Does the addition of convex uniplanar screws in hybrid constructs improve 3D surgical correction in thoracic adolescent idiopathic scoliosis posterior fusion?

Purpose

Hybrid techniques using thoracic sublaminar bands have proved their efficacy in adolescent idiopathic scoliosis posterior fusion, but clinical axial correction sometimes remained disappointing. One solution found was "the frame technique" and the second alternative was the replacement of the convex sublaminar bands by periapical uniplanar screws. The goal of this study was to compare clinical and radiological outcomes of both techniques in a consecutive cohort of adolescent idiopathic scoliosis patients.

Methods

All patients undergoing primary posterior fusion for thoracic adolescent idiopathic scoliosis between January 2017 and March 2020 were included. Two groups were compared: Group 1 with thoracic sublaminar bands only and Group 2 with periapical uniplanar screws. All patients underwent standing stereoradiographs. The main frontal, sagittal, and axial (apical vertebra rotation) radiological parameters of interest were analyzed. Functional outcomes were assessed using the Scoliosis Research Society 30 score.

Results

A total of 147 adolescents were included (Group 1, n = 73 and Group 2, n = 74 patients). In the frontal plane, a greater reduction index was observed in Group 2 (68% versus 62%, p < 0.001) as well as a better apical axial correction (67.8% versus 46.6%, p = 0.03). The number of thoracoplasty performed was reduced (6.7% versus 20.5%, p = 0.02) in Group 2, with a significant decrease in the rate of mechanical complication. No significant loss of correction was observed during follow-up in any of the group.

Conclusion

The adjunction of convex uniplanar screws at the periapical levels improved the three-dimensional surgical correction of thoracic adolescent idiopathic scoliosis treated with hybrid constructs.

Level of evidence

level III, retrospective comparative study.

Bivertebral pedicle-supralaminar autostable claw for proximal fixation of magnetic growing rods in early-onset scoliosis

BACKGROUND

The various methods for the proximal fixation of magnetic growing rods in patients with early-onset scoliosis (EOS) are associated with high rates of mechanical complications related to material failure or proximal junctional kyphosis (PJK). The bivertebral autostable claw (BAC) has been proven reliable in adolescent idiopathic scoliosis but has not been assessed when used with magnetic growing rods. The objective of this study was to describe the operative technique and outcomes of BAC proximal fixation of magnetic growing rods in children with EOS.

HYPOTHESIS

The BAC provides stable and effective proximal fixation in children with early-onset scoliosis.

MATERIAL AND METHODS

This retrospective observational study included 24 patients who had surgery in 2015-2019 for early-onset scoliosis with magnetic growing rod implantation and BAC proximal fixation. Radiological variables were measured in the coronal and sagittal planes before surgery, during the early postoperative period (<3months) and at last follow-up (≥2years).

RESULTS

No neurological complications were recorded. At last follow-up, four patients had radiological PJK, including one patient with clinical PJK due to material failure.

DISCUSSION

BAC proximal fixation is both effective and sufficiently stable (4.2% pull-out) to withstand the forces applied during distraction sessions and daily activities in children with EOS. Moreover, the polyaxial connecting rods ensure better BAC adaptation to the local proximal kyphosis, which is often marked in this population.

CONCLUSION

The BAC is a reliable proximal fixation device that is well-suited to magnetic growing rod fixation in children with EOS.

LEVEL OF EVIDENCE

IV, retrospective observational cohort study.

Descriptive analysis of pediatric orthopedic surgical emergencies during the COVID-19 lockdown: Single-center observational study in a pandemic red-zone area in France

INTRODUCTION

Lockdown involved strict confinement of children at home, radically affecting their way of life, with increased risk of domestic accidents and the temptation to step outside of the legal framework. The aim of the present study was to analyze the impact of lockdown on pediatric emergency turnover in a university reference center situated in a high-risk "red zone" and to describe specific management measures.

HYPOTHESIS

Pediatric emergency turnover and the corresponding lesion mechanisms were altered by lockdown.

MATERIALS AND METHODS

All children undergoing emergency orthopedic surgery during lockdown (group 1) were prospectively included, then retrospectively compared to series operated on during the same period in the previous 3 years. Demographic and surgical data were analyzed, and the pathway changes that were developed were detailed.

RESULTS

Turnover fell by a mean 33.5%, without change in indications. The most frequent lesions were wounds (54.3%), followed by fractures (34.3%) and infections (11.4%); the upper limbs were involved in 84.6% of cases. Lockdown had been infringed in 9.7% of traumas, mainly concerning fractures (55%). Postoperative management was modulated during lockdown in 34% of cases, without complications at the time of writing.

