliosis (AIS) remains the most common type of pediatric scoliosis, mostly affecting children between ages 10 and 18. Vertebral body tethering (VBT) offers a non-fusion alternative to the gold standard spinal fusion that permits flexibility and some growth within instrumented segments. This article will serve as a comprehensive literature review of the current state-of-the-art of VBT in relation to radiographic and clinical outcomes, complications, and the learning curve associated with the procedure. METHODS A systematic literature review was conducted on PubMed, Scopus, and Web of Science from April 2002 to December 2022. Studies were included if they discussed VBT and consisted of clinical studies in which a minimum 2-years follow-up was reported, and series that included anesthetic considerations, learning curve, and early operative morbidity. RESULTS Forty-nine studies spanning the period from April 2002 to December 2022 were reviewed. CONCLUSION This article illustrates the potential benefits and challenges of the surgical treatment of AIS with VBT and can serve as a basis for the further study and refinement of this technique ideally as a living document that will be updated regularly.
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Affiliation(s)
- Husni Alasadi
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rami Rajjoub
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Yazan Alasadi
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ashley Wilczek
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Baron S Lonner
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
- Chief of Minimally Invasive Scoliosis Surgery and Pediatric Spine, Department of Orthopaedic Surgery, Mount Sinai Hospital, Icahn School of Medicine, 5 E 98th St., 4th Floor, New York, NY, 10029, USA.
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Hwang SW, Plachta S, Pahys JM, Quinonez A, Grewal H, Samdani AF. The Impact of Anterior Vertebral Body Tethering on Pulmonary Function. Spine (Phila Pa 1976) 2024; 49:E128-E132. [PMID: 38239017 DOI: 10.1097/brs.0000000000004926] [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] [Received: 11/02/2023] [Accepted: 01/05/2024] [Indexed: 04/11/2024]
Abstract
STUDY DESIGN Retrospective, single-center study. OBJECTIVE To examine pulmonary function tests (PFTs) in patients undergoing anterior vertebral body tethering (AVBT). SUMMARY OF BACKGROUND DATA The effect of AVBT on pulmonary status remains unclear. MATERIALS AND METHODS The authors examined preoperative and postoperative PFTs following AVBT in a retrospective, single-center cohort of patients. Outcomes were compared using percent predicted values as continuous and categorical variables (using 10% change as significant) and divided into categorical values based on the American Thoracic Society standards. RESULTS Fifty-eight patients with adolescent idiopathic scoliosis were included, with a mean age of 12.5±1.4 years and a follow-up of 4.2±1.1 years. The mean thoracic curve was 47°±9°, which improved to 21°±12°. At baseline, the mean forced expiratory volume in one second (FEV1%) and forced vital capacity (FVC%) values were 79% and 82%, respectively. Four patients had normal FEV1% (≥100%), 67% had mild restrictive disease (70%-99%) and the rest had worse FEV1%. Mean FEV1 improved from 2.2 to 2.6 L ( P <0.05) and FVC improved from 2.5 to 3.0 L ( P <0.05); however, % predicted values remained unchanged (FEV1%: 79%-80%; FVC%: 82-80%, P >0.05) with mean postoperative PFTs at 37±12 months postoperative. The use of miniopen thoracotomy was not associated with worsening PFTs, but extension of the lowest instrumented vertebra below T12 was correlated with decreasing FEV1% in the bivariate analysis ( P <0.05). Patients with worse preoperative FVC% (80±13% vs. 90±11%, P =0.03) and FEV1% (77±17% vs. 87±12%, P =0.06) also had a greater likelihood of declining postoperative FEV1%. CONCLUSION Pulmonary function in most patients undergoing AVBT remained stable (76%) or improved (14%); however, a subset may worsen (10%). Further studies are needed to identify the risk factors for this group, but worse preoperative PFTs and extension below T12 may be risk factors for worsening pulmonary function.
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Affiliation(s)
| | | | | | | | - Harsh Grewal
- St. Christopher's Hospital for Children, Philadelphia, PA
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Cahill PJ, Miyanji F, Lullo BR, Samdani AF, Lonner BS, Pahys JM, Hwang SW, Haber LL, Alanay A, Shah SA, Parent S, Blakemore LC, Hoernschemeyer DG, Neal KM, Newton PO. Incidence of Tether Breakage in Anterior Vertebral Body Tethering. J Pediatr Orthop 2024; 44:e323-e328. [PMID: 38251438 DOI: 10.1097/bpo.0000000000002619] [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: 01/23/2024]
Abstract
BACKGROUND Thoracic anterior vertebral body tethering (TAVBT) is an emerging treatment for adolescent idiopathic scoliosis. Tether breakage is a known complication of TAVBT with incompletely known incidence. We aim to define the incidence of tether breakage in patients with adolescent idiopathic scoliosis who undergo TAVBT. The incidence of tether breakage in TAVBT is hypothesized to be high and increase with time postoperatively. METHODS All patients with right-sided, thoracic curves who underwent TAVBT with at least 2 and up to 3 years of radiographic follow-up were included. Tether breakage between 2 vertebrae was defined a priori as any increase in adjacent screw angle >5 degrees from the minimum over the follow-up period. The presence and timing of tether breakage were noted for each patient. A Kaplan-Meier survival analysis was performed to calculate expected tether breakage up to 36 months. χ 2 analysis was performed to examine the relationship between tether breakage and reoperations. Independent t test was used to compare the average final Cobb angle between cohorts. RESULTS In total, 208 patients from 10 centers were included in our review. Radiographically identified tether breakage occurred in 75 patients (36%). The initial break occurred at or beyond 24 months in 66 patients (88%). Kaplan-Meier survival analysis estimated the cumulative rate of expected tether breakage to be 19% at 24 months, increasing to 50% at 36 months. Twenty-one patients (28%) with a radiographically identified tether breakage went on to require reoperation, with 9 patients (12%) requiring conversion to posterior spinal fusion. Patients with a radiographically identified tether breakage went on to require conversion to posterior spinal fusion more often than those patients without identified tether breakage (12% vs. 2%; P =0.004). The average major coronal curve angle at final follow-up was significantly larger for patients with radiographically identified tether breakage than for those without tether breakage (31 deg±12 deg vs. 26 deg±12 deg; P =0.002). CONCLUSIONS The incidence of tether breakage in TAVBT is high, and it is expected to occur in 50% of patients by 36 months postoperatively. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Patrick J Cahill
- Children's Hospital of Philadelphia
- Perelman School of Medicine at the University of Pennsylvania
| | | | | | | | | | | | | | | | - Ahmet Alanay
- Acibadem Maslak Hospital, Maslal, Istanbul, Turkey
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Sullivan MH, Jackson TJ, Milbrandt TA, Larson AN, Kepler CK, Sebastian AS. Evidence-based Indications for Vertebral Body Tethering in Spine Deformity. Clin Spine Surg 2024; 37:82-91. [PMID: 37684718 DOI: 10.1097/bsd.0000000000001521] [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] [Received: 09/21/2022] [Accepted: 06/21/2023] [Indexed: 09/10/2023]
Abstract
Posterior spinal fusion has long been established as an effective treatment for the surgical management of spine deformity. However, interest in nonfusion options continues to grow. Vertebral body tethering is a nonfusion alternative that allows for the preservation of growth and flexibility of the spine. The purpose of this investigation is to provide a practical and relevant review of the literature on the current evidence-based indications for vertebral body tethering. Early results and short-term outcomes show promise for the first generation of this technology. At this time, patients should expect less predictable deformity correction and higher revision rates. Long-term studies are necessary to establish the durability of early results. In addition, further studies should aim to refine preoperative evaluation and patient selection as well as defining the benefits of motion preservation and its long-term effects on spine health to ensure optimal patient outcomes.
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Tsirikos AI, Ahuja K, Khan M. Minimally Invasive Surgery for Adolescent Idiopathic Scoliosis: A Systematic Review. J Clin Med 2024; 13:2013. [PMID: 38610778 PMCID: PMC11012693 DOI: 10.3390/jcm13072013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 03/15/2024] [Accepted: 03/27/2024] [Indexed: 04/14/2024] Open
Abstract
Background: Minimally invasive surgical (MIS) techniques have gained popularity as a safe and effective alternative to open surgery for degenerative, traumatic, and metastatic spinal pathologies. In adolescent idiopathic scoliosis, MIS techniques comprise anterior thoracoscopic surgery (ATS), posterior minimally invasive surgery (PMIS), and vertebral body tethering (VBT). In the current systematic review, the authors collected and analyzed data from the available literature on MIS techniques in AIS. Methods: The articles were shortlisted after a thorough electronic and manual database search through PubMed, EMBASE, and Google Scholar. Results: The authors included 43 studies for the review; 14 described the outcomes with ATS, 13 with PMIS, and 16 with VBT. Conclusions: While the efficacy of the ATS approach is well-established in terms of comparable coronal and sagittal correction to posterior spinal fusion, the current use of ATS for instrumented fusion has become less popular due to a steep learning curve, high pulmonary and vascular complication rates, implant failures, and increased non-union rates. PMIS is an effective alternative to the standard open posterior spinal fusion, with a steep learning curve and longer surgical time being potential disadvantages. The current evidence, albeit limited, suggests that VBT is an attractive procedure that merits consideration in terms of radiological correction and clinical outcomes, but it has a high complication and re-operation rate, while the most appropriate indications and long-term outcomes of this technique remain unclear.
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Affiliation(s)
- Athanasios I. Tsirikos
- Scottish National Spine Deformity Centre, Royal Hospital for Children and Young People, Edinburgh EH16 4TJ, UK; (K.A.); (M.K.)
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Shah SA, Kraft DB, Miyanji F. Anterior Vertebral Body Tethering: A Review of the Available Evidence. J Am Acad Orthop Surg 2024; 32:247-256. [PMID: 38271681 DOI: 10.5435/jaaos-d-23-00312] [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] [Received: 05/01/2023] [Accepted: 12/17/2023] [Indexed: 01/27/2024] Open
Abstract
Idiopathic scoliosis is a complex three-dimensional deformity of the spine with anterior overgrowth (hypokyphosis), coronal curvature, and axial rotation. Scoliosis treatment in the skeletally immature spine is therapeutically challenging because of growth and was commonly limited to observation, bracing treatment, or fusion. Fusion accomplishes powerful deformity correction at the expense of future growth and mobility of the involved segments, increasing the risk of adjacent segment degeneration and intervertebral disk disease later in life. Anterior vertebral body tethering is a motion-preserving technique that exploits the Hueter-Volkmann principle by applying compression at the anterior and convex aspects of the curve to stimulate differential vertebral growth for gradual deformity reduction without fusion. The appropriate timing, curve magnitude, tensioning, growth prediction, indications, and limitations of tethering are being refined as this technique becomes more prevalent. Early outcome studies show that growth modulation with vertebral body tethering is safe, can achieve good results, and preserve motion in select patients.
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Affiliation(s)
- Suken A Shah
- From the Department of Orthopaedic Surgery, Nemours Children's Health, Wilmington, DE (Shah), the Department of Orthopaedic Surgery, MedStar Georgetown University Hospital, Washington, DC (Dr. Kraft), and the Department of Orthopaedic Surgery, British Columbia Children's Hospital, Vancouver, British Columbia, Canada (Dr. Miyanji)
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13
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Samdani AF, Plachta SM, Pahys JM, Quinonez A, Samuel SP, Hwang SW. Results of posterior spinal fusion after failed anterior vertebral body tethering. Spine Deform 2024; 12:367-373. [PMID: 38142246 DOI: 10.1007/s43390-023-00796-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 11/18/2023] [Indexed: 12/25/2023]
Abstract
PURPOSE In patients with adolescent idiopathic scoliosis (AIS) undergoing anterior vertebral tethering (AVBT), some will subsequently require posterior spinal fusion (PSF). Limited data exist on clinical and radiographic outcomes of fusion after tether failure. METHODS 490 patients who underwent AVBT were retrospectively analyzed. Twenty patients (4.1%) subsequently underwent conversion to PSF. A control group of patients with primary PSF (no previous AVBT) was matched for comparison. Data were compared using paired t-tests and Fisher Exact Tests. RESULTS There was a significant increase in estimated blood loss (EBL) (p = 0.002), percent estimated blood volume (%EBV) (p = 0.013), operative time (p = 0.002), and increased amount of fluoroscopy (mGy) (p = 0.04) as well as number of levels fused (p = 0.02) in the AVBT conversion group compared to primary fusion. However, no difference was found in implant density (p = 0.37), blood transfusions (p = 0.11), or intraoperative neuromonitoring events (p > 0.99). Both groups attained similar thoracic and lumbar percent correction (major coronal curve angle) from pre-op to the latest follow-up (thoracic p = 0.507, lumbar p = 0.952). CONCLUSION A subset of patients with AVBT will require conversion to PSF. Although technically more challenging, revision surgery can be safely performed with similar clinical and radiographic outcomes to primary PSF. LEVEL OF EVIDENCE: 3
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Affiliation(s)
- Amer F Samdani
- Shriners Children's-Philadelphia, 3551 N Broad St, Philadelphia, PA, 19140, USA.
