Vertical Expandable Prosthetic Titanium Rib Research Articles

Increase in Early Onset Scoliosis Publications in Major Orthopaedic and Spine Journals: 2005-2020

Study Design: Retrospective review Purpose: To quantify trends in published research in 8 major orthopaedic and spine journals related to Early Onset Scoliosis (EOS) from 2005-2020. We also investigated publication trends in specific subtopics within EOS research. Methods: The electronic archives of 8 journals (Spine, European Spine Journal, Journal of Children’s Orthopaedics, Spine Deformity, Journal of Pediatric Orthopaedics, Journal of Pediatric Orthopaedics B, The Journal of Bone and Joint Surgery-American Volume and The Bone and Joint Journal) were queried for articles published from 2005-2020 containing search terms particular to the following subtopics of EOS research: congenital scoliosis, infantile scoliosis, thoracic insufficiency syndrome, scoliosis casting, Traditional Growing Rod, Vertical Expandable Prosthetic Titanium Rib, Magnetically Controlled Growing Rod and EOS in general. Results were screened to exclude editorials, conference papers and corrections. Included EOS articles were aggregated and analyzed with respect to journal, year of publication and subtopic. Results: From 2005-2020, a total of 32,000 publications were identified, of which 1,818 (5.7%) were qualified as EOS articles by the presence of at least one search term. The annual number of EOS articles increased from 60 in 2005 to 157 in 2020 and the annual ratio of EOS articles to total publications increased from 4.1% to 7.9%. Congenital spine-related terms matched to the greatest number of articles, while implant-related terms collectively experienced the greatest percentage increase in matching articles per year. Conclusion: The number of EOS articles published in 8 major orthopaedic and spine journals increased in both absolute and relative terms from 2005-2020. Implant-related subtopics saw the greatest increase.

Instrumentation failure following pediatric spine deformity growth-sparing surgery using traditional growing rods or vertical expandable prosthetic titanium ribs

BackgroundInstrumentation failure (IF) is a major complication associated with growth-sparing surgery for pediatric spinal deformities; however, studies focusing on IF following each surgical procedure are lacking. We aimed to evaluate the incidence, timing, and rates of unplanned return to the operating room (UPROR) associated with IF following each surgical procedure in growth-sparing surgeries using traditional growing rods (TGRs) and vertical expandable prosthetic titanium ribs (VEPTRs).MethodsWe reviewed 1,139 surgical procedures documented in a Japanese multicenter database from 2015 to 2017. Of these, 544 TGR and 455 VEPTR procedures were included for evaluation on a per-surgery basis. IF was defined as the occurrence of an implant-related complication requiring revision surgery.ResultsThe surgery-based incidences of IF requiring revision surgery in the TGR and VEPTR groups were 4.3% and 4.0%, respectively, with no significant intergroup difference. Remarkably, there was a negative correlation between IF incidence per surgical procedure and the number of lengthening surgeries in both groups. In addition, rod breakage in the TGR group and anchor-related complications in the VEPTR group tended to occur relatively early in the treatment course. The surgery-based rates of UPROR due to IF in the TGR and VEPTR groups were 2.0% and 1.5%, respectively, showing no statistically significant difference.ConclusionsWe found that IF, such as anchor related-complications and rod breakage, occurs more frequently earlier in the course of lengthening surgeries. This finding may help in patient counseling and highlights the importance of close postoperative follow-up to detect IF and improve outcomes.

Safety and efficacy of growth-friendly instrumentation for early-onset scoliosis in patients with spinal muscular atrophy type 1 in the disease-modifying treatment era.