DISCUSSION

Pediatric emergency turnover decreased, without major change in lesion mechanisms. Accidents associated with lockdown infringement were rare (<10%), demonstrating good adaptation on the part of these children living in an urban area. The adapted care pathway was beneficial, and will no doubt continue to optimize management in future, with accelerated circuits and use of telemedicine.

LEVEL OF EVIDENCE

IV, comparative retro-prospective study.

[Descriptive analysis of pediatric orthopedic surgical emergencies during the COVID-19 lockdown: Single-center observational study in a pandemic red-zone area in France]

Introduction

Le confinement a imposé un maintien strict des enfants à domicile, modifiant considérablement leur mode de vie avec un risque accru d’accidents domestiques et la tentation de désobéir au cadre légal. L’objectif était d’analyser l’impact du confinement sur l’activité d’urgence pédiatrique dans un centre universitaire de référence situé en zone rouge, et de décrire les modes de prise en charge spécifiques.

Hypothèse

L’activité chirurgicale d’urgence ainsi que les mécanismes lésionnels en orthopédie pédiatrique ont été modifiés par le confinement.

Matériels et méthodes

Tous les enfants pris en charge au bloc opératoire pour une urgence orthopédique pendant le confinement (groupe 1) ont été inclus de façon prospective, puis comparés de manière rétrospective aux patients opérés lors des mêmes périodes les 3 années précédentes. Les données démographiques et chirurgicales ont été analysées, et les circuits spécifiques instaurés ont été décrits.

Résultats

Une diminution moyenne de 33,5 % de l’activité a été constatée, sans modification des motifs de prise en charge. Les lésions les plus fréquentes étaient les plaies (54,3 %), suivies des fractures (34,3 %) et des infections (11,4 %) et concernaient le membre supérieur dans 84,6 % des cas. Le cadre légal était non respecté dans 9,7 % des traumatismes et occasionnant principalement des fractures (55 %). La prise en charge postopératoire a été modifiée durant le confinement dans 34 % des cas, sans complication à ce jour.

Discussion

Nos résultats ont retrouvé une diminution de l’activité d’urgence pédiatrique sans modification majeure des mécanismes lésionnels. Les accidents survenant en dehors du cadre légal sont demeurés rares (<10 %), témoignant de la bonne adaptation des enfants vivant en zone urbaine. L’adaptation du parcours patient qui a été utile pendant le confinement, a été efficace, et va sans doute permettre de continuer à optimiser la prise en charge dans le futur, avec des circuits raccourcis et la télémédecine.

Niveau de preuve

IV ; Étude comparative rétroprospective.

Does the use of intrawound povidone-iodine irrigation and local vancomycin powder impact surgical site infection rate in adolescent idiopathic scoliosis surgery?

PURPOSE

Surgical site infection (SSI) is a major complication after adolescent idiopathic scoliosis (AIS) surgery, with an incidence ranging from 0.5 to 7%. Intraoperative wound decontamination with povidone-iodine (PVP-I) irrigation and/or vancomycin powder in adult spinal surgery has gained attention in the literature with controversial results. The aim of this study was to investigate the impact of using intrawound PVP-I irrigation and local vancomycin powder (LVP) on the incidence of early SSI in AIS surgery.

METHODS

All AIS patients who underwent posterior spinal fusion between October 2016 and December 2019 were retrospectively reviewed. The incidence of early SSI was reported and compared between 2 groups defined by the treating spinal surgeons' preferences: group 1-intrawound irrigation with 2L of PVP-I and application of 3 g LVP before closure and control group 2-patients that did not receive either of these measures.

RESULTS

Nine early cases of SSI (2.9%) were reported among the 307 AIS posterior spinal fusion patients. Incidence of SSI in group 1 (2/178 = 1.1%) was significantly lower than in group 2 (7/129 = 5.4%; p = 0.04). There were no adverse reactions to the use of PVP-I and LVP in our study. At latest follow-up, rate of surgical revision for mechanical failure with pseudarthrosis was significantly lower in group 1 (2/178 = 1.1%) than in group 2 (9/129 = 7.0%; p = 0.01).

CONCLUSION

Intraoperative use of intrawound PVP-I irrigation and vancomycin powder is associated with a significant reduction of early SSI after AIS spine surgery.

LEVEL OF EVIDENCE IV

Retrospective study.

Posterior vertebral column resection for pediatric rigid spinal deformity

INTRODUCTION

Surgery for pediatric spinal deformity may involve vertebral osteotomies in complex cases. Vertebral column resection (VCR) is the most technically demanding procedure, with the severest morbidity. It can use a double anterior and posterior approach (APVCR), though a single posterior approach (PVCR) is gaining in popularity.