| | - Stephen M Plachta
- Shriners Children's-Philadelphia, 3551 N Broad St, Philadelphia, PA, 19140, USA
| | - Joshua M Pahys
- Shriners Children's-Philadelphia, 3551 N Broad St, Philadelphia, PA, 19140, USA
| | - Alejandro Quinonez
- Shriners Children's-Philadelphia, 3551 N Broad St, Philadelphia, PA, 19140, USA
| | - Solomon P Samuel
- Shriners Children's-Philadelphia, 3551 N Broad St, Philadelphia, PA, 19140, USA
| | - Stephen W Hwang
- Shriners Children's-Philadelphia, 3551 N Broad St, Philadelphia, PA, 19140, USA
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14
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Alfraihat A, Samdani AF, Balasubramanian S. Predicting radiographic outcomes of vertebral body tethering in adolescent idiopathic scoliosis patients using machine learning. PLoS One 2024; 19:e0296739. [PMID: 38215180 PMCID: PMC10786366 DOI: 10.1371/journal.pone.0296739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 12/18/2023] [Indexed: 01/14/2024] Open
Abstract
Anterior Vertebral Body Tethering (AVBT) is a growing alternative treatment for adolescent idiopathic scoliosis (AIS), offering an option besides spinal fusion. While AVBT aims to correct spinal deformity through growth correction, its outcomes have been mixed. To improve surgical outcomes, this study aimed to develop a machine learning-based tool to predict short- and midterm spinal curve correction in AIS patients who underwent AVBT surgery, using the most predictive clinical, radiographic, and surgical parameters. After institutional review board approval and based on inclusion criteria, 91 AIS patients who underwent AVBT surgery were selected from the Shriners Hospitals for Children, Philadelphia. For all patients, longitudinal standing (PA or AP, and lateral) and side bending spinal Radiographs were retrospectively obtained at six visits: preop and first standing, one year, two years, five years postop, and at the most recent follow-up. Demographic, radiographic, and surgical features associated with curve correction were collected. The sequential backward feature selection method was used to eliminate correlated features and to provide a rank-ordered list of the most predictive features of the AVBT correction. A Gradient Boosting Regressor (GBR) model was trained and tested using the selected features to predict the final correction of the curve in AIS patients. Eleven most predictive features were identified. The GBR model predicted the final Cobb angle with an average error of 6.3 ± 5.6 degrees. The model also provided a prediction interval, where 84% of the actual values were within the 90% prediction interval. A list of the most predictive features for AVBT curve correction was provided. The GBR model, trained on these features, predicted the final curve magnitude with a clinically acceptable margin of error. This model can be used as a clinical tool to plan AVBT surgical parameters and improve outcomes.
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Affiliation(s)
- Ausilah Alfraihat
- School of Biomedical Engineering, Science and Health Systems, Drexel University, Philadelphia, PA, United States of America
- Hashemite University, Zarqa, Jordan
| | - Amer F. Samdani
- Shriners Hospitals for Children, Philadelphia, PA, United States of America
| | - Sriram Balasubramanian
- School of Biomedical Engineering, Science and Health Systems, Drexel University, Philadelphia, PA, United States of America
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15
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Roser MJ, Askin GN, Labrom RD, Zahir SF, Izatt M, Little JP. Vertebral body tethering for idiopathic scoliosis: a systematic review and meta-analysis. Spine Deform 2023; 11:1297-1307. [PMID: 37432604 PMCID: PMC10587225 DOI: 10.1007/s43390-023-00723-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 06/17/2023] [Indexed: 07/12/2023]
Abstract
PURPOSE Vertebral body tethering (VBT) is a recent procedure to correct and reduce spinal curves in skeletally immature patients with adolescent idiopathic scoliosis (AIS). The purpose of this systematic review and meta-analysis is to determine the expected curve reduction and potential complications for adolescent patients after VBT. METHODS PubMed, Embase, Google Scholar and Cochrane databases were searched until February 2022. Records were screened against pre-defined inclusion and exclusion criteria. Data sources were prospective and retrospective studies. Demographics, mean differences in Cobb angle, surgical details and complication rates were recorded. Meta-analysis was conducted using a random-effects model. RESULTS This systematic review includes 19 studies, and the meta-analysis includes 16 of these. VBT displayed a statistically significant reduction in Cobb angle from pre-operative to final (minimum 2 years) measurements. The initial mean Cobb angle was 47.8° (CI 95% 42.9-52.7°) and decreased to 22.2° (CI 95% 19.9-24.5°). The mean difference is - 25.8° (CI 95% - 28.9-22.7) (p < 0.01). The overall complication rate was 23% (CI 95% 14.4-31.6%), the most common complication was tether breakage 21.9% (CI 95% 10.6-33.1%). The spinal fusion rate was 7.2% (CI 95% 2.3-12.1%). CONCLUSION VBT results in a significant reduction of AIS at 2 years of follow-up. Overall complication rate was relatively high although the consequences of the complications are unknown. Further research is required to explore the reasons behind the complication rate and determine the optimal timing for the procedure. VBT remains a promising new procedure that is effective at reducing scoliotic curves and preventing spinal fusion in the majority of patients. LEVEL OF EVIDENCE Systematic review of Therapeutic Studies with evidence level II-IV.
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Affiliation(s)
- Megan J. Roser
- Orthopaedics Department, Queensland Children’s Hospital, South Brisbane, Australia
- Biomechanics and Spine Research Group (BSRG), Centre for Children’s Health Research, Queensland University of Technology (QUT), Brisbane, Australia
| | - Geoffrey N. Askin
- Orthopaedics Department, Queensland Children’s Hospital, South Brisbane, Australia
- Biomechanics and Spine Research Group (BSRG), Centre for Children’s Health Research, Queensland University of Technology (QUT), Brisbane, Australia
| | - Robert D. Labrom
- Orthopaedics Department, Queensland Children’s Hospital, South Brisbane, Australia
- Biomechanics and Spine Research Group (BSRG), Centre for Children’s Health Research, Queensland University of Technology (QUT), Brisbane, Australia
| | - Syeda Farah Zahir
- Queensland Cyber Infrastructure Foundation (QCIF), Facility for Advanced Bioinformatics, The University of Queensland (UQ), Brisbane, Australia
| | - Maree Izatt
- Orthopaedics Department, Queensland Children’s Hospital, South Brisbane, Australia
- Biomechanics and Spine Research Group (BSRG), Centre for Children’s Health Research, Queensland University of Technology (QUT), Brisbane, Australia
| | - J. Paige Little
- Biomechanics and Spine Research Group (BSRG), Centre for Children’s Health Research, Queensland University of Technology (QUT), Brisbane, Australia
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16
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Boeyer M, Tweedy N, Hoernschemeyer D, Wiesemann S. Central Airway Obstruction with Persistent Pulmonary Decline After Vertebral Body Tethering: A Case Report. JBJS Case Connect 2023; 13:01709767-202312000-00007. [PMID: 37831807 DOI: 10.2106/jbjs.cc.23.00258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Abstract
CASE An 11-year-old girl with pectus excavatum presented with an acute airway obstruction and persistent pulmonary compromise after vertebral body tethering (VBT). The anterior instrumentation was occluding her right basilar bronchus, resulting in hyperinflation. Removal of the instrumentation reversed the hyperinflation. CONCLUSION This case illustrates the difficulty of performing VBT in a small patient with severe scoliosis and significant asymmetric pectus excavatum. We recommend using low-profile instrumentation and ensuring the trajectory of the instrumentation is anterior to the rib head and parallel to the articular facets.
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Affiliation(s)
- Melanie Boeyer
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - Nicole Tweedy
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
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Vatkar A, Najjar E, Patel M, Quraishi NA. Vertebral body tethering in adolescent idiopathic scoliosis with more than 2 years of follow-up- systematic review and meta-analysis. 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 2023; 32:3047-3057. [PMID: 37306799 DOI: 10.1007/s00586-023-07724-2] [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: 04/01/2022] [Revised: 04/01/2022] [Accepted: 04/17/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND CONTEXT Whilst spinal fusion remains the gold standard in the treatment of adolescent idiopathic scoliosis (AIS), anterior vertebral body tethering (AVBT) is gaining momentum with relatively few studies on its efficacy thus far. PURPOSE To conduct a systematic review reporting on the early results of AVBT for patients undergoing surgery for AIS. We aimed to systematically evaluate the relevant literature pertaining to the efficacy of AVBT with respect to degree of correction of the major curve Cobb angle, complications and revision rates. STUDY DESIGN/SETTING Systematic review. PATIENT SAMPLE Of a total of 259 articles, 9 studies met the inclusion criteria and were analysed. Overall, 196 patients of (mean age 12.08 years) underwent an AVBT procedure for correction of AIS with a mean follow-up of 34 months. OUTCOME MEASURES Degree of Cobb angle correction, complications and revision rates were used as outcome measures. METHODS A systematic review of the literature on AVBT was performed for studies published between Jan 1999-March 2021 applying the PRISMA guidelines. Isolated case reports were excluded. RESULTS Overall, 196 patients of (mean age 12.08 years) underwent an AVBT procedure for correction of AIS with a mean follow-up of 34 months. There was a significant correction of the main thoracic curve of scoliosis (mean preoperative Cobb angle 48.5°, post-operative Cobb angle at final follow-up of 20.1°, P = 0.01). Overcorrection and mechanical complications were seen in 14.3% and 27.5% of cases, respectively. Pulmonary complications including atelectasis and pleural effusion were seen in 9.7% of patients. Tether revision was performed in 7.85%, and revision to a spinal fusion in 7.88%. CONCLUSION This systematic review incorporated 9 studies of AVBT and 196 patients with AIS. The complication and revision to spinal fusion rates were 27.5% and 7.88%, respectively. The current literature on AVBT is restricted largely to retrospective studies with non-randomised data. We would recommend a prospective, multi-centre trial of AVBT with strict inclusion criteria and standardised outcome measures.
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Affiliation(s)
- Arvind Vatkar
- The Centre for Spinal Studies and Surgery (CSSS), Queen's Medical Centre, Nottingham University Hospitals, Derby Rd, Lenton, Nottingham, NG7 2UH, UK.
| | - Elie Najjar
- The Centre for Spinal Studies and Surgery (CSSS), Queen's Medical Centre, Nottingham University Hospitals, Derby Rd, Lenton, Nottingham, NG7 2UH, UK
| | - Mohammed Patel
- The Centre for Spinal Studies and Surgery (CSSS), Queen's Medical Centre, Nottingham University Hospitals, Derby Rd, Lenton, Nottingham, NG7 2UH, UK
| | - Nasir A Quraishi
- The Centre for Spinal Studies and Surgery (CSSS), Queen's Medical Centre, Nottingham University Hospitals, Derby Rd, Lenton, Nottingham, NG7 2UH, UK
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18
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Boeyer ME, Farid S, Wiesemann S, Hoernschemeyer DG. Outcomes of vertebral body tethering in the lumbar spine. Spine Deform 2023; 11:909-918. [PMID: 36820998 DOI: 10.1007/s43390-023-00662-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 01/21/2023] [Indexed: 02/24/2023]
Abstract
PURPOSE The use of vertebral body tethering (VBT) for the treatment of main thoracic deformities in adolescent idiopathic scoliosis patients is becoming increasingly more common, but limited data exist on its safety and efficacy in thoracolumbar deformities. We aimed to evaluate the postoperative outcomes of patients with thoracolumbar (TL) deformities that were treated with VBT. METHODS We assessed clinical and radiographic data from twenty-eight consecutive patients that were surgically managed with VBT, all of whom exhibited a TL deformity with at least two years (mean: 44.7 ± 14.5 months) of postoperative follow-up. Standard radiographic parameters were extracted from left hand wrist and standing posterior-anterior and lateral spine radiographs at various timepoints. Outcome variables were assessed based on preoperative Lenke Classification and included: deformity measures, complications, surgical revisions, and postoperative success. RESULTS The mean age at the time of instrumentation was 13.4 ± 1.3 years, with an average preoperative Sanders Stage of 4.6 ± 1.4. A significant reduction in preoperative deformities was observed at most postoperative timepoints. A perioperative complication was observed in three patients and surgical revision was required in another four patients. A suspected broken tether was observed in sixteen patients, most of which occurred at the apex of the lumbar deformity. Only one patient required surgical revision due to a suspected broken tether. We observed an overall success rate of 57%, regardless of Lenke Classification. CONCLUSIONS These data indicate that VBT can successfully correct TL deformity patterns in 57% of patients without an increase in the rate of perioperative complications, suspected broken tethers, or surgical revisions.
