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Aoun M, Daher M, Bizdikian AJ, Kreichati G, Kharrat K, Sebaaly A. Implant density in adolescent idiopathic scoliosis: a meta-analysis of clinical and radiological outcomes. Spine Deform 2024:10.1007/s43390-024-00860-9. [PMID: 38573487 DOI: 10.1007/s43390-024-00860-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 03/10/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Adolescent idiopathic scoliosis (AIS) affects 1-3% of adolescents, and treatment approaches, including the density of constructs in surgical fusion, vary among orthopedic surgeons. Studies have sought to establish whether high-density or low-density constructs offer superior clinical and radiological outcomes, yet conclusive results are lacking. This meta-analysis aims to provide a definitive answer to the controversial and ambiguous question surrounding the efficacy of different pedicle screw densities in treating AIS. METHODS PubMed, Cochrane, and Google Scholar (page 1-20) were searched till December 2023. The studied outcomes were Major Cobb angle, major curve correction, lumbar curve, kyphosis (T5-T12), lumbar lordosis, coronal balance, LIV Tilt angle, TAV translation, LAV translation, apical trunk rotation, trunk shift, SRS-22, operative time, blood loss, complications and cost. RESULTS Twenty-four studies (total of 1985 patients, 1045 in LD group and 940 in HD group) were included in this meta-analysis. A statistically significant better improvement in ATR (p = 0.02) and LIV tilt angle (p = 0.02) was seen in the high-density group. On the other hand, longer operative time (p = 0.002), blood loss (p = 0.0004) and costs (p = 0.02) were seen in the high-density group. No difference was seen in the remaining radiographic and clinical outcomes between both surgeries. CONCLUSION Both low-density (LD) and high-density (HD) screw constructs show comparable and satisfactory radiographic and QOL for AIS patients. Furthermore, HD constructs had increased costs, operative time, and blood loss associated. However, a definitive conclusion cannot be made and more studies taking into account multiple additional variables are necessary to do so.
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Affiliation(s)
- Marven Aoun
- School of Medicine, Saint Joseph University, Faculty of Medicine, Beirut, Lebanon
| | - Mohammad Daher
- School of Medicine, Saint Joseph University, Faculty of Medicine, Beirut, Lebanon
- Department of Orthopedic Surgery, Brown University, Providence, RI, 02906, USA
| | - Aren-Joe Bizdikian
- Department of Orthopedic Surgery, Hotel Dieu de France Hospital, Alfred Naccache Boulevard, Beirut, Lebanon
| | - Gaby Kreichati
- School of Medicine, Saint Joseph University, Faculty of Medicine, Beirut, Lebanon
- Department of Orthopedic Surgery, Hotel Dieu de France Hospital, Alfred Naccache Boulevard, Beirut, Lebanon
| | - Khalil Kharrat
- Department of Orthopedic Surgery, Hotel Dieu de France Hospital, Alfred Naccache Boulevard, Beirut, Lebanon
| | - Amer Sebaaly
- School of Medicine, Saint Joseph University, Faculty of Medicine, Beirut, Lebanon.
- Department of Orthopedic Surgery, Hotel Dieu de France Hospital, Alfred Naccache Boulevard, Beirut, Lebanon.
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Chotigavanichaya C, Adulkasem N, Pisutbenya J, Ruangchainikom M, Luksanapruksa P, Wilartratsami S, Ariyawatkul T, Korwutthikulrangsri E. Comparative effectiveness of different pedicle screw density patterns in spinal deformity correction of small and flexible operative adolescent idiopathic scoliosis: inverse probability of treatment weighting analysis. Eur Spine J 2023:10.1007/s00586-023-07615-6. [PMID: 36995418 DOI: 10.1007/s00586-023-07615-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 01/30/2023] [Accepted: 02/18/2023] [Indexed: 03/31/2023]
Abstract
PURPOSES An optimal pedicle screw density for spinal deformity correction in adolescent idiopathic scoliosis (AIS) remains poorly defined. We compared radiographic correction, operative time, estimated blood loss, and implant cost among different screw density patterns in operatively treated AIS patients. METHODS A retrospective observational cohort study of AIS patients who underwent posterior spinal fusion using all-pedicle screw instrumentation was conducted from January 2012 to December 2018. All patients were categorized into three different pedicle screw density groups: the very low density (VLD), the low density (LD), and the high density (HD) group. The comparative effectiveness between each pairwise comparison was performed under the inverse probability of the treatment weighting method to minimize the possible confounders imbalance among treatment groups. The primary endpoints in this study were the degrees of correction and deformity progression at 2 years postoperatively. RESULTS A total of 174 AIS patients were included in this study. The adjusted treatment effects demonstrated similar degrees of deformity correction after 2 years in the three treatment groups. However, the VLD and LD group slightly increased the curve progression at 2 years compared to the HD group by 3.9° (p = 0.005) and 3.2° (p = 0.044), respectively. Nevertheless, the limited screw density patterns (VLD and LD) significantly reduced the operative time, estimated blood loss, and implant cost per operated level. CONCLUSION The limited pedicle screw pattern (VLD and LD) in relatively flexible AIS spinal deformity correction results in similar coronal and sagittal radiological outcomes while reducing operative time, estimated blood loss, and implant cost compared to the high-density pedicle screw instrumentation.
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Affiliation(s)
- Chatupon Chotigavanichaya
- Department of Orthopaedic Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Prannok Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Nath Adulkasem
- Department of Orthopaedic Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Prannok Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Jirachai Pisutbenya
- Department of Orthopaedic Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Prannok Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Monchai Ruangchainikom
- Department of Orthopaedic Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Prannok Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Panya Luksanapruksa
- Department of Orthopaedic Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Prannok Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Sirichai Wilartratsami
- Department of Orthopaedic Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Prannok Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Thanase Ariyawatkul
- Department of Orthopaedic Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Prannok Road, Bangkoknoi, Bangkok, 10700, Thailand.