HYPOTHESIS

PVCR provides effective correction with acceptable morbidity in children.

METHOD

A single-center retrospective series included spinal deformities treated by PVCR. Surgical data and global pelvic-spinal balance parameters were analyzed.

RESULTS

Sixteen PVCRs were performed in 13 patients, with a mean age of 14.1±2.8 years. Mean operative time was 411±54minutes. Mean preoperative rigid principal Cobb angle was 74.3°. Mean correction was 64.3% postoperatively, without significant correction loss at last follow-up. Mean blood loss was 941±221ml. The cell-saver enabled 92.3% autologous transfusions, with 53.4% homologous transfusions. Transient monoplegia and permanent psoas deficit were observed during the postoperative period. Radiologic follow-up found 4 non-unions requiring revision.

CONCLUSION

PVCR provided major correction of rigid spinal deformity in children. Complications mainly comprised mechanical or neurological incidents.

LEVEL OF EVIDENCE

IV, non-comparative cohort study.

Halo-gravity traction followed by definitive fusion in severe early onset scoliosis: results of a trunk analysis based on biplanar 3D reconstructions

PURPOSE

Definitive fusion can be considered in early onset scoliosis (EOS) around triradiate cartilage closure. Halo-gravity traction (HGT) is an old strategy that can help lengthen and balance the spine before fusion. The postoperative changes of the trunk have never been investigated to date with modern imaging. The goal of this study was to analyze the 3D radiological outcomes, and the associated pulmonary function, of a cohort of severe EOS patients treated by definitive posterior fusion prepared by HGT.

METHODS

All consecutive EOS patients with severe (> 85°) and stiff (flexibility < 25%) curves, treated by HGT followed by posterior fusion, were followed. 3D radiological measurements and pulmonary function were assessed.

RESULTS

Forty-nine EOS patients underwent fusion, with a mean follow-up of 4 years (± 1). Age at surgery averaged 13.5 years old. HGT protocol reached on average 41% of body weight. Mean preoperative 3D Cobb angle was 95° (± 10) and final correction averaged 68.4% after surgery. 3D T4T12 kyphosis was reduced after surgery (11°, p < 0.01), while the apical vertebral rotation was improved by 27.8% (p = 0.06). 3D thoracic volume increased after surgery (p = 0.02), with a 3D T1T12 height gain averaging 3.7 cm (± 2). Both parameters were significantly correlated with total lung capacity improvement. Seven complications (14.2%) were reported, and 5 patients (10.6%) underwent unplanned revision.

CONCLUSION

HGT is a safe and efficient strategy to prepare posterior fusion in severe EOS patients. The 3D trunk analysis demonstrated significant postoperative gains in thoracic and spinal lengths, as well as in thoracic volume.

LEVEL OF EVIDENCE

IV.

Prognostic factors for intramedullary nailing in radial neck fracture in children

INTRODUCTION

Radial fracture accounts for 1% of fractures in children. It is potentially serious, and treatment is controversial. Several studies assessed prognostic factors, only one of which used exclusive intramedullary nailing, despite this being the gold standard.

HYPOTHESIS

Open surgery provides poor functional results in radial neck fracture.

MATERIAL AND METHOD

All patients undergoing reduction and internal fixation of radial neck fracture between 2005 and 2015 were analysed. Inclusion criteria comprised Jeffery type 1 fracture with open growth plate, complete file, and ≥1 year's follow-up. Treatment systematically comprised Métaizeau intramedullary nailing, with crossover to open reduction only in case of failure. Good results were defined as full range of motion and pain-free elbow.

RESULTS

Fifty-six patients were included: 33 girls, 23 boys; mean age, 9 years. On the Judet classification modified by Métaizeau, 4 fractures were grade 2, 29 grade 3, 15 grade 4A and 8 grade 4B. Closed reduction was performed in 48 cases, including 8 with the help of percutaneous leverage effect. Eight required a surgical approach. Twenty-three showed postoperative reduction defect. At a mean 74 months' follow-up, at a mean age of 15 years, 37 patients had reached full skeletal maturity. Sixteen had poor results. Open reduction was associated with poor outcome (p<0.01). Age, initial epiphyseal tilt, associated lesions, immobilisation time, time to nail removal and residual tilt after reduction did not significantly affect outcome (p-values>0.05). Percutaneous leverage effect had no impact on the quality of results (p=1).

DISCUSSION

Open reduction is to be avoided in radial neck fracture. A prospective study is needed to assess remodelling potential according to age.

LEVEL OF EVIDENCE

IV, retrospective study.