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Affiliation(s)
- Melanie E Boeyer
- Department of Orthopaedic Surgery, University of Missouri, 204 N. Keene Street #102, Columbia, MO, 65201, USA
- Missouri Orthopaedic Institute, Columbia, MO, USA
| | - Sophi Farid
- School of Medicine, University of Missouri, Columbia, MO, USA
| | - Sebastian Wiesemann
- Division of Thoracic Surgery, Department of Surgery, University of Missouri, Columbia, MO, USA
| | - Daniel G Hoernschemeyer
- Department of Orthopaedic Surgery, University of Missouri, 204 N. Keene Street #102, Columbia, MO, 65201, USA.
- Missouri Orthopaedic Institute, Columbia, MO, USA.
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19
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Guldeniz O, Yip CCH, Nafo W, Cheung KMC. Biomechanics of the tether breakage: tensile behaviour of a single-unit vertebral body tethering construct. Spine Deform 2023; 11:825-831. [PMID: 36763247 PMCID: PMC10261170 DOI: 10.1007/s43390-023-00657-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 01/29/2023] [Indexed: 02/11/2023]
Abstract
PURPOSE Tether breakage was reported as the most common complication of vertebral body tethering. However, as the literature suggests the physiological loads do not have the potential to cause the failure of the tether. Currently, the biomechanical reason behind the tether breakage is unknown. The current study aims to elucidate the effects of the tension forces on the failure mechanisms of the VBT and provide mechanical justification for how it can be identified radiographically. METHODS Tensile tests (20%/min strain rate) were performed on single-unit VBT samples. Failure modes and mechanical characteristics were reported. RESULTS The failure took place prematurely due to the slippage of the tether at the screw-tether junction where the tether is damaged significantly by the locking cap. Slippage was initiated at 10-13% tensile strain level where the tensile stress and tension force were 50.4 ± 1.5 MPa and 582.2 ± 30.8 N, respectively. CONCLUSION The failure occurs because of high-stress concentrations generated within the locking region which damages the tether surface and leads to the slippage of the tether. We observed that the loads leading to failure are within the physiological limits and may indicate the high likelihood of the tether breakage. The failure mode observed in our study is shown to be the dominant failure mode, and a design improvement on the gripping mechanism is suggested to avoid failure at the screw-tether junction. We observed that the tether elongates 10-13% prior to the breakage, which can be employed as a diagnostic criterion to screen for tether breakages radiographically.
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Affiliation(s)
- Ogulcan Guldeniz
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Christopher C H Yip
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Wanis Nafo
- Department of Mechanical System Engineering, Jeonbuk National University, Jeonju, Republic of Korea
| | - Kenneth M C Cheung
- Department of Orthopaedic Surgery, HKU-Shenzhen Hospital, Shenzhen, China.
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong SAR, China.
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20
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Farivar D, Parent S, Miyanji F, Heffernan MJ, El-Hawary R, Larson AN, Andras LM, Skaggs DL. Concave and convex growth do not differ over tethered vertebral segments, even with open tri-radiate cartilage. Spine Deform 2023; 11:881-886. [PMID: 37004694 PMCID: PMC10261211 DOI: 10.1007/s43390-023-00683-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 03/18/2023] [Indexed: 04/04/2023]
Abstract
PURPOSE To assess the following hypotheses related to vertebral body tethering (VBT): 1. VBT is associated with asymmetric (concave > convex) increases in height over the instrumented vertebra. 2. The instrumented Cobb angle improves following VBT surgery with growth. METHODS This is a retrospective case series of pediatric patients from a multicenter scoliosis registry treated with VBT between 2013 to 2021. INCLUSION CRITERIA patients with standing radiographs at < 4 months and ≥ 2 years after surgery. Distances between the superior endplate of the UIV and the inferior endplate of the LIV were measured at the concave corner, mid-point, and convex corner of the endplates. The UIV-LIV angle was recorded. Subgroup analyses included comparing different Risser scores and tri-radiate cartilage (TRC) closed versus open using student t-tests. RESULTS 83 patients met inclusion criteria (92% female; age at time of surgery 12.5 ± 1.4 years) with mean follow-up time of 3.8 ± 1.4 years. Risser scores at surgery were: 0 (n = 33), 1 (n = 12), 2 (n = 10), 3 (n = 11), 4 (n = 12), and 5 (n = 5). Of the 33 Risser 0 patients, 17 had an open TRC, 16 had a closed TRC. The UIV-LIV distance at concave, middle, and convex points significantly increased from immediate post-op to final-follow-up for Risser 0 patients, but not for Risser 1-5 patients. Increases in UIV-LIV distance were not significantly different between concave, middle, and convex points for all groups. There was no significant improvement or worsening in UIV-LIV angle for any group. CONCLUSION At a mean of 3.8 years following VBT, 33 Risser 0 patients demonstrated significant growth in the instrumented segment, though there was no difference between concave or convex growth, even for patients with open TRC.
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Affiliation(s)
- Daniel Farivar
- Cedars-Sinai Spine, 444 S San Vicente Blvd, Ste 901, Los Angeles, CA, 90048, USA
| | - Stefan Parent
- Department of Surgery, Université de Montréal, Montreal, QC, Canada
| | - Firoz Miyanji
- Department of Orthopedics, BC Children's Hospital, Vancouver, BC, Canada
| | - Michael J Heffernan
- Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Ron El-Hawary
- Orthopedics, Izaak Walton Killam (IWK) Health Centre, Halifax, Canada
| | - A Noelle Larson
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Lindsay M Andras
- Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - David L Skaggs
- Cedars-Sinai Spine, 444 S San Vicente Blvd, Ste 901, Los Angeles, CA, 90048, USA.
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21
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Welborn MC, Blakemore L, Handford C, Miyanji F, Parent S, El-Hawary R. Thoracolumbar curve behavior after selective thoracic anterior vertebral body tethering in Lenke 1A vs Lenke 1C curve patterns. Spine Deform 2023; 11:897-907. [PMID: 36892744 PMCID: PMC9996552 DOI: 10.1007/s43390-023-00664-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 02/04/2023] [Indexed: 03/10/2023]
Abstract
STUDY DESIGN Retrospective review of a prospective database. OBJECTIVES The purpose of this study is to evaluate changes in the thoracic and thoracolumbar/lumbar curves and truncal balance in patients treated with selective thoracic anterior vertebral body tethering (AVBT) with Lenke 1A vs 1C curves at a minimum of 2 years follow-up. Lenke 1C curves treated with selective thoracic AVBT demonstrate equivalent thoracic curve correction and reduced thoracolumbar/lumbar curve correction compared to Lenke 1A curves. Additionally, at the most recent follow-up, both curve types demonstrate comparable coronal alignment at C7 and the lumbar curve apex, though 1C curves have better alignment at the lowest instrumented vertebra (LIV). Rates of revision surgery are equivalent between the two groups. METHODS A matched cohort of 43 Risser 0-1, Sanders Maturity Scale (SMS) 2-5 AIS pts with Lenke 1A (1A group)and 19 pts with Lenke 1C curves (1C group) treated with selective thoracic AVBT and a minimum of 2-year follow-up were included. Digital radiographic software was used to assess Cobb angle and coronal alignment on preoperative, postoperative and subsequent follow-up radiographs. Coronal alignment was assessed by measuring the distance from the center sacral vertical line (CSVL) to the midpoint of the LIV, apical vertebra for thoracic and lumbar curves and C7. RESULTS There was no difference in the thoracic curve measured preoperatively, at first erect, pre-rupture or at the most recent follow-up, nor was there a significant difference in C7 alignment (p = 0.057) or apical thoracic alignment (p = 0.272) between the 1A and 1C groups. Thoracolumbar/lumbar curves were smaller in the 1A group at all-time points. However, there was no significant difference between the percent correction between the two groups thoracic (p = 0.453) and thoracolumbar/lumbar (p = 0.105). The Lenke 1C curves had improved coronal translational alignment of the LIV at the most recent follow-up p = 0.0355. At the most recent follow-up the number of patients considered to have successful curve correction (Cobb angle correction of both the thoracic and thoracolumbar//lumbar curves to ≤ 35 degrees), was equivalent between Lenke 1A and Lenke 1C curves (p = 0.80). There was also no difference in the rate of revision surgery between the two groups (p = 0.546). CONCLUSION This is the first study to compare the impact of lumbar curve modifier type on outcomes in thoracic AVBT. We found that Lenke 1C curves treated with selective thoracic AVBT demonstrate less absolute correction of the thoracolumbar/lumbar curve at all time points but have equivalent percent correction of the thoracic and thoracolumbar/lumbar curves. The two groups have equivalent alignment at C7 and the thoracic curve apex, and Lenke 1C curves have better alignment at the LIV at the most recent follow-up. Furthermore, they have an equivalent rate of revision surgery compared to Lenke 1A curves. Selective thoracic AVBT is a viable option for selective Lenke 1C curves, but despite equivalent correction of the thoracic curve, there is less correction of the thoracolumbar/lumbar curve at all-time points.
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Affiliation(s)
| | - Laurel Blakemore
- , 3101 SW Sam Jackson Park Road, Portland, OR, 97229, USA
- CEO, Pediatric Specialists of Virginia, Fairfax, VA, USA
| | - Cameron Handford
- , 3101 SW Sam Jackson Park Road, Portland, OR, 97229, USA
- Department of Orthopaedics, Royal North Shore Hospital, St. Leonards, NSW, Australia
| | - Firoz Miyanji
- , 3101 SW Sam Jackson Park Road, Portland, OR, 97229, USA
- Department of Orthopedics, British Columbia Children's Hospital, Vancouver, Canada
| | - Stefan Parent
- , 3101 SW Sam Jackson Park Road, Portland, OR, 97229, USA
- Département de Chirurgie, Sainte-Justine University Hospital Center, Université de Montréal, 3175 Côte-Sainte-Catherine, Montreal, Canada
| | - Ron El-Hawary
- , 3101 SW Sam Jackson Park Road, Portland, OR, 97229, USA
- Department of Surgery, IWK Health Centre Dalhousie University, Halifax, Canada
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22
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Wan SHT, Guldeniz O, Yeung MHY, Cheung JPY, Kwan KYH, Cheung KMC. Inter-screw index as a novel diagnostic indicator of tether breakage. Spine Deform 2023; 11:887-895. [PMID: 37014574 PMCID: PMC10261206 DOI: 10.1007/s43390-023-00679-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 03/11/2023] [Indexed: 04/05/2023]
Abstract
PURPOSE Tether breakage is the most common complication of Vertebral Body Tethering (VBT) occurring in up to 52% of Adolescent Idiopathic Scoliosis (AIS) patients and risks continued progression and revision. Radiographical diagnosis of tether breakage is commonly defined by a 5° increase in inter-screw angle and associates breakage with loss of correction. However, the sensitivity of this method was 56% only, suggesting that tethers can break without an increase in angulation, which was supported by other studies. To our knowledge, current literature lacks a method merely focusing on the diagnosis of tether breakage radiographically that does not associate the breakages with loss of correction. METHODS This was a retrospective review of prospectively collected data of AIS patients who underwent VBT. The "inter-screw index" is defined as the percentage increase in inter-screw distance since post-op, with ≥ 13% increase defined as tether breakage as suggested by our mechanical tests. CTs were reviewed to identify the breakages and compared with inter-screw angle and inter-screw index. RESULTS 94 segments from 13 CTs were reviewed, and 15 tether breakages were identified. Use of inter-screw index correctly identified 14 breakages (93%), whereas ≥ 5° increase in inter-screw angle only identified 12 breakages (80%). CONCLUSION Use of inter-screw index is proven to be more sensitive than inter-screw angle in identifying tether breakages. Therefore, we propose the use of inter-screw index to diagnose tether breakages radiographically. Tether breakages were not necessarily accompanied by a loss of segmental correction leading to an increase in inter-screw angle, especially after skeletal maturity. LEVEL OF EVIDENCE Level 3.
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Affiliation(s)
- Sandra H T Wan
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Ogulcan Guldeniz
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Matthew H Y Yeung
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Jason P Y Cheung
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Kenny Y H Kwan
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Kenneth M C Cheung
- Department of Orthopaedic Surgery, HKU-Shenzhen Hospital, Shenzhen, China.
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong SAR, China.
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23
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Mineiro J. Posterior Vertebral Pedicular Tethering for the Treatment of Idiopathic Adolescent Scoliosis. Healthcare (Basel) 2023; 11:1878. [PMID: 37444712 DOI: 10.3390/healthcare11131878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/23/2023] [Accepted: 06/26/2023] [Indexed: 07/15/2023] Open
Abstract
Over the last decade, there has been a new wave of interest in non-fusion techniques for the treatment of adolescent idiopathic scoliosis. These are not new techniques, as they were first published and presented in the late 1950s, using compression of the convexity or distraction of the concavity of the main curvature. More recently, anterior vertebral body tethering has raised great interest, as although it is a major procedure through the child's chest, it seems appropriate for the thoracic curves. The main objective of this article is to describe Posterior Vertebral Pedicular Tethering (PVPT) as a "new" technique performed as a less invasive spinal procedure for the treatment of certain thoracolumbar and lumbar scoliosis in growing adolescents. It is an alternative growth modulation technique appropriate for thoracolumbar and lumbar curvatures where we observe reduction of the three plane deformity of idiopathic scoliosis in adolescents.
