Prosthetic Rib Research Articles

Efficacy of distal pedicle screw fixation as a caudal foundation in VEPTR growing rod constructs for early onset scoliosis.

Surgical treatment of Early Onset Scoliosis (EOS) is challenging. Stable and robust foundations are vital. We have assessed a small cohort of patients with a rib-based proximal fixation and a pedicle screw-based distal foundation for a distraction based growing rod system. This is a single center study in a tertiary spinal deformity unit with a catchment population of over 6 million. We performed a retrospective radiographic evaluation of 15 patients with EOS treated with Vertical Expandable Titanium Prosthetic Rib (VEPTR) implant between 2007 and 2017. The review of medical records and imaging data was performed to identify growth of the spine and complications with pedicle screws. There were ten male and five female patients with an average age at index surgery of 4yrs 11months. Mean length of follow-up was 6yrs 9months. Serial radiographs revealed improvements in mean Cobb angle of 12 degrees, T1-T12 height of 29mm and T1-S1 height of 48mm with no deterioration in distal LIV tilt angle. We report that none of these patients had any complications related to their pedicle screws including cut-out. We report a technique which is efficacious and provides a mechanically robust distal fixation for VEPTR lengthening in early onset scoliosis.

Growth-preserving instrumentation in early-onset scoliosis patients with multi-level congenital anomalies.

Retrospective. To assess final outcomes in patients with early-onset scoliosis (EOS) who underwent growth-preserving instrumentation (GPI). Various types of growth-preserving instrumentation (GPI) are frequently employed, but until recently had not been utilized long enough to assess final outcomes. GPI "graduates" with multi-level congenital curves were identified. Graduation was defined as a final fusion or 5years of follow-up without planned future surgeries. Outcomes included radiographic parameters and complications. 26 patients were included. 11 had associated diagnoses; eight had fused ribs. 17 were treated with traditional growing rods, seven with vertically expandable prosthetic ribs, and two with Shilla procedures. The mean GPI spanned 12.3 levels including 10.7 motion segments, age at index surgery was 5.5years, treatment spanned 7.5years, and follow-up was 9.2years. 24 patients underwent final fusion. Mean major curve decreased from 73° to 49° with index surgery (p < 0.01) and remained unchanged through a final follow-up. Final major curve was < 40° in 9 patients (35%), 40°-60° in 11 patients (42%), and > 60° in 6 patients (23%). None worsened throughout treatment. Mean T1-T12 height increased 2.4cm with index surgery (p = 0.02) and 5.4cm total (p < 0.01). T1-T12 height increased in all patients and was ultimately < 18cm in 10 patients (38%), 18-22cm in 10 patients (38%), and > 22cm in 6 patients (23%). On average, there were 2.6 complications per patient, including 1.7 implant failures. 12 patients (46%) experienced ≥ 3 complications; four patients (15%) experienced none. We observed successful prevention of deformity progression but substantial residual deformity among GPI graduates with multi-level congenital EOS. Most coronal curve correction was attained during GPI implantation; thoracic height improved throughout treatment. While some favorable results were found, treatment strategies allowing improved deformity correction would be valuable for this challenging population. Therapeutic-III.

Three-Dimensional Printing for Chest Wall Reconstruction in Thoracic Surgery: Building on Experience.

Patients undergoing surgery for locally advanced lung cancer involving the chest wall require anatomical lung with extensive en-bloc chest wall resection and appropriate reconstruction.In this proof-of-concept study, we aimed to produce personalized three-dimensional (3D)-printed chest wall prosthesis for a patient undergoing chest wall resection and reconstruction using clinically obtained computed tomography (CT) data. Preoperative CT scans of three patients undergoing chest wall resection were analyzed and the areas of resection segmented. This was then used to produce a 3D print of the chest wall and a silicone mold was created from the model. This mold was sterilized and used to produce methyl methacrylate prostheses which were then implanted into the patients. Three patients had their chest wall reconstructed using this technique to produce a patient specific prosthesis. There were no early complications or deaths. It is possible to use 3D printing to produce a patient specific chest wall reconstruction for patients undergoing chest wall resection for malignancy that is cost-effective. This chest wall is thought to provide stability in the form of prosthetic ribs as well compliance in the form of an expanded polytetrafluoroethylene patch. Further research is required to measure chest wall compliance during the respiratory cycle and long-term follow-up from this method.