| | - Ekkapoj Korwutthikulrangsri
- Department of Orthopaedic Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Prannok Road, Bangkoknoi, Bangkok, 10700, Thailand
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Compton E, Gupta P, Gomez JA, Illingworth KD, Skaggs DL, Sponseller PD, Samdani AF, Hwang SW, Oetgen ME, Schottler J, Thompson GH, Vitale MG, Smith JT, Andras LM. How low can you go? Implant density in posterior spinal fusion converted from growing constructs for early onset scoliosis. Spine Deform 2021; 9:1479-1488. [PMID: 34228310 DOI: 10.1007/s43390-021-00321-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 02/22/2021] [Indexed: 10/20/2022]
Abstract
STUDY DESIGN Retrospective, multicenter comparative. OBJECTIVES Our purpose was to compare early onset scoliosis (EOS) patients treated with ultra-low, low, and high implant density constructs when undergoing conversion to definitive fusion. Larson et al. demonstrated that implant density (ID) at fusion does not correlate with outcomes in the treatment of adolescent idiopathic scoliosis, but did not address growth-friendly graduates. METHODS EOS patients treated with growth-friendly constructs converted to fusion between 2000 and 2017 were reviewed from a multicenter database. ID was defined as number of pedicle screws, hooks, and sublaminar/bands per level fused. Patients were divided into ultra-low ID (< 1.3), low (≥ 1.3 and < 1.6), and high ID (≥ 1.6). EXCLUSION CRITERIA < 2 years follow-up from fusion or inadequate radiographs. RESULTS A total of 152 patients met inclusion criteria with 39 (26%) patients in the high ID group, 33 (22%) patients in the low ID group, and 80 (52%) in the ultra-low ID group. Groups were similar in operative time (p = 0.61), pre-fusion major curve (p = 0.71), mean number of levels fused (p = 0.58), clinical follow-up (p = 0.30), and radiographic follow-up (p = 0.90). Patients in the low ID group (11.6 ± 1.5 years) were slightly younger at the time of definitive fusion than patients in the ultra-low ID group (12.9 ± 2.2 years) and high ID group (12.5 ± 1.7 years) (p = 0.009). There was significantly more blood loss in the high ID group than the other two groups (high ID: 946.8 ± 606.0 mL vs. low ID: 733.9 ± 434.5 mL and ultra-low ID: 617.4 ± 517.2 mL; p = 0.01), but there was no significant difference with regard to percent of total blood volume lost (high ID: 59.3 ± 48.7% vs. low ID: 54.5 ± 37.5% vs. ultra-low ID: 51.7 ± 54.9%; p = 0.78). There was a difference in initial improvement in major curve between the groups (high ID: 21.6° vs. low ID: 18.0° vs. ultra-low ID: 12.6°; p = 0.01). However, during post-fusion follow-up, correction decreased 7.1° in the high ID group, 2.6 in the low ID group, and 2.8 in the ultra-low ID group (p = 0.19). At final follow-up, major curve correction from pre-fusion was similar between groups (high ID: 14.5° vs. low ID: 15.5° vs. ultra-low ID: 9.7°, p = 0.14). At final follow-up, there was no difference in T1-T12 length gain (p = 0.85), T1-S1 length gain (p = 0.68), coronal balance (p = 0.56), or sagittal balance (p = 0.71). The revision rate was significantly higher in the ultra-low ID group (13.8%; 11/80) versus the high ID group (2/39; 5.1%) and low ID group (0/33; 0%) (p = 0.04). CONCLUSIONS Although an ID < 1.3 in growth-friendly graduates produces similar outcomes with regard to curve correction and spinal length gain as low and high ID, this study suggests that an ID < 1.3 is associated with an increased revision rate. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Edward Compton
- Children's Orthopaedic Center, Children's Hospital Los Angeles, 4650 Sunset Blvd, MS#69, Los Angeles, CA, 90027, USA
| | | | - Jaime A Gomez
- Division of Pediatric Orthopaedics, Children's Hospital At Montefiore Medical Center, Bronx, NY, USA
| | - Kenneth D Illingworth
- Children's Orthopaedic Center, Children's Hospital Los Angeles, 4650 Sunset Blvd, MS#69, Los Angeles, CA, 90027, USA
| | - David L Skaggs
- Children's Orthopaedic Center, Children's Hospital Los Angeles, 4650 Sunset Blvd, MS#69, Los Angeles, CA, 90027, USA
| | | | - Amer F Samdani
- Shriners Hospitals for Children-Philadelphia, Philadelphia, PA, USA
| | - Steven W Hwang
- Shriners Hospitals for Children-Philadelphia, Philadelphia, PA, USA
| | | | | | - George H Thompson
- Division of Pediatric Orthopaedic Surgery, Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, OH, USA
| | - Michael G Vitale
- Division of Pediatric Orthopedics, Columbia University Medical Center, New York, NY, USA
| | - John T Smith
- Department of Orthopedic Surgery, University of Utah, Salt Lake City, UT, USA
| | | | - Lindsay M Andras
- Children's Orthopaedic Center, Children's Hospital Los Angeles, 4650 Sunset Blvd, MS#69, Los Angeles, CA, 90027, USA.
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Lertudomphonwanit T, Berry CA, Jain VV, Sturm PF. Does Implant Density Impact Three-Dimensional Deformity Correction in Adolescent Idiopathic Scoliosis with Lenke 1 and 2 Curves Treated by Posterior Spinal Fusion without Ponte Osteotomies? Asian Spine J 2021; 16:375-385. [PMID: 33957744 PMCID: PMC9260411 DOI: 10.31616/asj.2020.0398] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 12/14/2020] [Indexed: 11/23/2022] Open
Abstract
Study Design Retrospective cohort study. Purpose To determine whether implant density impact three-dimensional deformity correction in posterior spinal fusion (PSF) without Ponte osteotomies (POs) for patients with Lenke 1 and 2 adolescent idiopathic scoliosis (AIS). Overview of Literature Currently, the optimal pedicle screw (PS) density for flexible moderate-sized thoracic AIS curve correction is still controversial. There are limited data regarding the impact of implant density on three-dimensional correction in PSF without the use of PO for thoracic AIS surgery. Methods A database of patients with AIS with Lenke 1 and 2 curves treated with PSF without PO and instrumented with PSs and ≥2-year follow-up was reviewed. The preoperative, immediate, and final follow-up postoperative radiographs were analyzed. The correlation between PS density and the following factors were determined: major curve correction (MCC), correction index (CI; MCC/curve flexibility), kyphosis angle change, and rib index (RI) correction. Then, patients were divided into low-density (LD) and high-density (HD) groups according to mean PS density for the entire cohort (1.5 PS per level). Demographics and radiographic and clinical outcomes were compared between groups. Results The study included 99 patients with Lenke 1 and 23 patients with Lenke 2 AIS. The average MCC was 67.2%. There was no correlation between screw density and these parameters: MCC (r=0.10, p=0.26), CI (r=0.16, p=0.07), change in T2–T12 kyphosis angle (r=−0.13, p=0.14), and RI correction (r=−0.09, p=0.37). Demographic and preoperative radiographic parameters were similar between the LD and HD groups. At the latest follow-up, there were no differences between the two groups in regard to MCC, CI, change in T2–T12 kyphosis angle, RI correction, and Scoliosis Research Society-30 scores (all p>0.05). Conclusions This study revealed no significant correlation between screw density and curve correction in any planes. HD construct may not provide better deformity correction in patients with flexible and moderate thoracic AIS undergoing PSF without PO.