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Affiliation(s)
- Jorge Mineiro
- Orthopaedic Spine Unit, Department of Orthopaedics and Traumatology, Hospital CUF Descobertas, 1998-018 Lisbon, Portugal
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24
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Mladenov KV, Pinnschmidt HO, Stücker R. Anterior Vertebral Body Tethering for Skeletally Immature Patients with AIS: Indication for Spinal Fusion at Skeletal Maturity Is Not Obviated in 60% of Cases. J Clin Med 2023; 12:3933. [PMID: 37373628 DOI: 10.3390/jcm12123933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 05/30/2023] [Accepted: 06/07/2023] [Indexed: 06/29/2023] Open
Abstract
The role of anterior vertebral body tethering (aVBT) in obviating the need for spinal fusion in patients with AIS remains unclear, and a large amount of variation exists in the data among different studies. The present study aims to investigate and analyze what factors have a potential influence on aVBT outcome. Skeletally immature patients with AIS who underwent aVBT for scoliosis correction were followed up until skeletal maturity. The mean age at the time of surgery was 13.4 ± 1.1, and the mean follow-up time was 2.5 ± 0.5 years. The Cobb angle of the main curve was 46.6 ± 9° at the time of surgery and was significantly corrected to 17.7 ± 10.4° (p < 0.001) immediately postoperatively. A significant loss of correction was observed during the latest follow-up (Cobb angle 33.8 ± 18.7°; p < 0.001). An indication for spinal fusion at skeletal maturity was not obviated in 60% of the patients. The factors identified as having an influence on the outcome were preoperative bone age and the magnitude of the major curve. Patients with advanced bone age and larger curves were more likely to reach an indication for spinal fusion at skeletal maturity. In conclusion, no general recommendation for aVBT can be made for AIS patients. The method can be discussed as a treatment option in skeletally very immature preadolescent patients (Sanders Stadium ≤ 2) with a moderate Cobb angle (≤50°) who failed previous brace therapy.
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Affiliation(s)
- Kiril V Mladenov
- Pediatric Orthopedic Department, Altona Children's Hospital, Bleickenallee 38, D-22763 Hamburg, Germany
- Department of Orthopedics, University Medical Center Hamburg-Eppendorf, D-20246 Hamburg, Germany
| | - Hans O Pinnschmidt
- Center for Experimental Medicine, Institute for Medical Biometry & Epidemiology, University Medical Center Hamburg-Eppendorf, Chrisoph-Probst-Weg 1, D-20246 Hamburg, Germany
| | - Ralf Stücker
- Pediatric Orthopedic Department, Altona Children's Hospital, Bleickenallee 38, D-22763 Hamburg, Germany
- Department of Orthopedics, University Medical Center Hamburg-Eppendorf, D-20246 Hamburg, Germany
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25
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Trobisch PD, Castelein R, Da Paz S. Radiographic outcome after vertebral body tethering of the lumbar spine. 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 2023:10.1007/s00586-023-07740-2. [PMID: 37133761 DOI: 10.1007/s00586-023-07740-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 02/21/2023] [Accepted: 04/22/2023] [Indexed: 05/04/2023]
Abstract
INTRODUCTION Multiple studies have analyzed the outcome after thoracic Vertebral Body Tethering (VBT). The results seem reproducible with most studies reporting coronal correction rates around 50% and a tether breakage rate near 20% at two years follow-up. There is a paucity of data on lumbar VBT, and no study has yet analyzed the radiographic outcome after lumbar VBT in a double tether technique at two years follow-up, which was the aim of this study. METHODS This is a retrospective, single surgeons' data analysis of all consecutive immature patients who have had VBT of the lumbar spine (to L3 or L4) between January 2019 and September 2020. Primary interest focused on coronal curve correction at two years post-operatively. Suspected tether breakages were analyzed separately and defined as an angular change of more than 5° between two adjacent screws. RESULTS Forty-one patients were eligible for this study and 35 (85%) had complete two-year follow-up data. Average age at surgery was 14.3 years. All patients had a Sanders stage of 7 or below. Average curve correction for thoracolumbar/lumbar curves at two years follow-up was 50%. 90% of patients had at least one level with a suspected tether breakage. No patient required a revision surgery within two years from surgery but two patients were surgically revised after two years. CONCLUSION VBT in the lumbar spine resulted in 50% coronal curve correction two years post-operatively despite a tether breakage in 90% of patients.
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Affiliation(s)
- Per D Trobisch
- Eifelklinik St. Brigida, Spine Surgery, Kammerbruchstr. 8, 52152, Simmerath, Germany.
| | - Rene Castelein
- University Medical Center Utrecht, Heidelberglaan 100, 3584 CZ, Utrecht, The Netherlands
| | - Stephanie Da Paz
- Eifelklinik St. Brigida, Spine Surgery, Kammerbruchstr. 8, 52152, Simmerath, Germany
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26
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Lemans JVC, Wijdicks SPJ, Overweg G, Hekman EEG, Schlösser TPC, Castelein RM, Verkerke GJ, Kruyt MC. Three-dimensional correction of scoliosis by a double spring reduction system as a dynamic internal brace: a pre-clinical study in Göttingen minipigs. Spine J 2023; 23:599-608. [PMID: 36343914 DOI: 10.1016/j.spinee.2022.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 10/07/2022] [Accepted: 10/26/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND CONTEXT Adolescent idiopathic scoliosis (AIS) is a major skeletal deformity that is characterized by a combination of apical rotation, lateral bending and apical lordosis. To provide full 3D correction, all these deformations should be addressed. We developed the Double Spring Reduction (DSR) system, a (growth-friendly) concept that continuously corrects the deformity through two different elements: A posterior convex Torsional Spring Implant (TSI) that provides a derotational torque at the apex, and a concave Spring Distraction System (SDS), which provides posterior, concave distraction to restore thoracic kyphosis. PURPOSE To determine whether the DSR components are able to correct an induced idiopathic-like scoliosis and to compare correction realized by the TSI alone to correction enforced by the complete DSR implant. STUDY DESIGN/SETTING Preclinical randomized animal cohort study. PATIENT SAMPLE Twelve growing Göttingen minipigs. OUTCOME MEASURES Coronal Cobb angle, T10-L3 lordosis/kyphosis, apical axial rotation, relative anterior lengthening. METHODS All mini-pigs received the TSI with a contralateral tether to induce an idiopathic-like scoliosis with apical rotation (mean Cobb: 20.4°; mean axial apical rotation: 13.1°, mean lordosis: 4.9°). After induction, the animals were divided into two groups: One group (N=6) was corrected by TSI only (TSI only-group), another group (N=6) was corrected by a combination of TSI and SDS (DSR-group). 3D spinal morphology on CT was compared between groups over time. After 2 months of correction, animals were euthanized. RESULTS Both intervention groups showed excellent apical derotation (TSI only-group: 15.0° to 5.4°; DSR-group: 11.2° to 3.5°). The TSI only-group showed coronal Cobb improvement from 22.5° to 6.0°, while the DSR-group overcorrected the 18.3° Cobb to -9.2°. Lordosis was converted to kyphosis in both groups (TSI only-group: -4.6° to 4.3°; DSR-group: -5.2° to 25.0°) which was significantly larger in the DSR-group (p<.001). CONCLUSIONS The TSI alone realized strong apical derotation and moderate correction in the coronal and sagittal plane. The addition of distraction on the posterior concavity resulted in more coronal correction and reversal of induced lordosis into physiological kyphosis. CLINICAL SIGNIFICANCE This study shows that dynamic spring forces could be a viable method to guide the spine towards healthy alignment, without fusing it or inhibiting its growth.
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Affiliation(s)
- Justin V C Lemans
- University Medical Center Utrecht, Department of Orthopaedic Surgery, PO Box 85500, 3553 GA, Utrecht, The Netherlands.
| | - Sebastiaan P J Wijdicks
- University Medical Center Utrecht, Department of Orthopaedic Surgery, PO Box 85500, 3553 GA, Utrecht, The Netherlands
| | - Gerrit Overweg
- University of Twente, Department of Biomechanical Engineering, PO Box 217, 7500 AE, Enschede, The Netherlands
| | - Edsko E G Hekman
- University of Twente, Department of Biomechanical Engineering, PO Box 217, 7500 AE, Enschede, The Netherlands
| | - Tom P C Schlösser
- University Medical Center Utrecht, Department of Orthopaedic Surgery, PO Box 85500, 3553 GA, Utrecht, The Netherlands
| | - René M Castelein
- University Medical Center Utrecht, Department of Orthopaedic Surgery, PO Box 85500, 3553 GA, Utrecht, The Netherlands
| | - Gijsbertus J Verkerke
- University of Twente, Department of Biomechanical Engineering, PO Box 217, 7500 AE, Enschede, The Netherlands; University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, PO Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Moyo C Kruyt
- University Medical Center Utrecht, Department of Orthopaedic Surgery, PO Box 85500, 3553 GA, Utrecht, The Netherlands; University of Twente, Department of Developmental BioEngineering, PO Box 217, 7500 AE, Enschede, The Netherlands
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Baroncini A, Courvoisier A. The different applications of Vertebral Body Tethering - Narrative review and clinical experience. J Orthop 2023; 37:86-92. [PMID: 36974090 PMCID: PMC10039119 DOI: 10.1016/j.jor.2023.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 02/02/2023] [Accepted: 02/21/2023] [Indexed: 03/29/2023] Open
Abstract
Background Vertebral body tethering (VBT) has been originally developed as a growth modulation technique for the surgical management of skeletally immature patients with adolescent idiopathic scoliosis (AIS). Given the positive results obtained in this setting, the use of VBT is gradually expanding to other patient categories, such as those with no or limited remaining growth or with non-idiopathic scoliosis. Aim of this manuscript is to offer an overview over the current applications of VBT, along with imaging and comments derived from the clinical experience. The work was based on a literature search conducted in January 2023 on Pubmed, Scopus and Web of Science databases. Following keywords were used for the search: vertebral body tethering, adolescent idiopathic scoliosis, early onset scoliosis, neuromuscular scoliosis, syndromic scoliosis. Results Three patient categories in which VBT has been applied have been highlighted: VBT for growth modulation in AIS, VBT as anterior scoliosis correction in AIS and VBT for non-idiopathic curves or early-onset scoliosis. Conclusion While growth modulation in AIS still represents the most widespread use of VBT, the use of this technique has yielded positive results in different settings as well, such as scoliosis correction in AIS or temporary or definitive curve management in non-AIS curves. While long-term results are lacking, patient selection seems to play a central role to reduce the complication rate and ensure predictable and stable results.
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Affiliation(s)
- A. Baroncini
- Department of Orthopaedics, RWTH Aachen University Clinic, Aachen, Germany
| | - A. Courvoisier
- Grenoble Alpes Scoliosis Center, Grenoble Alpes University Hospital, Grenoble, France
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Wang S, Zhao Y, Yang Y, Lin G, Shen J, Zhao Y, Wu N, Zhuang Q, Du Y, Zhang J. Hybrid technique versus traditional dual growing rod technique to treat congenital early-onset scoliosis: a comparative study with more than 3 years of follow-up. J Neurosurg Spine 2023; 38:199-207. [PMID: 36208432 DOI: 10.3171/2022.8.spine22618] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 08/30/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors' objective was to compare the intermediate outcomes of patients with severe congenital early-onset scoliosis (CEOS) treated with posterior vertebrectomy/hemivertebrectomy with short fusion and dual growing rods (hybrid technique [HT]) and those treated with traditional dual growing rods (TDGRs). METHODS A retrospective study of patients who underwent the HT and TDGR technique for CEOS was conducted. The inclusion criteria were CEOS (age < 10 years), Risser stage 0, treatment with HT or TDGR, index surgery performed between 2004 and 2017, and minimum follow-up of 3 years. For patients who completed lengthening procedures, the last lengthening procedure was considered the latest follow-up. Demographic, radiographic, clinical, and patient-reported outcomes and revisions were compared between groups. RESULTS Sixty-one patients with CEOS were included in this study, with 16 treated with HT and 45 with TDGR technique. There were no differences in age at index surgery, duration of treatment, or number of lengthening procedures. The lengthening interval was longer in the HT group. The preoperative mean ± SD main curve was 81.8° ± 17.1° for the HT group and 63.3° ± 16.9° for the TDGR group (p < 0.05). However, main curve correction was better in the HT group, and no differences in residual curve were found between groups. Although the preoperative apex vertebral translation (AVT) of the HT group was greater, the correction of AVT was better in the HT group (p < 0.05). No differences in T1-S1 and T1-12 height were found between groups at the latest follow-up. The growth of T1-S1 height was less in the HT group (p < 0.05), whereas the growth of T1-12 height was similar between groups. Patients in the HT group had a lower risk of mechanical complications but higher risks of dural tears and neurological complications. CONCLUSIONS HT may provide better correction and apex control ability than TDGR for EOS patients with severe and rigid deformity at the apex level, and it significantly decreased the risk of mechanical complications with little influence on growth of the thoracic spine. HT may be an option for patients with severe CEOS with large asymmetrical growth potential around the apex of the curve.
