Results of growth-friendly management of early-onset scoliosis in children with and without skeletal dysplasias

Outcome of distraction-based growing rods at graduation: a comparison of traditional growing rods and magnetically controlled growing rods

INTRODUCTION

Distraction-based growing rods have been considered as an alternative surgical option for the operative treatment of EOS. TGR has been challenged by MCGR, which is reported to have the advantage of non-invasive lengthening with fewer planned returns to theatre. This study explores the radiographic outcomes, Unplanned Returns to the Operating Room (UPROR) and complication profile of both the procedures at the end of the planned growing rod treatment with either TGR or MCGR.

METHODS

We included all the EOS cases from the PSSG database that underwent either TGR or MCGR with spine-based proximal anchors, followed up to the time of graduation. Any crossover or hybrid procedures were excluded. 549 patients (409 TGR and 140 MCGR) were eligible for review. We measured the coronal curve magnitude, Kyphosis, T1-T12, T1-S1 and L1-S1 lengths at 4 time points (before and after the index surgery and before and after the definitive surgery).

RESULTS

The TGR group were slightly younger at the time of the index procedure (7 years for TGR vs. 8.5 years for MCGR, p < 0.001). We noted an improvement in all radiological parameters after the growing rod implantation. The spinal lengths increased through the lengthening period, while the coronal curve magnitude and the kyphosis increased. The kyphosis normalized following the final fusion, the coronal curve magnitude reduced further with a further increase in spinal lengths. The final follow-up from the time of the index implantation to the definitive surgery was 5.1 years (IQR 3.8) in TGR and 3.5 years (IQR 1.65) in the MCGR groups. The total number of complications was fewer in the MCGR group. The overall risk of UPROR was lower in the MCGR group and implant breakage was less in the MCGR group by 4.7 times.

CONCLUSIONS

This study confirms the equivalence of both the distraction-based growing rods systems from the radiological stand-point, during the lengthening phase and at the time of the definitive surgery. The TGR was more kyphogenic during the lengthening period. The complications and UPROR were fewer in the MCGR groups.

Outcomes after completing growth-friendly surgical treatment for early-onset scoliosis in patients with skeletal dysplasia

Aims

The aim of this study was to compare outcomes after growth-friendly treatment for early-onset scoliosis (EOS) between patients with skeletal dysplasias versus those with other syndromes.

Methods

We retrospectively identified 20 patients with skeletal dysplasias and 292 with other syndromes (control group) who had completed surgical growth-friendly EOS treatment between 1 January 2000 and 31 December 2018. We compared radiological parameters, complications, and health-related quality of life (HRQoL) at mean follow-up of 8.6 years (SD 3.3) in the dysplasia group and 6.6 years (SD 2.6) in the control group.

Results

Mean major curve correction per patient did not differ significantly between the dysplasia group (43%) and the control group (28%; p = 0.087). Mean annual spinal height increase was less in the dysplasia group (9.3 mm (SD 5.1) than in the control group (16 mm (SD 9.2); p < 0.001). Mean annual spinal growth adjusted to patient preoperative standing height during the distraction period was 11% in the dysplasia group and 14% in the control group (p = 0.070). The complication rate was 1.6 times higher (95% confidence interval (CI) 1.3 to 2.0) in the dysplasia group. The following complications were more frequent in the dysplasia group: neurological injury (rate ratio (RR) 5.1 (95% CI 2.3 to 11)), deep surgical site infection (RR 2.2 (95% CI 1.2 to 4.1)), implant-related complications (RR 2.0 (95% CI 1.5 to 2.7)), and unplanned revision (RR 1.8 (95% CI 1.3 to 2.5)). Final fusion did not provide additional spinal height compared with watchful waiting (p = 0.054). There were no significant differences in HRQoL scores between the groups.

Conclusion

After growth-friendly EOS treatment, patients with skeletal dysplasias experienced a higher incidence of complications compared to those with other syndromes. Surgical growth-friendly treatment for skeletal dysplasia-associated EOS should be reserved for patients with severe, progressive deformities that are refractory to nonoperative treatment.

Paediatric syndromic scoliosis: proceedings of the half-day course at the 57th annual meeting of the Scoliosis Research Society

There are some syndromes that present with unique manifestations pertaining to the spinal column. A good working understanding of these common syndromes is useful for the spinal deformity surgeons and related healthcare providers. This review attempts to encompass these unique features and discuss them in three broad groups: hypermobility syndromes, muscle pathology-related syndromes, and syndromes related to poor bone quality. This review explores the features of these syndromes underpinning the aspects of surgical and medical management. This review represents the proceedings of the Paediatric Half-Day Course at the 57th Annual Meeting of the Scoliosis Research Society.