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Affiliation(s)
- Thamrong Lertudomphonwanit
- Department of Orthopaedics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Viral V Jain
- Division of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Peter F Sturm
- Division of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Skalak TJ, Gagnier J, Caird MS, Farley FA, Li Y. Higher pedicle screw density does not improve curve correction in Lenke 2 adolescent idiopathic scoliosis. J Orthop Surg Res 2021; 16:276. [PMID: 33882975 PMCID: PMC8061215 DOI: 10.1186/s13018-021-02415-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 04/07/2021] [Indexed: 11/19/2022] Open
Abstract
Purpose Higher pedicle screw density posterior spinal fusion (PSF) constructs have not been shown to result in improved curve correction in Lenke 1 and 5 adolescent idiopathic scoliosis (AIS) but do increase cost. The purpose of this study questioned whether higher screw density constructs improved curve correction and maintenance of correction in Lenke 2 AIS. Secondary goals were to identify predictive factors for correction and postoperative magnitude of curves in Lenke 2 AIS. Methods We identified patients 11 to 17 years old who underwent primary PSF for Lenke 2 AIS between 2007 and 2017 who had minimum follow-up of 2 years. Demographic and radiographic data were collected to perform regression and elimination analysis. Results Thirty patients (21 females, 9 males) were analyzed. Average age and SD at time of surgery was 14.0 ± 1.8 years (range, 11–17 years), and median follow-up was 2.8 years (IQR 2.1–4.0 years). Implant density did not predict final postoperative curve magnitude. Predictors of final postoperative curve magnitude were sex and preoperative curve magnitude. Predictors of percentage of correction of major curve were sex and age at the time of surgery. Predictors of final postoperative thoracic kyphosis were sex and percent flexibility preop. Females had lower final postoperative major curve magnitude, a higher percent curve correction, and lower postoperative thoracic kyphosis. Conclusions Increased implant density is not predictive of postoperative curve magnitude in Lenke 2 AIS. Predictors of postoperative curve magnitude are sex and preoperative curve magnitude. Level of evidence Level III, retrospective observational
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Affiliation(s)
- Timothy J Skalak
- Nationwide Children's Hospital, Columbus, OH, USA. .,, Columbus, USA.
| | - Joel Gagnier
- C.S. Mott Children's Hospital, University of Michigan Health System, Ann Arbor, MI, USA
| | - Michelle S Caird
- C.S. Mott Children's Hospital, University of Michigan Health System, Ann Arbor, MI, USA
| | - Frances A Farley
- C.S. Mott Children's Hospital, University of Michigan Health System, Ann Arbor, MI, USA
| | - Ying Li
- C.S. Mott Children's Hospital, University of Michigan Health System, Ann Arbor, MI, USA
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La Barbera L, Larson AN, Aubin CE. How do spine instrumentation parameters influence the 3D correction of thoracic adolescent idiopathic scoliosis? A patient-specific biomechanical study. Clin Biomech (Bristol, Avon) 2021; 84:105346. [PMID: 33848703 DOI: 10.1016/j.clinbiomech.2021.105346] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 03/24/2021] [Accepted: 03/29/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patient-specific models promises to support the surgical decision-making process, particularly in adolescent idiopathic scoliosis. The present computational biomechanical study investigates how specific instrumentation parameters impact 3D deformity correction in thoracic scoliosis. METHODS 1080 instrumentation simulations of a representative patient were run. The independent instrumentation parameters were: screw pattern, upper and lower instrumented vertebrae, rod curvature and rod stiffness. ANOVA and correlation analyses analyzed how the instrumentation parameters influenced the 3D correction. FINDINGS Coronal plane correction was affected by the lower instrumented vertebra and rod stiffness (explaining 84% and 11%, respectively, of its overall variance). The sagittal profile was controlled by rod curvature and the upper vertebra (56% and 36%). The transverse plane vertebral rotation was influenced by lower, upper instrumented vertebra and screw pattern (35%, 32% and 19%). The Cobb angle correction was strongly correlated with the number of fused vertebrae, particularly when grouped by the upper instrumented vertebra (r = -0.91) and rod stiffness (r = -0.73). Thoracic kyphosis was strongly correlated with the number of fused vertebrae grouped by rod curvature (r = 0.84). Apical vertebral rotation was moderately correlated with the number of fused vertebrae grouped by upper/lower instrumented vertebra (r = 0.55/0.58), although variations were minimal. INTERPRETATION Instrumenting the last vertebra touching the central sacral vertical line improves 3D correction. A trade-off between a more cranial vs. caudal upper instrumented vertebra, respectively beneficial for coronal/sagittal vs. transverse plane correction, is required. High rod stiffness, differential rod contouring, and screw pattern were effective for coronal correction, thoracic kyphosis, and axial vertebral derotation, respectively.
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Affiliation(s)
- Luigi La Barbera
- Department of Mechanical Engineering, Polytechnique Montréal, Montréal, Québec, Canada; Sainte-Justine University Hospital Centre, Montréal, Québec, Canada; Department of Chemistry, Materials and Chemical Engineering, Politecnico di Milano, Milan, Italy.