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Courvoisier A, Baroncini A, Jeandel C, Barra C, Lefevre Y, Solla F, Gouron R, Métaizeau JD, Maximin MC, Cunin V. Vertebral Body Tethering in AIS Management-A Preliminary Report. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020192. [PMID: 36832321 PMCID: PMC9955337 DOI: 10.3390/children10020192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 12/30/2022] [Accepted: 01/17/2023] [Indexed: 01/22/2023]
Abstract
Vertebral Body Tethering (VBT) is a recently developed surgical technique for the treatment of progressive and severe scoliosis in patients with significant growth potential. It has been used since the first exploratory series, which showed encouraging results on the progressive correction of the major curves. This study reports on a retrospective series of 85 patients extracted from a French cohort, with a follow-up at a minimum of two years after a VBT with recent screws-and-tether constructs. The major and compensatory curves were measured pre-operatively, at the 1st standing X-ray, at 1 year, and at the last available follow-up. The complications were also analyzed. A significant improvement was observed in the curve magnitude after surgery. Thanks to growth modulation, both the main and the secondary curves continued to progress over time. Both the thoracic kyphosis and lumbar lordosis remained stable over time. Overcorrection occurred in 11% of the cases. Tether breakage was observed in 2% of the cases and pulmonary complications in 3% of the cases. VBT is an effective technique for the management of adolescent idiopathic scoliosis patients with residual growth potential. VBT opens an era of a more subtle and patient-specific surgical management of AIS that considers parameters such as flexibility and growth.
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Affiliation(s)
- Aurélien Courvoisier
- TIMC, University Grenoble Alpes, CNRS, UMR 5525, VetAgro Sup, Grenoble INP, CHU Grenoble Alpes, 38000 Grenoble, France
- Grenoble Alps Scoliosis and Spine Center, Grenoble Alps University Hospital, Bvd de la Chantourne, CEDEX 09, 38043 Grenoble, France
- Correspondence: ; Tel.: +33-6-74-82-56-61
| | - Alice Baroncini
- Department of Orthopaedics, RWTH Uniklinik Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Clément Jeandel
- Grenoble Alps Scoliosis and Spine Center, Grenoble Alps University Hospital, Bvd de la Chantourne, CEDEX 09, 38043 Grenoble, France
| | - Clémentine Barra
- Service d’Orthopédie Pédiatrique, Hôpital Femme Mère Enfant, Hôpitaux civils de Lyon, 59 Bd Pinel, 69500 Bron, France
| | - Yan Lefevre
- Service d’Orthopédie Pédiatrique, CHU de Bordeaux, Pl. Amélie Raba Léon, 33000 Bordeaux, France
| | - Federico Solla
- Service d’Orthopédie Pédiatrique, Fondation Lenval, 57 Avenue de la Californie, 06200 Nice, France
| | - Richard Gouron
- Service d’Orthopédie Pédiatrique, CHU d’Amiens, Université Picardie Jules Verne, Chemin du Thil, CS 52501, CEDEX 1, 80025 Amiens, France
| | - Jean-Damien Métaizeau
- Service d’Orthopédie Pédiatrique, Centre Hospitalier Universitaire F.Mitterrand Dijon-Bourgogne, 14 Rue Paul Gaffarel, 21000 Dijon, France
| | - Marie-Christine Maximin
- Grenoble Alps Scoliosis and Spine Center, Grenoble Alps University Hospital, Bvd de la Chantourne, CEDEX 09, 38043 Grenoble, France
| | - Vincent Cunin
- Service d’Orthopédie Pédiatrique, Hôpital Femme Mère Enfant, Hôpitaux civils de Lyon, 59 Bd Pinel, 69500 Bron, France
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Hammad AM, Balsano M, Ahmad AA. Vertebral body tethering: An alternative to posterior spinal fusion in idiopathic scoliosis? Front Pediatr 2023; 11:1133049. [PMID: 36999081 PMCID: PMC10043194 DOI: 10.3389/fped.2023.1133049] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 02/24/2023] [Indexed: 04/01/2023] Open
Abstract
Introduction Skeletally immature patient with adolescent idiopathic scoliosis (AIS) whose curves continue to progress despite bracing should be treated surgically. Vertebral body tethering (VBT) is a non-fusion, compression-based, growth preserving alternative to posterior spinal fusion (PSF) based on the concept of 'growth modulation' to prevent possible functional complications secondary to fusion while correcting scoliotic deformity. This review aims to shed light on the indications of VBT, short- and medium-term outcomes, describe the surgical technique and associated complications, and to compare its efficacy to that of PSF. Methods A review of peer-reviewed literature on VBT as a surgical technique, its indications, outcomes, complications, and comparison with other surgical interventions to correct AIS was conducted in December 2022. Results Indications remain controversial and mainly include stage of skeletal maturity based on radiographic markers, curve location, magnitude and flexibility, and presence of secondary curve. Assessment of VBT clinical success should not be restricted to improvement in radiographic parameters but should include functional results and patient-centered outcomes, improved body image and pain, and durability of outcomes. In contrast to fusion, VBT seems to be associated with preserved spinal growth, shorter recovery, potentially better functional outcomes, less motion loss but possibly less curve correction. Discussion Yet still, with VBT there exists a risk of overcorrection, construct breakage or failure of procedure which require revision and at times conversion to PSF. Patient and family preferences must be accounted for acknowledging gaps in knowledge, attributes and drawbacks of each intervention.
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Affiliation(s)
- Ahmad M. Hammad
- Department of Orthopedics Surgery, American University of Beirut, Beirut, Lebanon
| | - Massimo Balsano
- Regional Spinal Department, University and Hospital Trust, Verona, Italy
| | - Alaaeldin A. Ahmad
- Department of Pediatric Orthopedic Surgery, Palestine Polytechnic University PPU, Hebron, Palestine
- Correspondence: Alaaeldin A. Ahmad
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31
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Meta-analysis on the efficacy and safety of anterior vertebral body tethering in adolescent idiopathic scoliosis. 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 2023; 32:140-148. [PMID: 36443510 DOI: 10.1007/s00586-022-07448-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 10/31/2022] [Accepted: 11/03/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE In this meta-analysis, we analyzed the efficacy and safety of anterior vertebral body tethering in patients with adolescent idiopathic scoliosis. METHODS We performed a literature search and analyzed the following data: baseline characteristics, efficacy measures (corrections of the main thoracic curve, proximal thoracic curve, and thoracolumbar curve, thoracic kyphosis, lumbosacral lordosis, rib hump, lumbar prominence and SRS-22 scores, and complications. Analyses were performed with Cochrane's Review Manager version 5.4. RESULTS Twelve studies met the inclusion criteria. Significant corrections of the main thoracic (MD 22.51, 95% CI 12.93 to 32.09) proximal thoracic (MD 10.14°, 95% CI 7.25° to 13.02°), and thoracolumbar curve (MD 12.16, 95% CI 9.14 to 15.18) were found. No statistically significant corrections were observed on the sagittal plane assessed by thoracic kyphosis (MD - 0.60°, 95% CI - 2.45 to 1.26; participants = 622; studies = 4; I2 = 36%) and lumbosacral lordosis (MD 0.19°, 95% CI - 2.16° to 2.54°). Significant corrections were identified for rib hump (MD 5.26°, 95% CI 4.19° to 6.32°) and lumbar prominence (MD 1.20°, 95% CI 0.27° to 2.13°) at final follow-up. Significant improvements of total SRS-22 score (MD - 0.96, 95% CI - 1.10 to - 0.83) were achieved at final follow-up. The most common complication was overcorrection (8.0%) and tether breakage (5.9%), with a reoperation rate of 10.1%. CONCLUSIONS Anterior vertebral body tethering is effective to reduce the curve in the coronal plane and clinical deformity. Maximum correction is achieved at one year. The method should, however, be optimized to reduce the rate of complications.
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Newton PO, Parent S, Miyanji F, Alanay A, Lonner BS, Neal KM, Hoernschemeyer DG, Yaszay B, Blakemore LC, Shah SA, Bastrom TP. Anterior Vertebral Body Tethering Compared with Posterior Spinal Fusion for Major Thoracic Curves. J Bone Joint Surg Am 2022; 104:2170-2177. [PMID: 37010479 DOI: 10.2106/jbjs.22.00127] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Anterior vertebral body tethering (AVBT) is an alternative to posterior spinal fusion (PSF) for the surgical treatment of scoliosis. The present study utilized a large, multicenter database and propensity matching to compare outcomes of AVBT to PSF in patients with idiopathic scoliosis. METHODS Patients with thoracic idiopathic scoliosis who underwent AVBT with a minimum 2-year follow-up retrospectively underwent 2 methods of propensity-guided matching to PSF patients from an idiopathic scoliosis registry. Radiographic, clinical, and Scoliosis Research Society 22-Item Questionnaire (SRS-22) data were compared preoperatively and at the ≥2-year follow-up. RESULTS A total of 237 AVBT patients were matched with 237 PSF patients. In the AVBT group, the mean age was 12.1 ± 1.6 years, the mean follow-up was 2.2 ± 0.5 years, 84% of patients were female, and 79% of patients had a Risser sign of 0 or 1, compared with 13.4 ± 1.4 years, 2.3 ± 0.5 years, 84% female, and 43% Risser 0 or 1 in the PSF group. The AVBT group was younger (p < 0.001), had a smaller mean thoracic curve preoperatively (48 ± 9°; range, 30° to 74°; compared with 53 ± 8°; range, 40° to 78° in the PSF group; p < 0.001), and had less initial correction (41% ± 16% correction to 28° ± 9° compared with 70% ± 11% correction to 16° ± 6° in the PSF group; p < 0.001). Thoracic deformity at the time of the latest follow-up was 27° ± 12° (range, 1° to 61°) for AVBT compared with 20° ± 7° (range, 3° to 42°) for PSF (p < 0.001). A total of 76% of AVBT patients had a thoracic curve of <35° at the latest follow-up compared with 97.4% of PSF patients (p < 0.001). A residual curve of >50° was present in 7 AVBT patients (3%), 3 of whom underwent subsequent PSF, and in 0 PSF patients (0%). Forty-six subsequent procedures were performed in 38 AVBT patients (16%), including 17 conversions to PSF and 16 revisions for excessive correction, compared with 4 revision procedures in 3 PSF patients (1.3%; p < 0.01). AVBT patients had lower median preoperative SRS-22 mental-health component scores (p < 0.01) and less improvement in the pain and self-image scores between preoperatively and the ≥2-year follow-up (p < 0.05). In the more strictly matched analysis (n = 108 each), 10% of patients in the AVBT group and 2% of patients in the PSF group required a subsequent surgical procedure. CONCLUSIONS At a mean follow-up of 2.2 years, 76% of thoracic idiopathic scoliosis patients who underwent AVBT had a residual curve of <35° compared with 97.4% of patients who underwent PSF. A total of 16% of cases in the AVBT group required a subsequent surgical procedure compared with 1.3% in the PSF group. An additional 4 cases (1.3%) in the AVBT group had a residual curve of >50° that may require revision or conversion to PSF. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Peter O Newton
- Division of Orthopedics & Scoliosis, Rady Children's Hospital, San Diego, California
| | - Stefan Parent
- Department of Orthopaedics, CHU Sainte-Justine, Montreal, Québec, Canada
- Department of Surgery, University of Montreal, Montréal, Québec, Canada
| | - Firoz Miyanji
- Department of Orthopaedics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Ahmet Alanay
- Department of Orthopaedics and Traumatology, Acibadem University School of Medicine, Istanbul, Turkey
| | - Baron S Lonner
- Department of Orthopedic Surgery, Mount Sinai Hospital, New York, NY
| | - Kevin M Neal
- Department of Orthopedic Surgery, Nemours Children's Health, Jacksonville, Florida
| | | | - Burt Yaszay
- Department of Orthopedics and Sports Medicine, Seattle Children's Hospital, Seattle, Washington
| | - Laurel C Blakemore
- Division of Pediatric Orthopedics, Pediatric Specialists of Virginia, Virginia
| | - Suken A Shah
- Department of Orthopedic Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Tracey P Bastrom
- Division of Orthopedics & Scoliosis, Rady Children's Hospital, San Diego, California
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Zhu F, Qiu X, Liu S, Man-Chee Cheung K. Minimum 3-year experience with vertebral body tethering for treating scoliosis: A systematic review and single-arm meta-analysis. J Orthop Surg (Hong Kong) 2022; 30:10225536221137753. [PMID: 36420934 DOI: 10.1177/10225536221137753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Over the past 12 years, vertebral body tethering (VBT) has been gradually promoted for treating scoliosis, but there are few published studies, with only short-term follow-up. This study aimed to systematically review VBT efficacy and safety for treating scoliosis. METHODS PubMed, Web of Science, Embase, and the Cochrane Library were searched for studies on VBT treatment of scoliosis published up to November 2021. Two researchers independently screened the literature, extracted data, and assessed the risk of bias in included studies. Data on clinical efficacy, unplanned reoperations, and complications were extracted. The meta-analysis was performed with R 4.1.0. RESULTS Twenty-six studies involving 1045 patients were included in the meta-analysis. The correction rate of major curve immediately post-operation was 46.6% ± 13.8% (16%-69%) and that at final follow-up was 53.2% ± 17.9% (16%-79%). The single-arm meta-analysis results of all included studies showed that VBT was effective in general. The overall clinical success rate was 73.02% (95% confidence interval [CI]: 68.31%-78.05%). The pooled overall unplanned reoperation rate was 8.66% (95% CI: 5.53%-13.31%). The overall incidence rate of complications was 36.8% (95% CI: 23.9%-49.7%). The subgroup analysis based on follow-up time indicated that patients with follow-up time >36 months had increased clinical success rate, unplanned reoperation rate, and incidence rate of complications compared with those with <36 months' follow-up time. The preliminary results showed that after 36 months of follow-up, only 7.17% (95% CI: 4.81%-10.55%) of patients required posterior spinal fusion (PSF) surgery and nearly 93% of patients avoided spinal fusion surgeries. CONCLUSIONS The current evidence from at least 3-year follow-up in different countries indicates that VBT is an effective surgical approach for treating scoliosis, with 73.88% of patients achieving clinical success. Nevertheless, about one in seven patients (15.8%) required unplanned reoperations, but only 7.17% required PSF. About half (52.17%) of the patients experienced complications. Due to the limitation of the study number and quality, our conclusion may be biased and requires verification by further studies with longer follow-up times.
