How to Select the Lower Instrumented Vertebra in Traditional Growing Rods Index Surgery

BACKGROUND

There are still no consensus criteria on how to select the lower instrumented vertebra (LIV) for traditional growing rods (TGRs) at index surgery. The aim was to evaluate whether the criteria used for adolescent idiopathic scoliosis fusion adapts to early onset scoliosis (EOS).

METHODS

Retrospective analysis of prospectively longitudinal collected data in a consecutive cohort of patients with EOS treated with TGR, expanding from index surgery to 2 years after graduation. The LIV was analyzed regarding its relation to the stable vertebra (SV), substantially touched vertebra (STV), and not STV (NSTV). Failure of LIV selection was considered when revision surgery with distal extension was needed during follow up, due to adding on (ΔLIV tilt > 10°).

RESULTS

A total of 25 patients met inclusion criteria. Mean age was 8.6 ± 3 (at index surgery), 15.1 ± 1.8 (at graduation), and 17.8 ± 1.6 (at final follow up). The most frequent LIV at index surgery was L3 (13/25); in 13 cases, STV was selected as LIV; in 7, it was NSTV; and in 5, SV on the standard postero-anterior radiographs. During follow up, a significant increase in the mean LIV tilt (P = .049) and distal junctional angle (P = .017) was found. Nine of the 25 patients (36%) developed adding on: 20% (1/5) of those with LIV at SV, 38.5% (5/13) at STV, and 42.8% (3/7) at NSTV. Of those 9 cases of adding on, only four needed distal extension (mean LIV tilt = 17.6°): 2 STV patients (15.4%), and 2 NSTV patients (28.6%). None of the patients with the LIV chosen at SV needed distal extension due to adding on.

CONCLUSIONS

The more cranial the selection of the LIV above the SV, the higher the risk of adding on and of revision surgery with distal extension during follow up. Saving motion segments could be justified by choosing STV as LIV because the need for distal extension is not high, and it can be scheduled during lengthening procedures or at graduation surgery.

LEVEL OF EVIDENCE

4.

CLINICAL RELEVANCE

Choosing the correct LIV in TGR index surgery is crucial to have a secure distal foundation, control and correct the deformity during growth, and save distal segments to allow growth and mobility.

Decision Making of Graduation in Patients With Early-Onset Scoliosis at the End of Distraction-Based Programs: Risks and Benefits of Definitive Fusion

STUDY DESIGN

Retrospective comparative analysis.

OBJECTIVE

Study early-onset scoliosis (EOS) graduated patients to establish founded criteria for graduation decision making and determine the risks and benefits of definitive fusion.

SUMMARY OF BACKGROUND DATA

EOS is treated by growth-friendly techniques until skeletal maturity. Afterwards, patients can be "graduated," either by definitive fusion (posterior spinal fusion [PSF]) or by retaining the previous implants (Observation) with no additional surgery. Criteria for this decision making and the outcomes of definitive fusion are still underexplored.

METHODS

We analyzed a consecutive cohort of "graduated" patients after a distraction-based lengthening program. We gathered demographic, radiographic, and surgical data. The results of the two final treatment options were compared after 2 years' follow-up.

RESULTS

A total of 32 patients were included. Four patients had incomplete records. Thirteen underwent PSF, and 15 were observed. The mean age at initial treatment was 8 ± 3 years, with a mean follow-up of 8.3 ± 2.9 years. Both groups had similar preoperative and final radiographic parameters (p > .05). The criteria for undergoing PSF were as follows: implant-related complications, main curve magnitude (PSF = 63.2° ± 9° vs. OBS = 47.9° ± 15°; p = .008), curve progression >10°, and sagittal misalignment (SVA). During PSF 12/13 patients underwent multiple osteotomies, one vertebrectomy, and 3 costoplasties. Surgical time was 291.5 ± 58 minutes; blood loss was 946 ± 375 mL; and the number of levels fused was 13.7. Coronal deformity was corrected 31%, T1-S1 length gained was 31 ± 19.6 mm and T1-T12 length gained was 9.3 ± 39 mm; kyphosis was reduced by 22%. However, coronal balance worsened by 2.3 ± 30.8 mm. No major complications were encountered in these patients.