| | - A Noelle Larson
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Carl-Eric Aubin
- Department of Mechanical Engineering, Polytechnique Montréal, Montréal, Québec, Canada; Sainte-Justine University Hospital Centre, Montréal, Québec, Canada
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Wolfram JM, Kristen VA, Cip J, Bach CM. Influence of implant density and flexibility index on curve correction after scoliosis surgery. Musculoskelet Surg 2021. [PMID: 33751424 DOI: 10.1007/s12306-021-00707-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Accepted: 03/10/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Numerous studies proved that all pedicle screw constructs produce the best outcome in the surgical treatment of patients with scoliosis. However, the optimal amount and distribution of screws has not yet been defined. In recent studies on idiopathic scoliosis, the correlation between curve correction and implant density has been discussed with diversifying results. PURPOSE The aim of this study was to detect a possible correlation of sagittal and coronal curve correction in dependence of metal load and flexibility index. MATERIALS AND METHODS Twenty-six patients were included in this study with surgical correction by one surgeon between January 2014 and December 2017. Clinical data and radiographic images (preoperative, postoperative and one-year follow-up) were retrospectively analyzed and metal load, flexibility index, correction rate and correction index were consequently calculated. The Pearson correlation analysis was used for metal load-correction index and metal load-correction rate, correction of kyphosis-metal load and correction of lordosis-metal load. According to the mean metal load of 88%, patients were divided into two subgroups-a low-density group of 12 patients and a high-density group of 14 patients. Clinical and radiographic features were examined by an independent two-sided t-test. RESULTS Eight patients were male, 18 patients female. Ten suffered from neuromuscular and 16 from idiopathic scoliosis. Mean age was 17.1 years. Correction rate directly postoperative was 70.43%, at the follow-up 67.90%. Mean correction index directly postoperative was 3.40 and at the follow-up 3.23. Pearson correlation of metal load-correction index directly postoperative was - 0.188 and one year postoperative - 0.189. The correlation between metal load-correction rate immediately after the surgery was 0.324 and at the follow-up 0.285. Correlation for correction of kyphosis-metal load postoperative was - 0.120 and one year later - 0.178. Pearson coefficient of lordosis-metal load directly after the surgical intervention was - 0.214 and at the follow-up - 0.220. Dependency of flexibility index and correction rate showed a positive trend (Pearson flexibility-correction rate direct 0.616; flexibility index-correction rate follow-up 0.516). A statistically significant difference between the high- and the low-density group was detected in the correction rate directly postoperative (p = 0.047). CONCLUSION With an implant density over 70%, satisfactory surgical treatment can be achieved in idiopathic and neuromuscular scoliosis. No statistical significance between the high-density (88-100%) and the low-density (73-87%) group could be verified in curve correction, ICU stay and complications.
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Ferlic PW, Hauser L, Götzen M, Lindtner RA, Fischler S, Krismer M. Correction of adolescent idiopathic scoliosis using a convex pedicle screw technique with low implant density. Bone Joint J 2021; 103-B:536-541. [PMID: 33641409 DOI: 10.1302/0301-620x.103b3.bjj-2020-0760.r1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The aim of this retrospective study was to compare the correction achieved using a convex pedicle screw technique and a low implant density achieved using periapical concave-sided screws and a high implant density. We hypothesized that there would be no difference in outcome between the two techniques. METHODS We retrospectively analyzed a series of 51 patients with a thoracic adolescent idiopathic scoliosis. There were 26 patients in the convex pedicle screw group who had screws implanted periapically (Group 2) and a control group of 25 patients with bilateral pedicle screws (Group 1). The patients' charts were reviewed and pre- and postoperative radiographs evaluated. Postoperative patient-reported outcome measures (PROMs) were recorded. RESULTS The number of implants (14.5 vs 17.1) and the implant density (1.5 vs 1.9) were significantly lower in Group 2 (p < 0.001). Operating time was 27 minutes shorter in Group 2 than in Group 1, with a mean of 217 minutes (SD 50.5; 120 to 346). The duration of surgery per instrumented vertebra was reduced by 19% in Group 2 (p = 0.011). No statistical difference was found in the postoperative Cobb angle, vertebral rotation, the relative correction achieved, or postoperative PROMs. CONCLUSION Despite a lower implant density and achieving correction through a convex rod, surgical correction of the Cobb angle and vertebral body rotation was similar in both groups. Periapical pedicle screws and primary correction on the concave side do not seem to be mandatory in order to achieve good surgical results in idiopathic thoracic scoliosis. The operating time was shorter in the group with lower implant density. In conclusion, the technique provided good results and has the potential to reduce complications and costs. Cite this article: Bone Joint J 2021;103-B(3):536-541.
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Affiliation(s)
- Peter W Ferlic
- Department of Orthopaedic Surgery, Medical University of Innsbruck, Innsbruck, Austria.,Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Laurenz Hauser
- Department of Orthopaedic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Götzen
- Department of Orthopaedic Surgery, Medical University of Innsbruck, Innsbruck, Austria.,Department of Orthopaedics and Traumatology, Hospital Feldkirch, Feldkirch, Austria
| | - Richard Andreas Lindtner
- Department of Orthopaedic Surgery, Medical University of Innsbruck, Innsbruck, Austria.,Department for Trauma Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Stefan Fischler
- Department of Orthopaedic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Martin Krismer
- Department of Orthopaedic Surgery, Medical University of Innsbruck, Innsbruck, Austria
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La Barbera L, Larson AN, Aubin CE. Correction objectives have higher impact than screw pattern and density on the optimal 3D correction of thoracic AIS: a biomechanical study. Spine Deform 2021; 9:655-664. [PMID: 33501602 PMCID: PMC8064979 DOI: 10.1007/s43390-020-00275-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 12/14/2020] [Indexed: 11/04/2022]
Abstract
STUDY DESIGN Assessment of screw pattern, implant density (ID), and optimization of 3D correction through computer-based biomechanical models. OBJECTIVE To investigate how screw pattern and ID affect intraoperative 3D correction of thoracic curves in adolescent idiopathic scoliosis, and how different correction objectives impact the optimal screw pattern. Screw pattern, ID, correction objectives and surgical strategies for posterior fusion of AIS are highly variable among experienced surgeons. The "optimal" instrumentation remains not well defined. METHODS 10 patient-specific multibody models of representative adolescent idiopathic scoliosis Lenke 1A cases were built and used to compare alternative virtual correction surgeries. Five screw patterns and IDs (average: 1.6 screws/instrumented level, range: 1.2-2) were simulated, considering concave rod rotation, en bloc derotation, and compression/distraction as primary correction maneuvers. 3D correction descriptors were quantified in the coronal, sagittal and transverse planes. An objective function weighting the contribution of intraoperative 3D correction and mobility allowed rating of the outcomes of the virtual surgeries. Based on surgeon-dependent correction objectives, the optimal result among the simulated constructs was identified. RESULTS Low-density (ID ≤ 1.4) constructs provided equivalent 3D correction compared to higher (ID ≥ 1.8) densities (average differences ranging between 2° and 3°). The optimal screw pattern varied from case to case, falling within the low-density screw category in 14% of considered scenarios, 73% in the mid-density (1.4 < ID < 1.8) and 13% in the high-density. The optimal screw pattern was unique in five cases; multiple optima were found in other cases depending on the considered correction objectives. CONCLUSIONS Low-density screw patterns provided equivalent intraoperative 3D correction to higher-density patterns. Simulated surgeon's choice of correction objectives had the greatest impact on the selection of the optimal construct for 3D correction, while screw density and ID had a limited impact. LEVEL OF EVIDENCE N/A.