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Affiliation(s)
- Feng Zhu
- Department of Spinal Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China.,Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, 25809The University of Hong Kong, Hong Kong, China
| | - Xin Qiu
- Department of Spinal Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China.,Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, 25809The University of Hong Kong, Hong Kong, China
| | - Shunan Liu
- Department of Spinal Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Kenneth Man-Chee Cheung
- Department of Spinal Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China.,Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, 25809The University of Hong Kong, Hong Kong, China
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The preliminary outcomes of vertebral body tethering in treating adolescent idiopathic scoliosis: a systematic review. Spine Deform 2022; 10:1233-1243. [PMID: 35841473 DOI: 10.1007/s43390-022-00546-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 06/18/2022] [Indexed: 10/17/2022]
Abstract
PURPOSE VBT is a novel alternative to spinal fusion surgery to treat skeletally immature AIS and was approved to correct idiopathic scoliosis in August 2019 by US Federal Drug Administration (FDA). To systemically review the preliminary outcomes of vertebral body tethering (VBT) in treating adolescent idiopathic scoliosis. METHODS The electronic databases PubMed, EMBASE, and Web of Science were queried up to January 2022 for articles regarding VBT. Basic characteristics of patients, changes of radiographic parameters in coronal and sagittal planes, and clinical outcomes of surgical treatment of VBT including complication and revision rates were summarized. RESULTS Twenty five studies met the inclusion criteria. Most studies (23/25) included patients with only skeletal immaturity. The average % correction of the main/tethered curve at final follow-up, and % correction of thoracic kyphosis at final follow-up were reported to be 15.6-106.5% and - 31.8 to 20.0%, respectively. The most common complications for VBT were tether breakage (n = 145;21.3%), pulmonary complications (n = 49; 6.9%), and overcorrection (n = 30; 4.2%). The revision rate was 13.1%. CONCLUSION VBT could effectively and safely correct spinal deformity in skeletally immature patients with AIS and preserve the motion and growth of the spine. However, VBT has a relatively high complication and revision rates. Therefore, surgeons should cautiously consider VBT for treating AIS. Future research efforts are needed to lower the complication and revision rates. Whatever, VBT is still in its infancy and may have a promising future as a non-fusion solution for AIS.
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Baroncini A, Migliorini F, Eschweiler J, Hildebrand F, Trobisch P. The timing of tether breakage influences clinical results after VBT. 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 2022; 31:2362-2367. [PMID: 35864248 DOI: 10.1007/s00586-022-07321-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 07/01/2022] [Accepted: 07/06/2022] [Indexed: 05/20/2023]
Abstract
INTRODUCTION Tether breakage is a frequent mechanical complications after vertebral body tethering (VBT), but not all patients with a breakage show loss of correction. The reason of this clinical finding has not yet been clarified. We hypothesized that the integrity of the tether is relevant only in the early stages after VBT, when it drives growth modulation and tissue remodelling. After these mechanisms have taken place, the tether loses its function and a breakage will not alter the new shape of the spine. Thus, tether breakage would have a greater clinical relevance when occurring shortly after surgery. METHODS All consecutive patients who underwent VBT and had a min. 2-year follow-up were included. The difference in curve magnitude between the 1st standing x-ray and the last follow-up was calculated (ΔCobb). For each curve, the presence and timing of tether breakage were recorded. The curves were grouped according to if and when the breakage was observed (no breakage, breakage at 0-6 months, 6-12 months, > 12 months). The ΔCobb was compared among these groups with the analysis of variance (ANOVA). RESULTS Data from 152 curves were available: 68 with no breakage, 12 with a breakage at 0-6 months, 37 at 6-12 months and 35 > 12 months. The ANOVA found significant difference in the ΔCobb among the groups (Sum of square 2553.59; degree of freedom 3; mean of square 851.1; Fisher test 13.8; P < 0.0001). Patients with no breakage or breakage at > 12 months had similar ΔCobb (mean 4.8° and 7.8°, respectively, P = 0.3), smaller than the 0-6 or 6-12 groups (15.8° and 13.8°, respectively). CONCLUSION Tether breakage leads to a consistent loss of correction when occurring within the first 12 months, while it has limited clinical relevance when occurring later on.
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Affiliation(s)
- A Baroncini
- Department of Orthopaedic Surgery, RWTH Aachen University Clinic, Pauwelsstrasse 30, 52074, Aachen, Germany.
- Department of Spine Surgery, Eifelklinik St. Brigida, Simmerath, Germany.
| | - F Migliorini
- Department of Orthopaedic Surgery, RWTH Aachen University Clinic, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - J Eschweiler
- Department of Orthopaedic Surgery, RWTH Aachen University Clinic, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - F Hildebrand
- Department of Orthopaedic Surgery, RWTH Aachen University Clinic, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - P Trobisch
- Department of Spine Surgery, Eifelklinik St. Brigida, Simmerath, Germany
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Jackson TJ, Milbrandt TA, Mathew SE, Heilman JA, Larson AN. Intervertebral Disk Health Following Vertebral Body Tethering for Adolescent Idiopathic Scoliosis: A Preliminary Study. J Pediatr Orthop 2022; 42:347-353. [PMID: 35543608 DOI: 10.1097/bpo.0000000000002172] [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: 02/07/2023]
Abstract
BACKGROUND Interest in vertebral body tethering (VBT) as an alternative to posterior spinal fusion for adolescent idiopathic scoliosis (AIS) continues to grow. The purpose of this study was to prospectively assess intervertebral disk health on magnetic resonance imaging (MRI) at 1 year following VBT in AIS patients. METHODS AIS patients were enrolled in a prospective surgeon-sponsored Food and Drug Administration (FDA) Investigational Device Exemption (IDE) Study and underwent MRI at 1-year following VBT. All spanned disks and the untethered disks immediately adjacent to the upper instrumented vertebra and lowest instrumented vertebra levels were evaluated according to Pfirrmann grading criteria. Associations between patient factors and preoperative and postoperative disk health and patient-reported outcomes were evaluated. RESULTS Twenty-two patients were enrolled with a postoperative MRI (25 curves, 188 disks), and 7 patients (7 curves) had both preoperative and postoperative MRIs (67 disks). The mean age was 12.7 years. Most were Risser 0 (65%) and either Sanders Skeletal Maturity Score 3 (35%) or 4 (53%). In the 7 patients with preoperative and postoperative MRI, the mean Pfirrmann grade of the disks spanned by the tether was 1.88 preoperatively and 2.31 postoperatively ( P =0.0075). No statistically significant differences in preoperative versus postoperative Pfirrmann grade were identified in the disks adjacent to the upper or lower instrumented vertebrae. No association was found between patient-reported outcomes and Pfirrmann grade. CONCLUSION At 1 year postoperatively, increased degenerative changes in disks spanned by the tether was identifiable on MRI without evidence of adjacent segment disk disease. These changes were not associated with patient-reported outcomes. LEVEL OF EVIDENCE Level III.
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Baroncini A, Trobisch PD, Birkenmaier C, Da Paz S, Migliorini F. Radiographic Results after Vertebral Body Tethering. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2022; 160:387-392. [PMID: 33873229 DOI: 10.1055/a-1387-8334] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Vertebral body tethering (VBT), otherwise known as fusion-less anterior scoliosis correction (ASC), is a new and increasingly interesting therapeutic option for selected scoliosis patients. The available data on this surgical technique are still limited and guidelines on patient selection or surgical timing are not available. The aim of this study was to conduct a systematic review of the available literature on VBT. The analysis was performed in accordance with the PRISMA Statement. Nine studies with data from 175 patients were available. On average, 7.3 vertebrae were instrumented. Surgical time was 230 min and the estimated blood loss 153 ml. The mean correction on the coronal plane was 52%, and there was no significant change in sagittal parameters. The revision rate was 18.9%. The methodological quality assessment with the Coleman score gave unsatisfactory results, so that available data are not sufficient to propose general indications or guidelines to perform VBT.
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Affiliation(s)
- Alice Baroncini
- Klinik für Orthopädie, Uniklinik RWTH Aachen, Germany.,Wirbelsäulenchirurgie, Artemed SE, Simmerath, Germany
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Anterior vertebral body tethering for idiopathic scoliosis: how well does the tether hold up? Spine Deform 2022; 10:799-809. [PMID: 35258844 DOI: 10.1007/s43390-022-00490-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 02/19/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Durability of outcomes following vertebral body tethering (VBT) is a concern and may be impacted by tether breakage (TB), which has been unstudied in a large cohort. We characterized TB rates and their impact on clinical outcomes in the largest single-surgeon series to date. METHODS Inclusion criteria were VBT patients with AIS, major Cobb angle ≤ 75°, and minimum 2-year follow-up (FU). TBs were identified on 1- and 2-year FU X-rays. TB rates between single-cord and double-cord tethers were evaluated using two-proportion z test. Curve correction rates and SRS-22 scores between patients with and without TB at 2 years were evaluated using Mann-Whitney U test. RESULTS 69 patients were included. By 2-year FU, 18 (27%) had experienced TB. TB primarily occurred in major (70%) versus minor curves and thoracolumbar tethers (75%) versus thoracic. TB rates between thoracolumbar single (32%) and double-cord tethers (30%) were not significantly different (p = 0.88). Mean major curve correction at 2-year FU was lower (p = 0.02) in patients with major curve TB (48° to 24°, 50%) versus those without (53°-21°, 60%). 2 patients (3%) required reoperation, 1 due to foraminal encroachment from a screw tip and 1 for curve progression with TB. CONCLUSION TB rate was 27% at 2 years following VBT. Broken major curve tethers are associated with minor loss of correction that may not be clinically significant. TB rates are higher for thoracolumbar curvatures and double cords may not be protective against TB. Further study of long-term TB rates is imperative. LEVEL OF EVIDENCE IV.