Comparing Risk of Unplanned Returned to the Operating Room (UPROR): Magnetically Controlled Growing Rod (MCGR) System vs Prosthetic Rib Constructs (PRC)

Comparing Risk of Unplanned Returned to the Operating Room (UPROR): Magnetically Controlled Growing Rod (MCGR) System vs Prosthetic Rib Constructs (PRC)

How Often Do You Lengthen? A Physician Survey on Lengthening Practice for Prosthetic Rib Devices

Study DesignPhysician survey. ObjectivesTo identify physician practice patterns in use of prosthetic rib devices. BackgroundManagement of scoliosis with prosthetic ribs involves repeated expansions. Despite this, there is a paucity of literature on expansion practice. We believe that despite minimal literature, there exist surgeon practice patterns. MethodsThirty-seven surgeons from the Children’s Spine Study Group, with prosthetic rib experience, were anonymously surveyed about their expansion practice. ResultsThere was strong consensus that elapsed time since previous surgery was the most important factor in choosing lengthening intervals, with 94.5% of responders agreeing. Surgeons indicated that they often apply a standard expansion interval. 97.3% reported using one in >25% of cases, with 70.3% using a standard interval in >80% of cases. Six months was the most commonly reported elapsed time interval, with 78.4% of responders in agreement. There was also consensus on non-time factors. Patient maturity was cited a major factor in choosing lengthening interval in >80% of cases by 59.5% of responders. Patient age was frequently cited as a factor, with 73% of surgeons using it in >25% of cases. Additionally, there was consensus on factors that were not utilized. More than three-fourths (75.7%) stated that they use patients' bone quality <25% of the time. Similarly, 70.3% used resistance encountered in the last lengthening <25% of the time, with 13.5% never considering. ConclusionDespite the lack of evidence-based guidelines regarding lengthening practice for prosthetic ribs, there is some consensus on the factors used to choose an appropriate expansion interval. The greatest consensus surrounded the use of a standard six-month elapsed time interval between expansions. From these data, we conclude that specialists have reached relative consensus on factors important for choosing an appropriate expansion interval. We believe these data are an important step toward developing best practice guidelines and identifying areas of equipoise amenable for future research. Level of EvidenceLevel V.

Treatment strategies for early-onset scoliosis.

Early-onset scoliosis (EOS) is defined as a spinal deformity occurring before the age of ten years.Untreated EOS or early spinal fusion resulting in a short spine is associated with increased mortality and cardiopulmonary compromise.EOS may progress rapidly, and therefore prompt clinical diagnosis and referral to a paediatric orthopaedic or spine unit is necessary.Casting under general anaesthesia can be effective and may prevent or delay the need for surgery in curves of less than 60°.‘Growing’ rods (traditional or magnetically-controlled) represent the standard surgical treatment in progressive curves of 45° or greater.Children with congenital scoliosis associated with fused ribs benefit from surgery with a vertical titanium prosthetic rib.Surgery with growth-friendly instrumentation is associated with a high risk of complications.Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170051

Personalized reconstruction of large chest wall defect with rapid prototype prosthetic rib: early result and long-term patient outcomes in three cases

The innovation from merging computed tomography (CT) measurement data to rapid prototyping, that now allow the production of solid copies of the patient's bones, has presented thoracic surgeons with new opportunities in large chest wall reconstruction. Since 2010, our department applied this technique to prepare rapid prototype prosthetic ribs (RPPRs) which were customized for each patient.