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Affiliation(s)
- Luigi La Barbera
- Department of Mechanical Engineering, Polytechnique Montreal, Downtown Station, P.O. Box 6079, Montreal, QC, H3C 3A7, Canada. .,Research Center, Sainte-Justine University Hospital Center, 3175, Cote Sainte-Catherine Road, Montreal, QC, H3T 1C5, Canada. .,Laboratory of Biological Structure Mechanics, Department of Chemistry, Materials and Chemical Engineering, Giulio Natta, Politecnico di Milano, Piazza Leonardo da Vinci 32, 20133, Milano, Italy.
| | - A. Noelle Larson
- grid.66875.3a0000 0004 0459 167XDepartment of Orthopedic Surgery, Mayo Clinic, Rochester, MN USA
| | - Carl-Eric Aubin
- grid.183158.60000 0004 0435 3292Department of Mechanical Engineering, Polytechnique Montreal, Downtown Station, P.O. Box 6079, Montreal, QC H3C 3A7 Canada ,grid.411418.90000 0001 2173 6322Research Center, Sainte-Justine University Hospital Center, 3175, Cote Sainte-Catherine Road, Montreal, QC H3T 1C5 Canada
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Laumonerie P, Tibbo ME, Kerezoudis P, Langlais T, de Gauzy JS, Accadbled F. Influence of the sublaminar band density in the treatment of Lenke 1 adolescent idiopathic scoliosis. Orthop Traumatol Surg Res 2020; 106:1269-1274. [PMID: 31883867 DOI: 10.1016/j.otsr.2019.10.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 10/16/2019] [Accepted: 10/30/2019] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Optimal pedicle screw density for the treatment of adolescent idiopathic scoliosis (AIS) remains unknown. It is not clear whether higher implant density results in better clinical outcomes. Large variability in implant density exists among hybrid or all screw constructs. Significant heterogeneity exists with respect to the number of sublaminar bands (SB) used, and the influence of SB density on curve correction in the treatment of AIS. HYPOTHESIS We hypothesize that increased SB density does not improve sagittal or coronal plane curve correction. METHODS A single-center, retrospective study of 131 consecutive patients (118 females) with Lenke 1 adolescent idiopathic scoliosis, all operated between 2012 and 2015 by two surgeons using identical surgical technique and type of instrumentation (SB hybrid instrumentation treatment). SB density was measured using the number of SB reported as well as the number of vertebrae instrumented. Radiographic measurements included preoperative thoracic curve flexibility, Cincinnati reduction index (CRI), and postoperative thoracic Cobb (POCC) and kyphosis (POKC) angle correction measured on immediate postoperative radiographs and at 2 years postoperatively. RESULTS Median patient age was 15.6 years (IQR, 12-18). The median SB density was 0.4 (IQR 0.4-0.5). No statistically significant correlation was identified between SB density and CRI (p=0.71), POCC (p=0.55), or POKC (p=0.61) at 2-years postoperatively. Preoperative curve flexibility was found to have significant effect both on immediate (r=-3.02, p<0.001) and 2-year (r=-2.69, p<0.001). DISCUSSION SB utilized as a part of a hybrid construct for patients with flexible Lenke I AIS achieve satisfactory deformity correction regardless of SBd. The use of low SB density is appropriate for a subset of patients with flexible Lenke 1 adolescent idiopathic scoliosis.
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Affiliation(s)
- Pierre Laumonerie
- Department of Orthopaedics, Children's Hospital, Toulouse University Hospital, France.
| | - Meagan E Tibbo
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | | | - Tristan Langlais
- Department of Orthopaedics, Children's Hospital, Toulouse University Hospital, France
| | - Jérôme Sales de Gauzy
- Department of Orthopaedics, Children's Hospital, Toulouse University Hospital, France
| | - Franck Accadbled
- Department of Orthopaedics, Children's Hospital, Toulouse University Hospital, France
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Baky FJ, Echternacht SR, Milbrandt TA, Maradit Kremers H, Ransom J, Stans AA, Shaughnessy WJ, Larson AN. Predictors of cost for posterior spinal fusion in adolescent idiopathic scoliosis. Spine Deform 2020; 8:421-6. [PMID: 32096128 DOI: 10.1007/s43390-020-00053-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 11/16/2019] [Indexed: 10/24/2022]
Abstract
STUDY DESIGN Single-center retrospective review of pediatric patients who underwent posterior spinal fusion for adolescent idiopathic scoliosis (AIS). OBJECTIVE To determine what clinical and operative factors influence inflation-adjusted hospital costs of posterior spine fusion surgery for AIS. With rising healthcare costs and the advent of bundled payments, it is essential understand the predictors of costs for surgical procedures. We sought to determine the components of hospital costs for AIS posterior spine fusion surgery using standardized, inflation-adjusted, line-item costs for services and procedures. METHODS The study population comprised 148 AIS patients who underwent spinal fusion surgery at a large tertiary care center between 2009 and 2016. Data on medical characteristics, curve type, curve magnitude, number of screws and the number of levels was collected through manual chart review of X-rays and medical records. Hospital costs from admission until discharge were retrieved from an institutional database that contained line-item details of all procedures and services billed during the hospital episode. Bottom-up microcosting valuation techniques were used to generate standardized inflation-adjusted estimates of costs and standard deviations in 2016 dollars. RESULTS Mean cost of AIS surgery was $48,058 ± 9379. Physician fees averaged 15% of the total cost ($7045 ± 1732). Implant costs and surgical/anesthesia/surgeon's fees accounted for over 70% of the hospital costs. Mean number of screws was 16 ± 4.5, mean number of levels fused was 11.2 ± 2.2, and the mean implant density (screws per level fused) was 1.45 ± 0.35. On multivariate analysis, the number of screws per level fused, number of levels fused, curve magnitude and length of stay were all significantly associated with hospital costs (p < 0.01). CONCLUSIONS Bundled payments for AIS surgery should include adjustments for number of levels fused and curve size. Areas for cost savings include further reduction in implant costs, shortening length of stay, and reducing intraoperative costs. LEVEL OF EVIDENCE III.