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Shaw KA, Welborn MC, Matsumoto H, Parent S, Sachwani N, El-Hawary R, Skaggs D, Newton PO, Blakemore L, Vitale M, Samdani A, Murphy JS. To tether or fuse? Significant equipoise remains in treatment recommendations for idiopathic scoliosis. Spine Deform 2022; 10:763-773. [PMID: 35316524 DOI: 10.1007/s43390-022-00497-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 03/05/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE Vertebral body tethering (VBT) continues to grow in interest from both a patient and surgeon perspective for the treatment of scoliosis. However, the data are limited when it comes to surgeon selection of both procedure type and instrumented levels. This study sought to assess surgeon variability in treatment recommendation and level selection for VBT versus posterior spinal fusion (PSF) for the management of scoliosis. METHODS Surgeon members of the Pediatric Spine Study Group and Harms Study Group were queried for treatment recommendations and proposed upper instrumented vertebra (UIV) and lower instrumented vertebra (LIV) selection for PSF and VBT based on 17 detailed clinical vignettes. Responses were subdivided in each clinical vignette according to surgeon experience and treatment recommendations with assessment of intra-rater reliability. Binomial distribution tests were used to establish equipoise, selecting p < 0.10 to indicate the presence of a treatment choice with consensus set > 70% agreement. For treatment choice, responses were assessed first for consensus on the decision to proceed with PSF or VBT. RESULTS Thirty-five surgeons with varied experience completed the survey with 26 surgeons (74%) completing the second follow-up survey. Overall, VBT was the recommended treatment by 47% of surgeons, ranging by clinical vignette. Consensus in treatment recommendation was present for 6 clinical vignettes including 3 for VBT and 3 for PSF, with equipoise present for the remaining 11. Of the 17 vignettes, 12 demonstrated moderate intra-observer reliability including the 3 consensus vignettes for VBT. Sanders stage ≤ 3 and smaller curve magnitude were related with VBT recommendation but neither age nor curve flexibility significantly influenced the decision to recommend VBT. Surgeons with high VBT volume, ≥ 11 VBT cases/year, were more likely to recommend VBT than those with low volumes (0-10 cases per year (p < 0.0001)). High VBT volume surgeons demonstrated consensus in VBT recommendation for Lenke 5/6 curves (75% mean recommendation). High VBT volume surgeons had a significantly higher VBT recommendation rate for Lenke 1A, 2A curves (71.8% vs 48.0%, p = 0.012), and Lenke 3 curves (62% vs 26.9%, p = 0.023). Equipoise was present for all vignettes in low volume surgeons. In addition, high VBT volume surgeons trended toward including more instrumented levels than low VBT volume surgeons (7.17 vs 6.69 levels). CONCLUSION Significant equipoise is present among pediatric spine surgeons for treatment recommendations regarding VBT and PSF. Surgeon-, patient-, and curve-specific variables were identified to influence treatment recommendations, including surgeon experience, curve subtype, deformity magnitude, and skeletal maturity. This study highlights the need for continued research in identifying the optimal indications for VBT and PSF in the treatment of pediatric spinal deformity.
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Affiliation(s)
- K Aaron Shaw
- Department of Orthopaedic Surgery, Dwight D. Eisenhower Army Medical Center, Fort Gordon, GA, USA
| | - Michelle C Welborn
- Department of Spine Surgery, Shriners Hospital for Children Portland, Portland, OR, USA
| | - Hiroko Matsumoto
- Department of Pediatric Orthopaedic Surgery, New York-Presbyterian Morgan Stanley Children's Hospital of New York, New York, NY, USA
| | - Stefan Parent
- Department of Orthopaedic Surgery, Hospital Ste-Justine (HSJ), Montreal, QC, Canada
| | - Numera Sachwani
- Department of Pediatric Orthopaedic Surgery, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Ron El-Hawary
- Department of Orthopaedic Surgery, IWK Health Centre, Halifax, NS, Canada
| | - David Skaggs
- Department of Orthopaedics, Cedars-Sinai, Los Angeles, CA, USA
| | - Peter O Newton
- Department of Pediatric Orthopaedic Surgery, Rady Children's Hospital, San Diego, CA, USA
| | - Laurel Blakemore
- Department of Pediatric Orthopaedic Surgery, Pediatric Specialists of Virginia, Merrifield, VA, USA
| | - Michael Vitale
- Department of Pediatric Orthopaedic Surgery, New York-Presbyterian Morgan Stanley Children's Hospital of New York, New York, NY, USA
| | - Amer Samdani
- Department of Neurosurgery, Shriners Hospital-Philadelphia, Philadelphia, PA, USA
| | - Joshua S Murphy
- Department of Pediatric Orthopaedic Surgery, Children's Healthcare of Atlanta, Atlanta, GA, USA.
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Pulmonary Complications after Vertebral Body Tethering: Incidence, Treatment, Outcomes and Risk Factor Analysis. J Clin Med 2022; 11:jcm11133778. [PMID: 35807062 PMCID: PMC9267721 DOI: 10.3390/jcm11133778] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 05/09/2022] [Accepted: 06/28/2022] [Indexed: 02/06/2023] Open
Abstract
Introduction: Vertebral body tethering (VBT) is gaining popularity for the management of selected AIS patients. The most frequent non-mechanical complications after VBT are pulmonary complications, with a reported incidence of up to 8% for recurrent pleural effusion. However, only trace data have been published on this topic. We aimed to analyze the incidence, timing, treatment, outcomes and risk factors of pulmonary complications after VBT. Materials and Methods: All patients who underwent VBT between September 2018 and September 2022 were retrospectively reviewed. The rate of pulmonary complications was analyzed and the symptoms, timing of onset, treatment and outcomes were recorded. An analysis of demographic, radiographic, surgical and pulmonary function data was conducted to explore possible risk factors for pulmonary complications. Results: Data from 140 patients were available: 14 experienced a pulmonary complication 1 day to 6 weeks after VBT, with 9 presenting a recurrent pleural effusion. A total of 13 patients required invasive treatment. All recovered without sequelae. The risk factor analysis did not result in any significant observations. However, 11/14 patients had had a diaphragm split. Conclusion: Pulmonary complications were observed in 10% of patients. The timing, symptoms and required treatment were heterogeneous. Pleural effusion seems to be more common after diaphragm crossing, but evidence is not yet conclusive.
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Meyers J, Eaker L, Zhang J, di Pauli von Treuheim T, Lonner B. Vertebral Body Tethering in 49 Adolescent Patients after Peak Height Velocity for the Treatment of Idiopathic Scoliosis: 2-5 Year Follow-Up. J Clin Med 2022; 11:jcm11113161. [PMID: 35683548 PMCID: PMC9181769 DOI: 10.3390/jcm11113161] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 05/27/2022] [Accepted: 05/31/2022] [Indexed: 02/05/2023] Open
Abstract
Vertebral Body Tethering (VBT) is a non-fusion surgical treatment for Adolescent Idiopathic Scoliosis (AIS) that elicits correction via growth modulation in skeletally immature patients. VBT after peak height velocity is controversial and is the subject of this study. A retrospective review of Risser 3−5 AIS patients treated with VBT, and min. 2-year FU was performed. Pre to post-op changes in clinical outcomes were compared using Student’s t-test or the Mann-Whitney test. A total of 49 patients met criteria, age 15.0 ± 1.9 years, FU 32.5 ± 9.1 months. For thoracic (T) major curvatures, T curvature improved from 51.1 ± 6.9° to 27.2° ± 8.1° (p < 0.01) and TL from 37.2° ± 10.7° to 19.2° ± 6.8° (p < 0.01). For thoracolumbar (TL) major curvatures, T improved from 37.2° ± 10.7° to 18.8° ± 9.4° (p < 0.01) and TL from 49.0° ± 6.4° to 20.1° ± 8.5° (p < 0.01). Major curve inclinometer measurements and SRS-22 domains, except activity, improved significantly (p ≤ 0.05). At the latest FU, one (2%) patient required fusion of the T curve and revision of the TL tether due to curve progression in the previously uninstrumented T curve and tether breakage (TB) in the TL. Twenty (41%) patients experienced TB. VBT in AIS patients with limited remaining skeletal growth resulted in satisfactory clinical outcomes at the latest FU.
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Vertebral Body Tethering: Indications, Surgical Technique, and a Systematic Review of Published Results. J Clin Med 2022; 11:jcm11092576. [PMID: 35566702 PMCID: PMC9099651 DOI: 10.3390/jcm11092576] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/28/2022] [Accepted: 04/30/2022] [Indexed: 02/01/2023] Open
Abstract
Vertebral body tethering (VBT) represents a new surgical technique to correct idiopathic scoliosis using an anterior approach, spinal instrumentation with vertebral body screws, and a cable compressing the convexity of the curve. According to the Hueter-Volkmann principle, compression reduces and distraction increases growth on the growth plates. VBT was designed to modulate spinal growth of vertebral bodies and hence, the term ‘growth modulation’ has also been used. This review describes the indications and surgical technique of VBT. Further, a systematic review of published studies was conducted to critically evaluate the results and complications of this technique. In a total of 23 included studies on 843 patients, the preoperative main thoracic curve corrected from 49 to 23 degrees in a minimum 2 year follow-up. The complication rate of VBT was 18%. The results showed that 15% of VBT patients required reoperations for pulmonary or tether-related issues (10%) and less than 5% required conversion to spinal fusion. While the reported median-term results of VBT appear promising, long-term results of this technique are currently lacking.
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Larson AN. Innovation With Ethics in Pediatric Orthopaedics. J Pediatr Orthop 2022; 42:S39-S43. [PMID: 35405701 DOI: 10.1097/bpo.0000000000002099] [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: 02/07/2023]
Abstract
Surgeons should thoughtfully consider whether to introduce a new procedure into their practice. Considerations include the severity of the condition, potential risk of harm, treatment alternatives, patient population, ability to appropriately consent patient/families, and available clinical and institutional resources as well as published evidence and regulatory status. Whenever possible, new procedures should be standardized, studied, and reported upon so that the greater community can learn from experience and refine the indications to minimize risks for future patients. Small scale innovation can readily be introduced into practice. Surgeons should always strive to systemically study new procedures so as to be able to assess benefits and effects.
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Affiliation(s)
- A Noelle Larson
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
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Anterior vertebral tethering: imaging of tether rupture. Pediatr Radiol 2022; 52:1187-1190. [PMID: 34981178 DOI: 10.1007/s00247-021-05259-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 10/28/2021] [Accepted: 12/05/2021] [Indexed: 10/19/2022]
Abstract
Anterior vertebral tethering, also known as vertebral body tethering, is an evolving, minimally invasive surgical technique to correct spinal curvature in skeletally immature patients. The procedure involves placement of vertebral screws that are connected by an anterolateral tether. This procedure may be complicated by rupture of the non-radiopaque tether. The radiologist should be aware of imaging findings that suggest this complication on follow-up spine radiographs.
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Newton PO, Takahashi Y, Yang Y, Yaszay B, Bartley CE, Bastrom TP, Munar C. Anterior vertebral body tethering for thoracic idiopathic scoliosis leads to asymmetric growth of the periapical vertebrae. Spine Deform 2022; 10:553-561. [PMID: 34982419 DOI: 10.1007/s43390-021-00464-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 12/18/2021] [Indexed: 02/06/2023]
Abstract
PURPOSE To evaluate 3D growth of the periapical vertebrae and discs in the 2 years after anterior vertebral body tether (AVBT) placement in patients with idiopathic scoliosis (IS). METHODS Patients with IS treated with AVBT, ≥ 2 years of follow-up, and 3D spine reconstructions created from simultaneous, biplanar radiographs were studied. Patients were divided into two groups: progressive scoliosis correction (PC) or no/limited correction (NPC). The average of the 3 apical vertebral and disc heights and angular measures were made. The rate of change for each measure (mm/mo, °/mo) from first erect to 2-year follow-up was compared between groups. RESULTS Fourteen (Risser 0, Sanders 2-3) patients aged 11.4 ± 1.4 years with right thoracic scoliosis of 52 ± 9° were included. There were 7 patients per group (6F, 1M). Mean follow-up was 3.6 ± 1.1 (range 2-5) years. PC left-sided vertebral height increased 0.13 mm/months compared to 0.05 mm/mo in the NPC group (p = 0.001). Right (tethered side) vertebral growth was not different (PC: 0.07 mm/mo, NPC: 0.05 mm/mo, p = 0.2). Coronal vertebral wedging occurred at - 0.11°/mo compared to - 0.02°/mo for the PC and NPC groups, respectively (p = 0.004). Coronal disc angulation change was - 0.12°/mo in the PC group and - 0.04°/mo in the NPC group (p = 0.03), and was associated with loss of right disc height (PC: - 0.06 mm/mo) with little effect on the left disc height (PC: -0.01 mm/mo). CONCLUSIONS AVBT in immature patients with thoracic scoliosis can asymmetrically modulate growth of the periapical vertebrae and discs. Progressive reduction in scoliosis after AVBT was associated with greater concave growth rates in the vertebrae and loss of disc height on the convex side.
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Affiliation(s)
- Peter O Newton
- Division of Orthopedics and Scoliosis, Rady Children's Hospital, 3020 Children's Way, MC 5062, San Diego, CA, 92123, USA.