Evaluating the Use of PROMs in Paediatric Orthopaedic Registries

Patient-reported outcome measures (PROMs) provide structured information on the patient's health experience and facilitate shared clinical decision-making. Registries that collect PROMs generate essential information about the clinical course and efficacy of interventions. Whilst PROMs are increasingly being used in adult orthopaedic registries, their use in paediatric orthopaedic registries is not well known. The purpose of this systematic review was to identify the frequency and scope of registries that collect PROMs in paediatric orthopaedic patient groups. In July 2023, six databases were systematically searched to identify studies that collected PROMs using a registry amongst patients aged under 18 years with orthopaedic diagnoses. Of 3190 identified articles, 128 unique registries were identified. Three were exclusively paediatric, 27 were majority paediatric, and the remainder included a minority of paediatric patients. One hundred and twenty-eight registries collected 72 different PROMs, and 58% of these PROMs were not validated for a paediatric population. The largest group of orthopaedic registries collected PROMs on knee ligament injuries (21%). There are few reported dedicated orthopaedic registries collecting PROMs in paediatric populations. The majority of PROMs collected amongst paediatric populations by orthopaedic registries are not validated for patients under the age of 18 years. The use of non-validated PROMs by registries greatly impedes their utility and impact. Dedicated orthopaedic registries collecting paediatric-validated PROMs are needed to increase health knowledge, improve decision-making between patients and healthcare providers, and optimise orthopaedic management.

Matched Comparison of Magnetically Controlled Growing Rods with Traditional Growing Rods in Severe Early-Onset Scoliosis of ≥90°: An Interim Report on Outcomes 2 Years After Treatment

BACKGROUND

Severe early-onset scoliosis (EOS) is managed surgically but represents a challenge due to limited implant fixation points, large curve size, and fragile patients with comorbidities. Magnetically controlled growing rods (MCGRs) have the advantage of avoiding surgical intervention for routine lengthening, but their ability to address severe EOS has not been studied, to our knowledge.

METHODS

A retrospective review of a prospectively collected international database identified 44 children with severe (≥90°) EOS treated with MCGRs who met our study criteria. Etiology, age, and sex-matched patients treated with traditional growing rods (TGRs) were identified from the same database. Patients were evaluated at a 2-year follow-up. No patients with vertically expandable prosthetic titanium ribs (VEPTRs) were included. The health-related quality of life was evaluated with the 24-Item Early Onset Scoliosis Questionnaire (EOSQ-24).

RESULTS

The mean preoperative major coronal curve was 104° in the MCGR group and 104° in the TGR group. At the 2-year follow-up, the mean major coronal curves were 52° and 66° (p = 0.001), respectively. The mean T1-T12 heights were 155 mm and 152 mm preoperatively and 202 mm and 192 mm at the 2-year follow-up (p = 0.088). According to Kaplan-Meier analysis, the 2-year unplanned-revision-free survival was 91% in the MCGR group and 71% in the TGR group (p < 0.005). The 2-year score in the EOSQ-24 pulmonary function domain was better in the MCGR group. There were no other significant differences in the EOSQ-24 scores between the groups.

CONCLUSIONS

MCGRs for severe EOS provided significantly better major curve correction with significantly fewer unplanned revisions than TGRs at a 2-year follow-up.

LEVEL OF EVIDENCE

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

Developments, Focuses, and Trends in Early-Onset Scoliosis From 2005 to 2020: A Systematic Bibliometric Analysis

OBJECTIVE

Although several studies have been reported on early-onset scoliosis (EOS), a bibliometric analysis is still lacking. A systematic bibliometric analysis will enable researchers to understand the scope of the research topics, identify research focuses and key literature, and predict future research directions.

METHODS

Literature data were retrieved from the Web of Science Core Collection database. The Web of Science Results Analysis and Citation Report were used to analyze the reported studies in different views. CiteSpace and VOSviewer were used for further analysis, including a cooperation network analysis of the authors, institutions, countries and/or regions, discipline and journal analysis, reference co-citation analysis, and keyword co-occurrence analysis.

RESULTS

The final analysis included 674 relevant studies reported from 2005 to 2020. During the study period, the field of EOS has expanded rapidly. Multiple cooperation was found among the authors, institutions, and countries and/or regions, with some making great contributions. The results of the reference co-citation analysis showed that the studies had several main focuses, including the growing rod (GR), magnetically controlled GR, an EOS 24-item questionnaire, and a growth evaluation.

CONCLUSIONS

From 2005 to 2020, surgical treatment has remained the focus of research in the EOS field. The magnetically controlled GR is the latest research focus, which might become more comprehensive in the future. The Gr has remained the most popular topic, and potential new surgical techniques might require improvement to become the favored techniques. In addition, assessing the health-related quality of life and growth parameters of patients with EOS have become a popular topic.