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Delman C, Cage JM, Lausé G, Roberto R, Gupta MC, Klineberg E. Anterior and Posterior Fusion for Large, Rigid Idiopathic Scoliosis: Does Implant Density Matter? World Neurosurg 2019; 134:e37-e45. [PMID: 31470168 DOI: 10.1016/j.wneu.2019.08.123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 08/16/2019] [Accepted: 08/17/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Despite advancements in surgical techniques, controversy remains regarding the optimal implant density for the correction of idiopathic scoliosis. Recent evidence has suggested that equivalent radiographic and clinical outcomes can be achieved with lower implant densities for those with moderate curves and good flexibility. Among the experts, the consensus has continued that higher implant densities should be used for larger, stiffer curves. The purpose of the present study was to compare the radiographic results between high-implant density (HID) and low-implant density (LID) constructs in patients with large (>65°), rigid (<50% flexibility) curves who had undergone anterior release and posterior spinal fusion. METHODS We reviewed the idiopathic scoliosis cases performed at a single institution from 2006 to 2014. Only those meeting the inclusion criteria were selected. The patients were divided into HID and LID groups. The postoperative radiographs were compared for coronal correction, thoracic kyphosis, pelvic tilt, lumbar lordosis, and sagittal vertical axis. RESULTS A statistically significant improvement in coronal correction was detected in the HID group at all follow-up points (final follow-up: HID, 81.1% vs. LID, 70.4%; P = 0.01). When preoperative thoracic kyphosis was considered, no differences were found between the 2 groups. No differences were found in the other sagittal parameters. CONCLUSION In patients with large, rigid idiopathic scoliosis undergoing anterior release and posterior spinal fusion, a small, but statistically, significant improvement in the coronal Cobb angle was seen. It remains to be determined whether this small difference in radiographic correction will have any influence on the clinical outcome.
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Affiliation(s)
- Connor Delman
- Department of Orthopaedic Surgery, University of California, Davis, Sacramento, California, USA
| | - J Matthew Cage
- Department of Orthopaedic Surgery, Tripler Army Medical Center, Honolulu, Hawaii, USA.
| | - Greg Lausé
- Department of Orthopaedic Surgery, Tripler Army Medical Center, Honolulu, Hawaii, USA
| | - Rolando Roberto
- Department of Orthopaedic Surgery, University of California, Davis, Sacramento, California, USA; Department of Orthopaedic Surgery, Shriners Hospital for Children, Northern California, Sacramento, California, USA
| | - Munish C Gupta
- Department of Orthopedic Surgery, School of Medicine, Washington University, Saint Louis, Missouri, USA
| | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Sacramento, California, USA; Department of Orthopaedic Surgery, Shriners Hospital for Children, Northern California, Sacramento, California, USA
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Clin J, Le Navéaux F, Driscoll M, Mac-Thiong JM, Labelle H, Parent S, Shah SA, Lonner BS, Newton PO, Serhan H. Biomechanical Comparison of the Load-Sharing Capacity of High and Low Implant Density Constructs With Three Types of Pedicle Screws for the Instrumentation of Adolescent Idiopathic Scoliosis. Spine Deform 2019; 7:2-10. [PMID: 30587316 DOI: 10.1016/j.jspd.2018.06.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 06/05/2018] [Accepted: 06/09/2018] [Indexed: 10/27/2022]
Abstract
STUDY DESIGN Biomechanical numerical simulation analysis of implant design and density in adolescent idiopathic scoliosis posterior instrumentation. OBJECTIVES To evaluate the combined effect of pedicle screw design and density on deformity correction and construct load-sharing capacity. SUMMARY OF BACKGROUND DATA Screw density is an area of popular study because of the impact of cost and potential patient morbidity of higher-density constructs. Using fewer screws raises concern about reduced correction and greater forces on each screw. METHODS Personalized spinal numerical models were created for five patients. The correction techniques from five spine surgeons using both a high- and a low-density implant pattern (2 vs. 1.4 ± 0.22 screws/level) with uniaxial, multiaxial, and favored angle screws were simulated. The predicted correction and forces sustained by the implants were compared. The postoperative load-sharing capacity of a high- and a low-density construct, with or without crosslinks, was compared by simulating daily activities motions. RESULTS The major coronal curve correction was similar with high- and low-density constructs (73% ± 10% vs. 72% ± 10%; p > .05) but was higher when using uniaxial (77% ± 8%) compared to multiaxial (69% ± 11%) and favored angle screws (71% ± 10%; p = .009). High- and low-density constructs sustained similar intraoperative peak forces (305 ± 61 N vs. 301 ± 73 N; p = .23) regardless of screw design (all p > .05). Multiaxial and favored angle screws reduced the peak axial force by 23% and 38% compared to uniaxial screws (p = .007). The high-density construct reduced the postoperative loads sustained by each implant by 31% (p = .006). Crosslinks had no effect on load sharing (p = .23). CONCLUSION High- and low-density implant patterns achieved similar coronal correction with equivalent capacity to share corrective forces regardless of the screw design. Increased degrees of freedom of the screw head reduces the capacity to correct coronal deformity but generates lower bone-screw forces. The reduced number of screws increased the postoperative forces sustained by each screw, but its effect on potential complications requires further investigations. LEVEL OF EVIDENCE Level 4.
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Affiliation(s)
- Julien Clin
- Spinologics, Inc., 6750 Avenue de l'Esplanade #290, Montréal, Quebec, H2V 1A2, Canada
| | - Franck Le Navéaux
- Spinologics, Inc., 6750 Avenue de l'Esplanade #290, Montréal, Quebec, H2V 1A2, Canada.