CONCLUSIONS

Graduation by PSF depended on unacceptable or progressive major curve deformity, sagittal misalignment, or complications with previous implants. Observation depended on curve stabilization, Cobb <50°, and coronal misalignment <20 mm. Definitive fusion effectively corrected coronal and sagittal deformity and increased trunk height. However, it exposed patients to a very demanding surgery without improvement in coronal balance.

LEVEL OF EVIDENCE

Level III, therapeutic.

Platelet-rich fibrin in arthroscopic repair of massive rotator cuff tears: a prospective randomized pilot clinical trial

The objective of this study was to prospectively evaluate the feasibility of a large- scale project on the influence of local application of Platelet Rich Fibrin (PRF) on the functional outcome and integrity of the arthroscopically repaired tendons in patients with massive tears of the rotator cuff. A prospective, randomized pilot clinical trial was performed on 28 patients (22 females, 6 males) with an average age of 65 years (range: 53 to 77) undergoing complete arthroscopic repair of a massive rotator cuff tear. After the repair was completed, 6 ml PRF (Vivostat) was locally applied to the repair site in 14 patients; no similar action was done in the other 14 patients. All patients underwent a clinical examination and an arthro-MRI to evaluate the integrity of the repair, one year after the operation. They were followed clinically for a minimum of 2 years. Functional outcome was evaluated with the Constant and DASH scores. There were no reported complications in either group. None of the patients was lost to follow-up. Globally, the Constant score improved from 45 preoperatively (range: 25 to 65) to 64 at one year (range: 20 to 79) (p < 0.001), with no significant change at two years (mean 63, range: 20 to 77). The VAS for pain improved from 5.6/10 preoperatively to 1.7/10 at the most recent examination (p < 0.001). All but two patients were satisfied. With the numbers of patients available, we could not detect a significant difference in the preoperative (46 vs. 43; p = 037) or postoperative Constant score (61 vs. 68; p = 0.125) between the control group and the PRF group. On arthro-MRI, 19 of the 28 patients (68%) were found to have a large re-tear : 10/14 in the PRF group and 9/14 in the control group. Local application of autologous PRF to the repair site of massive rotator cuffs fully reconstructed arthroscopically failed to improve the clinical outcome and the healing rate, compared with a standard repair. However, a large-scale study would be necessary to confirm these results.

Proximal junctional vertebral fracture-subluxation after adult spine deformity surgery. Does vertebral augmentation avoid this complication? A case report

Background

To report to the orthopedic community a case of vertebral fracture and adjacent vertebral subluxation through the upper instrumented vertebra after thoracolumbar fusion with augmentation of the cranial level.

Methods

This report reviewed the patient`s medical record, her imaging studies and related literature. The possible factors contributing to this fracture are hypothesized.

Results

A 70-year-old woman underwent decompressive surgery and posterolateral fusion for adult lumbar scoliosis. We used pedicular screws from T10 to S1 and iliac screw at the right side, augmented with cement at T10, T11, L1, L5 and S1; and prophylactic vertebroplasty at T9 to avoid the "topping-off syndrome".

Thirty days after discharge, without recognizable inciting trauma, the patient complained of pain in the lower thoracic area. The exam revealed overall neurological deficit below the level of fracture.

CT scan and MRI demonstrated a T10 vertebral collapse and T9 vertebral subluxation with morphologic features of flexion-distraction fracture through the upper edge of the screw.

At this point, the authors performed posterior decompression at T9 to T10 and extended posterolateral arthrodesis from T2 to T10.

To our knowledge, this is an unreported fracture.

Conclusions

Augmentation of the cranial level in a long thoracolumbar fusion has been developed to avoid the junctional kyphosis and compression fractures at that level. We alert the orthopedic community that this augmentation may lead to further and more severe fractures, although this opinion requires investigation for confirmation.