- Department of Orthopaedics, University of California, San Diego, CA, USA.
| | - Yohei Takahashi
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yi Yang
- Department of Orthopaedics, The Royal Children's Hospital, Melbourne, Australia
| | - Burt Yaszay
- Department of Orthoedics, University of Washington, Seattle, USA
| | - Carrie E Bartley
- Division of Orthopedics and Scoliosis, Rady Children's Hospital, 3020 Children's Way, MC 5062, San Diego, CA, 92123, USA
| | - Tracey P Bastrom
- Division of Orthopedics and Scoliosis, Rady Children's Hospital, 3020 Children's Way, MC 5062, San Diego, CA, 92123, USA
| | - Carlo Munar
- Division of Orthopedics and Scoliosis, Rady Children's Hospital, 3020 Children's Way, MC 5062, San Diego, CA, 92123, USA
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Trobisch P, Baroncini A, Berrer A, Da Paz S. Difference between radiographically suspected and intraoperatively confirmed tether breakages after vertebral body tethering for idiopathic scoliosis. 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 2022; 31:1045-1050. [PMID: 34999968 DOI: 10.1007/s00586-021-07107-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 12/08/2021] [Accepted: 12/29/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Vertebral body tethering (VBT) has shown promising results but also a high tether breakage rate, which has been reported in up to 48% of patients. Tether breakages can lead to loss of correction, and the most used definition for tether breakage is a loss of segmental correction of > 5°. However, there may also be some breakages that do not have a negative influence on curve correction. Analyzing the real breakage rate was the aim of this study. METHODS All patients who underwent anterior revision surgery after VBT were included in this retrospective study. Real (intraoperatively confirmed) tether breakages were compared to preoperatively suspected tether breakages. The definition for a suspected tether breakage was an angular change of more than 5° between an early and the latest radiograph. RESULTS Ten patients who received 11 revision surgeries with a total of 15 revised curves were analyzed. Of the 80 analyzed segments, 36 were found to have a breakage. Of these 36 segments, 20 were suspected to be broken preoperatively. Sixteen breakages were not identified on preoperative radiographs (44%). One suspected broken tether was intraoperatively found to be intact. CONCLUSION By using the > 5° rule, only 56% of the tether breakages could be diagnosed. On the other hand, many tether breakages will not result in a loss of correction.
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Mackey C, Hanstein R, Lo Y, Vaughan M, St Hilaire T, Luhmann SJ, Vitale MG, Glotzbecker MP, Samdani A, Parent S, Gomez JA. Magnetically Controlled Growing Rods (MCGR) Versus Single Posterior Spinal Fusion (PSF) Versus Vertebral Body Tether (VBT) in Older Early Onset Scoliosis (EOS) Patients: How Do Early Outcomes Compare? Spine (Phila Pa 1976) 2022; 47:295-302. [PMID: 34610613 DOI: 10.1097/brs.0000000000004245] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective review of prospective data from multicenter registry. OBJECTIVE Compare outcomes of posterior spinal fusion (PSF) versus magnetically controlled growing rods (MCGR) versus vertebral body tethers (VBT) in 8- to 11-year-old idiopathic early onset scoliosis (EOS) patients. SUMMARY OF BACKGROUND DATA In EOS, it is unclear at what age the benefit of growth-sparing strategies outweighs increased risks of surgical complications, compared with PSF. METHODS One hundred thirty idiopathic EOS patients, 81% female, aged 8-11 at index surgery (mean 10.5 yrs), underwent PSF, MCGR, or VBT. Scoliosis curve, kyphosis, thoracic and spinal height, complications, and Quality of Life (QoL) were assessed preoperatively and at most recent follow-up (prior to final fusion for VBT/MCGR). RESULTS Of 130 patients, 28.5% received VBT, 39.2% MCGR, and 32.3% PSF. The VBT cohort included more females (P < 0.0005), was older (P < 0.0005), more skeletally mature (P < 0.0005), and had smaller major curves (P < 0.0005). At follow-up, scoliosis curve corrected 41.1 ± 22.4% in VBT, 52.2 ± 19.9% in PSF, and 27.4 ± 23.9% in MCGR (P < 0.0005), however, not all VBT/MCGR patients finished treatment. Fifteen complications occurred in 10 VBTs, 6 requiring unplanned surgeries; 45 complications occurred in 31 MCGRs, 11 requiring unplanned surgeries, and 9 complications occurred in 6 PSFs, 3 requiring unplanned revisions. Cox proportional hazards regression adjusted for age, gender, and preoperative scoliosis curve revealed that MCGR (hazard ratio [HR] = 21.0, 95% C.I. 4.8-92.5; P < 0.001) and VBT (HR = 7.1, 95% C.I. 1.4-36.4; P = 0.019) patients were at increased hazard of requiring revision, but only MCGR patients (HR = 5.6, 95% C.I. 1.1-28.4; P = 0.038) were at an increased hazard for unplanned revisions compared with PSF. Thoracic and spinal height increased in all groups. QoL improved in VBT and PSF patients, but not in MCGR patients. CONCLUSION In older idiopathic EOS patients, MCGR, PSF, and VBT controlled curves effectively and increased spinal height. However, VBT and PSF have a lower hazard for an unplanned revision and improved QoL.Level of Evidence: 3.
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Affiliation(s)
- Catherine Mackey
- Department of Orthopaedic Surgery, Montefiore Medical Center, Bronx, NY
| | - Regina Hanstein
- Department of Orthopaedic Surgery, Montefiore Medical Center, Bronx, NY
| | - Yungtai Lo
- Department of Epidemiology and Population Health, Montefiore Medical Center, Bronx, NY
| | | | | | | | - Michael G Vitale
- Columbia University Medical Center/Morgan Stanley Children's Hospital, New York, NY
| | | | - Amer Samdani
- Shriners Hospital for Children, Philadelphia, PA
| | | | - Jaime A Gomez
- Department of Orthopaedic Surgery, Montefiore Medical Center, Bronx, NY
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Bernard J, Bishop T, Herzog J, Haleem S, Lupu C, Ajayi B, Lui DF. Dual modality of vertebral body tethering : anterior scoliosis correction versus growth modulation with mean follow-up of five years. Bone Jt Open 2022; 3:123-129. [PMID: 35119295 PMCID: PMC8886322 DOI: 10.1302/2633-1462.32.bjo-2021-0120.r1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Aims Vertebral body tethering (VBT) is a non-fusion technique to correct scoliosis. It allows correction of scoliosis through growth modulation (GM) by tethering the convex side to allow concave unrestricted growth similar to the hemiepiphysiodesis concept. The other modality is anterior scoliosis correction (ASC) where the tether is able to perform most of the correction immediately where limited growth is expected. Methods We conducted a retrospective analysis of clinical and radiological data of 20 patients aged between 9 and 17 years old, (with a 19 female: 1 male ratio) between January 2014 to December 2016 with a mean five-year follow-up (4 to 7). Results There were ten patients in each group with a total of 23 curves operated on. VBT-GM mean age was 12.5 years (9 to 14) with a mean Risser classification of 0.63 (0 to 2) and VBT-ASC was 14.9 years (13 to 17) with a mean Risser classification of 3.66 (3 to 5). Mean preoperative VBT-GM Cobb was 47.4° (40° to 58°) with a Fulcrum unbend of 17.4 (1° to 41°), compared to VBT-ASC 56.5° (40° to 79°) with 30.6 (2° to 69°)unbend. Postoperative VBT-GM was 20.3° and VBT-ASC Cobb angle was 11.2°. The early postoperative correction rate was 54.3% versus 81% whereas Fulcrum Bending Correction Index (FBCI) was 93.1% vs 146.6%. The last Cobb angle on radiograph at mean five years’ follow-up was 19.4° (VBT-GM) and 16.5° (VBT-ASC). Patients with open triradiate cartilage (TRC) had three over-corrections. Overall, 5% of patients required fusion. This one patient alone had a over-correction, a second-stage tether release, and final conversion to fusion. Conclusion We show a high success rate (95%) in helping children avoid fusion at five years post-surgery. VBT is a safe technique for correction of scoliosis in the skeletally immature patient. This is the first report at five years that shows two methods of VBT can be employed depending on the skeletal maturity of the patient: GM and ASC. Cite this article: Bone Jt Open 2022;3(2):123–129.
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Affiliation(s)
- Jason Bernard
- Complex Spinal Division, Neurosciences Atkinson Morley Wing, St. George's Hospital, London, UK
| | - Timothy Bishop
- Complex Spinal Division, Neurosciences Atkinson Morley Wing, St. George's Hospital, London, UK
| | - Jan Herzog
- Complex Spinal Division, Neurosciences Atkinson Morley Wing, St. George's Hospital, London, UK
| | - Shahnawaz Haleem
- Complex Spinal Division, Neurosciences Atkinson Morley Wing, St. George's Hospital, London, UK
| | - Cristina Lupu
- Complex Spinal Division, Neurosciences Atkinson Morley Wing, St. George's Hospital, London, UK
| | - Bisola Ajayi
- Complex Spinal Division, Neurosciences Atkinson Morley Wing, St. George's Hospital, London, UK
| | - Darren F Lui
- Complex Spinal Division, Neurosciences Atkinson Morley Wing, St. George's Hospital, London, UK
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Inter- and intra-rater reliability and accuracy of Sanders Skeletal Maturity Staging System when used by surgeons performing vertebral body tethering. Spine Deform 2022; 10:97-106. [PMID: 34292528 DOI: 10.1007/s43390-021-00386-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 07/03/2021] [Indexed: 12/24/2022]
Abstract
PURPOSE Pediatric orthopedic surgeons must accurately assess the skeletal stage of adolescent idiopathic scoliosis (AIS) patients for selection and timing of optimal treatment. Successful treatment using vertebral growth modulation is highly dependent on skeletal growth remaining. We sought to evaluate the current-state use of the Sanders Skeletal Maturity System (SSMS) in regard to precision and accuracy. We hypothesized that pediatric orthopedic surgeons currently use SSMS with moderate precision and accuracy. METHODS Eight practicing pediatric orthopedic surgeons who perform vertebral body tethering surgery without specific training in SSMS were asked to assign the SSMS stage for 34 de-identified hand radiographs from AIS patients. Precision was evaluated as inter-rater reliability, using both Krippendorff's α and Weighted Cohen's kappa statistics, and as intra-rater reliability, using only Weighted Cohen's kappa statistics. Surgeon accuracy was evaluated using Weighted Cohen's kappa statistics with comparison of surveyed surgeons' responses to the gold standard rating. RESULTS Inter-rater reliability across the surveyed surgeons indicated moderate to substantial agreement using both statistical methods (α = 0.766, κ = 0.627) with the majority of discord occurring when assigning SSMS stages 2 through 4. The surveyed surgeons displayed substantial accuracy when compared to the gold standard (κ = 0.627) with the majority of inaccuracy involving the identification of stage 3B. When re-surveyed, the surgeons showed substantial intra-rater reliability (κ = 0.71) with increased inconsistencies when deciding between SSMS stage 3A and stage 3B. CONCLUSION The current-state use of SSMS across pediatric orthopedic surgeons for evaluation of AIS patients displays adequate but imperfect precision and accuracy with difficulties delineating SSMS stages 2 through 4, which correlate with adolescent growth periods germane to scoliosis growth modulation surgery. Centralized assessment of hand-bone age may help ensure standardized reporting for non-fusion scoliosis research.
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The effects of vertebral body tethering on sagittal parameters: evaluations from a 2-years follow-up. 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; 31:1060-1066. [PMID: 34910244 DOI: 10.1007/s00586-021-07076-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 10/14/2021] [Accepted: 11/24/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION While the effects of VBT on coronal parameters have been investigated in various studies, this has not yet been the case for sagittal parameters. This is of particular relevance considering that VBT does not allow direct correction of the sagittal profile. Thus, we investigated the effects of VBT on sagittal parameters in patients with adolescent idiopathic scoliosis. MATERIALS AND METHODS Retrospective, 2-Center study. Patients who underwent VBT and presented a 2-years follow-up were included. The differences in sagittal parameters were evaluated, along with modifications of sagittal profile following Abelin-Genevois' classification. RESULTS Data from 86 patients were obtained. Mean Cobb angle was 52.4 ± 13.9° at thoracic level and 47.6 ± 14.3° at lumbar level before surgery, and 28.5 ± 13.6 and 26.6 ± 12.7° at the 2-year follow-up, respectively. Mean thoracic kyphosis increased from 28.3 ± 13.8 to 33 ± 13°, the lumbar lordosis (LL) was unvaried (from 47.5 ± 13.1 to 48.4 ± 13.5°), PT decreased from 9.4 ± 8.5 to 7.4 ± 6.1°, the sagittal vertical axis SVA decreased from 4.5 ± 31.4 to - 3.6 ± 27.9 mm. No kyphotic effect on LL in patients who underwent lumbar instrumentation was observed. Before surgery, 39 patients had a type 1 sagittal profile, 18 were type 2a, 14 type 2b and 15 type 3. Postoperatively, 54 were type 1, 8 were 2a, 13 were 2b and 11 were type 3. CONCLUSIONS VBT positively influences sagittal parameters and does not have a kyphotic effect on LL.
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