| | - Mark Driscoll
- Spinologics, Inc., 6750 Avenue de l'Esplanade #290, Montréal, Quebec, H2V 1A2, Canada
| | - Jean-Marc Mac-Thiong
- Spinologics, Inc., 6750 Avenue de l'Esplanade #290, Montréal, Quebec, H2V 1A2, Canada
| | - Hubert Labelle
- Spinologics, Inc., 6750 Avenue de l'Esplanade #290, Montréal, Quebec, H2V 1A2, Canada
| | - Stefan Parent
- Spinologics, Inc., 6750 Avenue de l'Esplanade #290, Montréal, Quebec, H2V 1A2, Canada
| | - Suken A Shah
- Nemours Alfred I. Dupont Hospital for Children, 1600 Rockland Rd, Wilmington, DE 19803, USA
| | - Baron S Lonner
- Mount Sinai Hospital, E 101st St, New York, NY 10029, USA
| | - Peter O Newton
- Rady Children's Hospital, 3020 Children's Way, San Diego, CA 92123, USA
| | - Hassan Serhan
- DePuy Synthes Spine Inc., 325 Paramount Drive, Raynham, MA 02767, USA
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Le Navéaux F, Larson AN, Labelle H, Aubin CE. Significant variability in surgeons' preferred correction maneuvers and instrumentation strategies when planning adolescent idiopathic scoliosis surgery. Scoliosis Spinal Disord 2018; 13:21. [PMID: 30324149 PMCID: PMC6174067 DOI: 10.1186/s13013-018-0169-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 08/21/2018] [Indexed: 12/04/2022]
Abstract
BACKGROUND Increased implant number is thought to provide better control on the scoliotic spine, but there is limited scientific evidence of improved deformity correction and surgical outcomes with high-density constructs. The objective is to assess key anchor points used by experienced spinal deformity surgeons and to evaluate the effect of implant density pattern on correction techniques. METHODS Seventeen experienced spine surgeons reviewed five Lenke 1 adolescent idiopathic scoliosis cases and provided their preferred posterior correction technique (implant pattern, correction maneuvers, and implants used for their execution) and an alternative technique with the minimal implant density they felt would be acceptable (170 surgical plans total). Additionally, for each case, they selected acceptable screw patterns for surgery from seven published implant configurations. Variability in the surgeons' plans was assessed, including instrumentation and correction strategies. RESULTS The preferred correction plan involved an average of 1.65 implants/vertebra, with 88% of the available anchor points at the apex ± 1 vertebra used for the execution of correction maneuvers and only 43% of possible anchor points used proximal and distal to the apical area. The minimal density that surgeons found acceptable was 1.24 implants/vertebra. The minimal density plan involved more in situ rod contouring (53 vs. 41%), fewer vertebral derotation maneuvers (82 vs. 96%), and fewer implants used for compression/distraction maneuvers (1.18 and 1.42 respectively) (p < 0.05). Implant placement at alternate levels or dropout of convex implants above and below the apical area was most frequently considered acceptable (> 70% agreement). CONCLUSIONS Implant position and number affect surgeons correction maneuvers selection. For low implant density constructs, dropout in the convexity and particularly in the periapical region is accepted by surgeons, with minor influence on planned correction maneuvers. Thus, preoperative implant planning must take into account which anchor points are needed for desired correction maneuvers.
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Affiliation(s)
- Franck Le Navéaux
- Department of Mechanical Engineering, Polytechnique Montreal, P.O. Box 6079, Downtown Station, Montreal, QC H3C 3A7 Canada
- Research Center, Sainte-Justine University Hospital Center, 3175, Cote Sainte-Catherine Road, Montreal, QC H3T 1C5 Canada
- Canada Research Chair in Orthopedic Engineering, and NSERC/Medtronic Industrial Research Chair in Spine Biomechanics, Department of Mechanical Engineering, Polytechnique Montreal, P.O. Box 6079, Downtown Station, Montreal, QC H3C 3A7 Canada
| | | | - Hubert Labelle
- Research Center, Sainte-Justine University Hospital Center, 3175, Cote Sainte-Catherine Road, Montreal, QC H3T 1C5 Canada
| | - Carl-Eric Aubin
- Department of Mechanical Engineering, Polytechnique Montreal, P.O. Box 6079, Downtown Station, Montreal, QC H3C 3A7 Canada
- Research Center, Sainte-Justine University Hospital Center, 3175, Cote Sainte-Catherine Road, Montreal, QC H3T 1C5 Canada
- Canada Research Chair in Orthopedic Engineering, and NSERC/Medtronic Industrial Research Chair in Spine Biomechanics, Department of Mechanical Engineering, Polytechnique Montreal, P.O. Box 6079, Downtown Station, Montreal, QC H3C 3A7 Canada
| | - Minimize Implants Maximize Outcomes Study Group
- Department of Mechanical Engineering, Polytechnique Montreal, P.O. Box 6079, Downtown Station, Montreal, QC H3C 3A7 Canada
- Research Center, Sainte-Justine University Hospital Center, 3175, Cote Sainte-Catherine Road, Montreal, QC H3T 1C5 Canada
- Mayo Clinic, 200 1st Street SW, Rochester, MN 55902 USA
- Canada Research Chair in Orthopedic Engineering, and NSERC/Medtronic Industrial Research Chair in Spine Biomechanics, Department of Mechanical Engineering, Polytechnique Montreal, P.O. Box 6079, Downtown Station, Montreal, QC H3C 3A7 Canada
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Abstract
The article addresses patient safety topics in spine surgery, including infection, length of stay, instrumentation strategies, pedicle screw malposition, radiation exposure, and neurologic events. Quality, safety, and value are concepts that are practical, easy to understand, and can be implemented on any scale and may be matched to individual practices. Further, with quality improvement, there is a culture shift to openly share information, protocols, and strategies so that more patients can rapidly benefit.
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Affiliation(s)
- Bayard C Carlson
- Department of Orthopedic Surgery, Mayo Clinic Rochester, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Todd A Milbrandt
- Department of Orthopedic Surgery, Mayo Clinic Rochester, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - A Noelle Larson
- Department of Orthopedic Surgery, Mayo Clinic Rochester, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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Shen M, Jiang H, Luo M, Wang W, Li N, Wang L, Xia L. Comparison of low density and high density pedicle screw instrumentation in Lenke 1 adolescent idiopathic scoliosis. BMC Musculoskelet Disord 2017; 18:336. [PMID: 28768503 PMCID: PMC5541645 DOI: 10.1186/s12891-017-1695-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 07/24/2017] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND The correlation between implant density and deformity correction has not yet led to a precise conclusion in adolescent idiopathic scoliosis (AIS). The aim of this study was to evaluate the effects of low density (LD) and high density (HD) pedicle screw instrumentation in terms of the clinical, radiological and Scoliosis Research Society (SRS)-22 outcomes in Lenke 1 AIS. METHODS We retrospectively reviewed 62 consecutive Lenke 1 AIS patients who underwent posterior spinal arthrodesis using all-pedicle screw instrumentation with a minimum follow-up of 24 months. The implant density was defined as the number of screws per spinal level fused. Patients were then divided into two groups according to the average implant density for the entire study. The LD group (n = 28) had fewer than 1.61 screws per level, while the HD group (n = 34) had more than 1.61 screws per level. The radiographs were analysed preoperatively, postoperatively and at final follow-up. The perioperative and SRS-22 outcomes were also assessed. Independent sample t tests were used between the two groups. RESULTS Comparisons between the two groups showed no significant differences in the correction of the main thoracic curve and thoracic kyphosis, blood transfusion, hospital stay, and SRS-22 scores. Compared with the HD group, there was a decreased operating time (278.4 vs. 331.0 min, p = 0.004) and decreased blood loss (823.6 vs. 1010.9 ml, p = 0.048), pedicle screws needed (15.1 vs. 19.6, p < 0.001), and implant costs ($10,191.0 vs. $13,577.3, p = 0.003) in the LD group. CONCLUSIONS Both low density and high density pedicle screw instrumentation achieved satisfactory deformity correction in Lenke 1 AIS patients. However, the operating time and blood loss were reduced, and the implant costs were decreased with the use of low screw density constructs.