Monopolar-probe monitoring during spinal surgery with expandable prosthetic ribs

BackgroundIntraoperative monitoring (IOM) has been proven to decrease the risk of neurological injury during scoliosis surgery. The vertical expandable prosthetic titanium rib (VEPTR) is a device that allows spinal growth. However, injuries to the spinal cord and brachial plexus have been reported after VEPTR implantation in 2 and 5% of patients, respectively. Simultaneous monitoring of these two structures requires the use of multiple time-consuming and complex methods that are ill-suited to the requirements of paediatric surgery, particularly when repeated VEPTR lengthening procedures are needed. We developed a monopolar stimulation method derived from Owen's monitoring technique. This method is easy to implement, requires only widely available equipment, and allows concomitant monitoring of the spinal cord and brachial plexus. The primary objective of this study was to assess the reliability of our technique for brachial plexus monitoring by comparing the stability of neurogenic mixed evoked potentials (NMEPs) at the upper and lower limbs. HypothesisWe hypothesised that the coefficients of variation (CVs) of NMEPs were the same at the upper and lower limbs. Material and methodsTwelve VEPTR procedures performed in 6 patients between 1st January 2012 and 1st September 2014 were monitored using a monopolar stimulating probe. NMEPs were recorded simultaneously at the upper and lower limbs, at intervals of 150s. The recording sites were the elbow over the ulnar nerve and the popliteal fossa near the sciatic nerve. Wilcoxon's test for paired data was used to compare CVs of the upper and lower limb NMEPs on the same side. ResultsMean CV of NMEP amplitude at the lower limbs was 16.34% on the right and 16.67% on the left; corresponding values for the upper limbs were 18.30 and 19.75%, respectively. Mean CVs of NMEP latencies at the lower limbs were 1.31% on the right and 1.19% on the left; corresponding values for the upper limbs were 1.96 and 1.73%. The risk of type I error for a significant difference between the upper and lower limbs was 0.5843 on the right and 0.7312 on the left for NMEP amplitudes and 0.7618 on the right and 0.4987 on the left for NMEP latencies. ConclusionUsing an epidural active electrode and a sternal return electrode allows simultaneous stimulation of the cervical spinal cord and brachial plexus roots. The NMEPs thus obtained are as stable (reliable) at the upper limbs as at the lower limbs. This easy-to-implement method allows simultaneous monitoring of the upper and lower limbs. It seems well suited to VEPTR procedures. Level of evidenceIV, retrospective single-centre non-randomised study.

Non-fusion and growing instrumentation in the correction of congenital spinal deformity associated with split spinal cord malformation: an early follow-up outcome

A retrospective case review. To evaluate the safety and efficacy of the non-fusion technique in achieving and maintaining the proper correction for congenital spinal deformity (CSD) and allowing normal spinal growth in patients with split spinal cord malformation (SSCM). Seven patients who had CSD and SSCM were adopted, with a mean age of 8 years. All the patients in this study received Halo-gravity traction (HGT) prior to expansion of the spine and instrumentation with vertical expandable titanium prosthetic rib, growing rod or their hybrid. Five of them underwent opening wedge thoracoplasty simultaneously. And the two patients with type I SSCM underwent bony spur excision in the initial surgery before corrective manipulation. Then all the patients received a lengthened operation every six months. Changes of their major curve and length of T1-S1 spine were measured, and complications, neurological status were recorded. All the patients were followed up with an average of 32.6 months. Their mean major curve improved from 90.1° to 58.6° with a correction rate of 34.9 %. The T1-S1 length increased from 26.3 to 34.7 cm at final follow-up. Especially, one of the type I SSCM patients whose neurological deterioration was found preoperatively was significantly improved. Preoperative Halo-gravity traction followed by non-fusion and growing instrumentation may be effective and safe for young children of CSD associated with SSCM. But it is an ongoing study and additional large multicenter studies are necessary to further assess the safety and efficacy of non-fusion and growing instrumentation.

Prosthetic Rib May Be Effective in Treating Patients With Severe Spina Bifida

Lippincott's Bone and Joint Newsletter: February 2011 - Volume 17 - Issue 2 - p 18-19 doi: 10.1097/01.BONEJ.0000394017.08329.6d

PRINCIPLES OF GROWTH MODULATION IN THE TREATMENT OF SCOLIOTIC DEFORMITIES

Intraoperative manipulation to correct scoliotic deformities relies upon spinal instrumentation for stabilization and fusion. However, novel strategies and innovative implant biotechnologies have emerged, applying natural growth and elongation of the immature spine for the treatment of scoliosis in young patients. In this work, we review the principles of growth modulation and the Hueter-Volkmann law as it applies to experimental models of scoliosis formation and correction. Current implant technologies, including shape memory alloy vertebral staples, growing rods, and vertical expandable titanium prosthetic ribs, are explored, with regards to implant design, surgical techniques, and clinical investigations. An exciting area of spinal implant technology is now becoming available to expand the surgical armamentarium for treating severe scoliotic deformity in young patients.