Shilla Growth Guidance Compared With Magnetically Controlled Growing Rods in the Treatment of Neuromuscular and Syndromic Early-onset Scoliosis

STUDY DESIGN

Retrospective review of consecutive series of patients treated at two institutions.

OBJECTIVE

The aim of this study was to compare the health-related quality of life (HRQoL) and surgical outcomes of Shilla growth guidance and magnetically controlled growing rod (MCGR) treatment in patients with syndromic and neuromuscular early-onset scoliosis (EOS).

SUMMARY OF BACKGROUND DATA

Knowledge of the outcomes of Shilla instrumentation is limited.

METHODS

We identified 13 children treated with Shilla and 18 children treated with MCGR with syndromic or neuromuscular EOS (major curve ≥45 degree) before the age of 10 years with minimum 2-year follow-up. Outcome parameters included clinical data, radiographic as well as HRQoL outcomes (EOSQ-24 questionnaire).

RESULTS

Mean preoperative major curves were 64 degree (range, 45-108 degree) in the Shilla group and 58 degree (range, 45-85 degree) in the MCGR group (P = 0.151). At final follow-up, mean major curves were 31 degree (range, 9.4-54 degree ) and 30 degree (range, 16-53 degree), respectively (P = 0.392). The mean major curve correction was 45% in the Shilla group and 48% in the MCGR group during the follow-up (P = 0.383). Spinal (T1-S1) and T1-T12 growth were significantly better (P = 0.006 and 0.042) in the MCGR than in the Shilla group during the distraction period. At final follow-up, 11 (85%) children in the Shilla group and 17 (94%) in the MCGR group had achieved T1-T12 length of ≥18 cm (P = 0.202). There were significantly more surgical procedures in the MCGR group (mean 2.6 vs. 1.4, P = 0.034) with no difference in the number of complications (P = 0.768). EOSQ24 domains were similar at final follow-up.

CONCLUSION

Shilla growth guidance provided similar correction of spinal deformity, equal number of complications, but with significantly less surgical procedures in patients treated for EOS when compared with MCGR instrumentation. MCGR provided with slightly better spinal growth during the distraction period. There were no significant differences between the quality of life assessments.

LEVEL OF EVIDENCE

3.

Systematic investigation of metallosis associated with magnetically controlled growing rod implantation for early-onset scoliosis

AIMS

To investigate metallosis in patients with magnetically controlled growing rods (MCGRs) and characterize the metal particle profile of the tissues surrounding the rod.

METHODS

This was a prospective observational study of patients with early onset scoliosis (EOS) treated with MCGRs and undergoing rod exchange who were consecutively recruited between February 2019 and January 2020. Ten patients were recruited (mean age 12 years (SD 1.3); 2 M:8 F). The configurations of the MCGR were studied to reveal the distraction mechanisms, with crucial rod parts being the distractable piston rod and the magnetically driven rotor inside the barrel of the MCGR. Metal-on-metal contact in the form of ring-like wear marks on the piston was found on the distracted portion of the piston immediately outside the barrel opening (BO) through which the piston rod distracts. Biopsies of paraspinal muscles and control tissue samples were taken over and away from the wear marks, respectively. Spectral analyses of the rod alloy and biopsies were performed to reveal the metal constituents and concentrations. Histological analyses of the biopsies were performed with haematoxylin and eosin staining.

RESULTS

Titanium (Ti), vanadium (V), and neodymium (Nd) concentrations in the biopsies taken near the wear marks were found to be significantly higher than those in the control tissue samples. Significantly increased Nd concentrations were also found in the tissues near the barrel of the MCGR. Chronic inflammation was revealed by the histological studies with fibrosis and macrophage infiltration. Black particles were present within the macrophages in the fibrotic tissues.

CONCLUSION

Ti and V were generated mainly at the BO due to metal-on-metal contact, whereas the Nd from the rotor of the MCGR is likely released from the BO during distraction sessions. Phagocytotic immune cells with black particles inside raise concern regarding the long-term implications of metallosis. Cite this article: Bone Joint J 2020;102-B(10):1375-1383.

Best practice guidelines for management of spinal disorders in skeletal dysplasia

BACKGROUND

Disorders of the spine present a common and difficult management concern in patients with skeletal dysplasia. Due to the rarity of these conditions however, the literature, largely consisting of small, single institution case series, is sparse in regard to well-designed studies to support clinical decision making in these situations.

METHODS

Using the Delphi method, an international, multi-disciplinary group of individuals, with significant experience in the care of patients with skeletal dysplasia, convened to develop multi-disciplinary, "best practice" guidelines in the care of spinal disorders in patients with skeletal dysplasia.

RESULTS

Starting with 33 statements, the group a developed a list of 31 "best practice" guidelines.

CONCLUSIONS

The guidelines are presented and discussed to provide context for clinicians in their decision making in this often-challenging realm of care.