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Affiliation(s)
- Mingkui Shen
- Institute of Spinal Deformity, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, People's Republic of China
| | - Honghui Jiang
- Department of Orthopaedic Surgery, Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, People's Republic of China
| | - Ming Luo
- Institute of Spinal Deformity, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, People's Republic of China
| | - Wengang Wang
- Institute of Spinal Deformity, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, People's Republic of China
| | - Ning Li
- Institute of Spinal Deformity, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, People's Republic of China
| | - Lulu Wang
- Institute of Spinal Deformity, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, People's Republic of China
| | - Lei Xia
- Institute of Spinal Deformity, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, People's Republic of China.
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Di Silvestre M, Bakaloudis G, Ruosi C, Pipola V, Colella G, Greggi T, Ruffilli A, Vommaro F. Segmental vs non-segmental thoracic pedicle screws constructs in adolescent idiopathic scoliosis: is there any implant alloy effect? Eur Spine J 2017; 26:533-538. [PMID: 28349268 DOI: 10.1007/s00586-017-5046-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Revised: 03/10/2017] [Accepted: 03/12/2017] [Indexed: 11/28/2022]
Abstract
PURPOSE The aim of this study is to understand how many anchor sites are necessary to obtain maximum posterior correction of idiopathic scoliotic curve and if the alloy of instrumentation, stainless steel or titanium, may have a role in the percent of scoliosis correction. METHODS We reviewed 143 consecutive patients, affected by AIS (Lenke 1-2), who underwent a posterior spinal fusion with pedicle screw-only instrumentation between 2002 and 2005. According to the implant density and alloy used we divided the cohort in four groups. RESULTS All 143 patients were reviewed at an average follow-up of 7, 2 years, the overall final main thoracic curve correction averaged 61.4%, whereas the implant density within the major curve averaged 71%. A significant correlation was observed between final% MT correction and preoperative MT flexibility and implant density. CONCLUSIONS When stainless steel instrumentation is used non-segmental pedicle screw constructs seem to be equally effective as segmental instrumentations in obtaining satisfactory results in patients with main thoracic AIS. When the implant alloy used is titanium one, an implant density of ≥60% should be guaranteed to achieve similar results.
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Affiliation(s)
- Mario Di Silvestre
- Spine Deformity Department, Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136, Bologna, Italy.
| | - Georgeous Bakaloudis
- Spine Deformity Department, Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136, Bologna, Italy
| | - Carlo Ruosi
- Spine Deformity Department, Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136, Bologna, Italy
| | - Valerio Pipola
- Spine Deformity Department, Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136, Bologna, Italy
| | - Gianluca Colella
- Spine Deformity Department, Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136, Bologna, Italy
| | - Tiziana Greggi
- Spine Deformity Department, Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136, Bologna, Italy
| | - Alberto Ruffilli
- Spine Deformity Department, Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136, Bologna, Italy
| | - Francesco Vommaro
- Spine Deformity Department, Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136, Bologna, Italy
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Le Navéaux F, Larson AN, Labelle H, Wang X, Aubin CÉ. How does implant distribution affect 3D correction and bone-screw forces in thoracic adolescent idiopathic scoliosis spinal instrumentation? Clin Biomech (Bristol, Avon) 2016; 39:25-31. [PMID: 27639485 DOI: 10.1016/j.clinbiomech.2016.09.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 09/01/2016] [Accepted: 09/05/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Optimal implant densities and configurations for thoracic spine instrumentation to treat adolescent idiopathic scoliosis remain unknown. The objective was to computationally assess the biomechanical effects of implant distribution on 3D curve correction and bone-implant forces. METHODS 3D patient-specific biomechanical spine models based on a multibody dynamic approach were created for 9 Lenke 1 patients who underwent posterior instrumentation (main thoracic Cobb: 43°-70°). For each case, a factorial design of experiments was used to generate 128 virtual implant configurations representative of existing implant patterns used in clinical practice. All instances except implant configuration were the same for each surgical scenario simulation. FINDINGS Simulation of the 128 implant configurations scenarios (mean implant density=1.32, range: 0.73-2) revealed differences of 2° to 10° in Cobb angle correction, 2° to 7° in thoracic kyphosis and 2° to 7° in apical vertebral rotation. The use of more implants, at the concave side only, was associated with higher Cobb angle correction (r=-0.41 to -0.90). Increased implant density was associated with higher apical vertebral rotation correction for seven cases (r=-0.20 to -0.48). It was also associated with higher bone-screw forces (r=0.22 to 0.64), with an average difference between the least and most constrained instrumentation constructs of 107N per implant at the end of simulated instrumentation. INTERPRETATION Low-density constructs, with implants mainly placed on the concave side, resulted in similar simulated curve correction as the higher-density patterns. Increasing the number of implants allows for only limited improvement of 3D correction and overconstrains the instrumentation construct, resulting in increased forces on the implants.
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Affiliation(s)
- Franck Le Navéaux
- Polytechnique Montréal, Department of Mechanical Engineering, P.O. Box 6079, Downtown Station, Montréal, Québec H3C 3A7, Canada; Research Center, Sainte-Justine University Hospital Center, 3175, Côte Sainte-Catherine Road, Montréal, Québec H3T 1C5, Canada
| | | | - Hubert Labelle
- Research Center, Sainte-Justine University Hospital Center, 3175, Côte Sainte-Catherine Road, Montréal, Québec H3T 1C5, Canada
| | - Xiaoyu Wang
- Polytechnique Montréal, Department of Mechanical Engineering, P.O. Box 6079, Downtown Station, Montréal, Québec H3C 3A7, Canada; Research Center, Sainte-Justine University Hospital Center, 3175, Côte Sainte-Catherine Road, Montréal, Québec H3T 1C5, Canada
| | - Carl-Éric Aubin
- Polytechnique Montréal, Department of Mechanical Engineering, P.O. Box 6079, Downtown Station, Montréal, Québec H3C 3A7, Canada; Research Center, Sainte-Justine University Hospital Center, 3175, Côte Sainte-Catherine Road, Montréal, Québec H3T 1C5, Canada.
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