Growing Rod Techniques in Early-Onset Scoliosis

The surgical treatment of severe early-onset scoliosis (EOS) is controversial. Obtaining and maintaining deformity correction, achieving adequate spinal growth, allowing lung development, and the high complication rate make surgical treatment very challenging. Growing rods are the most common method of management. Currently, there are 3 systems being used for the surgical treatment of EOS: single growing rod, dual growing rods, and the vertical expandable titanium prosthetic rib implant. Each system has its advantages and disadvantages. These are presented and discussed in this review. The current clinical and radiographic results indicate that all 3 techniques can be effective in the surgical management of EOS. Vertical expandable prosthetic titanium rib (VEPTR), which is not considered a true growing rod system, is particularly effective in congenital scoliosis with fused ribs. The current expandable spinal implant systems appear effective in controlling progressive EOS, allowing for spinal growth and improving lung development. All have a moderate complication rate, especially rod breakage and hook displacement.

Growth of the thoracic spine in congenital scoliosis after expansion thoracoplasty.

Children with congenital thoracic scoliosis associated with fused ribs with a unilateral unsegmented bar adjacent to convex hemivertebrae will invariably have curve progression without treatment. Surgery has been thought to have a negligible growth-inhibition effect on the thoracic spine in such patients because it has been assumed that the concave side of the curve and the unilateral unsegmented bar do not grow, but we are unaware of any conclusive studies regarding this assumption. The changes in the length of the concave and convex sides, anterior and posterior vertebral edges, posterior arch, and unilateral unsegmented bars of the thoracic spine were measured in the twenty-one children with congenital scoliosis and fused ribs after expansion thoracoplasty had been carried out with use of a vertical, expandable titanium prosthetic rib. Three of these children had undergone posterior spinal fusion previously. Measurements were made with use of a three-dimensional software program that analyzed baseline and follow-up computed tomography scans. The technique was validated through measurement of the thorax of a small female adult cadaver. The patients without spine fusion had an average age of 3.3 years at the time of the baseline computed tomography scan, and the average duration of follow-up was 4.2 years. On the average, these patients showed significant growth (p < 0.0001) of the concave side of the thoracic spine (an increase in length of 7.9 mm/yr, or 7.1%/yr) and the convex side (8.3 mm/yr, or 6.4%/yr) compared with the baseline lengths. There was no significant difference in the increases in length (p = 0.38) between the concave and convex sides. Eleven patients with an unsegmented bar had an average 7.3% increase in the length of the bar (p < 0.0001). In the three children with prior spinal fusion, the increase in length averaged only 4.6 mm/yr (3%/yr) on the concave side of the thoracic spine and 3.7 mm/yr (2.2%/yr) on the convex side; both increases were significant (p < 0.0001). Longitudinal growth of the thoracic spine in a normal child has been estimated to be 0.6 cm/yr between the ages of five and nine years. After expansion thoracoplasty, growth of the thoracic spine was approximately 8 mm/yr in our series of children with congenital scoliosis and fused ribs. After expansion thoracoplasty, both the concave and the convex side of the thoracic spine and unilateral unsegmented bars appeared to grow in these patients. When a thorax is already foreshortened by congenital scoliosis, control of spine deformity with expansion thoracoplasty allows growth of the thoracic spine, and it is likely that the longer thorax provides additional volume for growth of the underlying lungs with probable clinical benefit. Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

Treatments for flail chest

Two patients with flail chest due to chest trauma were treated.Many authors have recommended a respiratory fixing method with the use of a ventilator. However the surgical fixation is most important both in simple chest trauma and in severe dislocation of fracture segments. This method shortens the respiratory fixing times. Prosthetic ribs made from alumina ceramics are thought to be excellent materials for rib fixing.