To evaluate the safety of growth-friendly instrumentation for early-onset scoliosis (EOS) in patients with spinal muscular atrophy (SMA) type 1 who received disease-modifying treatment (DMT) and analyze short-term efficacy. Retrospective search was conducted between 2017 and 2023. Patients with genetically confirmed SMA type 1 who were surgically treated for spinal deformity and receiving DMTs (nusinersen, risdiplam, or onasemnogene abeparvovec) were included. SMA types 2 and 3 and patients who do not receive DMTs were excluded. Clinical and radiographic data were collected at preoperative, postoperative, and latest follow-up visits. Twenty-eight patients (mean follow-up: 16 months (range 2-41)) were included. The mean age at surgery was 60 months (range 29-96). Fifteen were treated with dual magnetically controlled growing rods (MCGR), four with unilateral MCGR and a contralateral guided growth system, three with Vertical Expandable Prosthetic Titanium Rib (VEPTR®) implants, five with self-distracting systems, and one with traditional dual growing rods. The mean amount of correction was 57% (44°± 17) for scoliosis and 83% (13°± 11) for pelvic obliquity. The mean T1-12 height gain during surgery was 31 mm (±16 mm), while the mean T1 S1 height gain was 51 mm (±24 mm), and instrumented growth was observed during follow-up. Five patients (18%) developed six serious adverse events: three surgical site infections, two anchor failures, and one rod fracture, and all required unplanned reoperations. No neurologic complication, difficulty during nusinersen injections, or respiratory decline was recorded. We report that spinal deformity in this population can be safely treated with growth-friendly instrumentation, with similar complication rates when compared with SMA type 2.

Serum Titanium Levels Remain Elevated But Urine Titanium is Undetectable in Children With Early Onset Scoliosis Undergoing Growth-Friendly Surgical Treatment: A Prospective Study

Background: Elevated serum titanium levels have been found in patients with early onset scoliosis (EOS) treated with traditional growing rods (TGR), magnetically controlled growing rods (MCGR), and vertical expandable prosthetic titanium rib (VEPTR). No studies have investigated whether serum titanium remains persistently elevated and if titanium is excreted. Our purpose was to compare serum titanium levels in patients with EOS with growth-friendly instrumentation to age-matched controls and evaluate urine titanium and serial serum titanium levels in patients with EOS. Methods: This was a prospective case-control study. Patients with EOS with TGR, MCGR, or VEPTR underwent urine titanium and serial serum titanium collection at a minimum 6-month interval. Control patients did not have a history of metal implant insertion and underwent serum titanium collection before fracture fixation. Results: Twenty patients with EOS (6 TGR, 8 MCGR, and 6 VEPTR) and 12 controls were analyzed. The control group had no detectable serum titanium (0 ng/mL), whereas the patients with EOS had a median serum titanium of 4.0 ng/mL (P < 0.001). Analysis of variance showed significantly higher median serum titanium levels in the MCGR and VEPTR groups than the TGR group at time point 1 (5.5 vs 6.0 vs 2.0 ng/mL, P = 0.01) and time point 2 (6.5 vs 7.5 vs 2.0 ng/mL, P < 0.001). Binary comparisons showed a significant difference in serum titanium level between TGR and MCGR (time point 1: P = 0.026, time point 2: P = 0.011) and TGR and VEPTR (time point 1: P = 0.035, time point 2: P = 0.003). However, there was no difference between MCGR and VEPTR (time point 1: P = 0.399, time point 2: P = 0.492) even though the VEPTR group had a longer duration of follow-up (P = 0.001) and a greater number of lengthenings per patient at the first serum collection (P = 0.016). No patients with EOS had detectable urine titanium. Conclusions: Patients with EOS treated with titanium alloy growth-friendly instrumentation had elevated serum titanium levels compared with age-matched controls that persisted over time with no evidence of renal excretion. Additional studies are necessary to assess for local and systemic accumulation of titanium and the significance of long-term exposure to titanium in growing children. Level of Evidence: Level III, therapeutic.

Growth-preserving instrumentation for early onset scoliosis

Early onset scoliosis is defined as aspinal deformity originating in the first 10years of life. Growth-preserving spinal instrumentation has therefore been designed to preserve growth of spine and chest wall and lungs to avoid serious pulmonary complications after early spine fusion. Indications, surgical technique and results of the vertical expandable prosthetic titanium rib (VEPTR) technique, traditional growing rods (TGR), and magnetically controlled growing rods (MCGR) will be described. Indications for VEPTR are so-called mixed congenital deformities (type3) associated with vertebral malformations in association with chest wall deformities, especially fused ribs. There are also indications for neuromuscular or syndromic early onset scoliosis with bilateral rib-to-ilium constructs. However, most of those deformities are currently treated with either GR or MCGR in most centers. GR and MCGR are currently the treatment of choice for the majority of early onset scoliosis. There is no indication for growth-preserving strategies if the patients are mature or there is only little growth remaining. In these cases, final fusion should be performed. While the VEPTR technique involves an extensive approach with muscular dissections to the thoracic cage including rib osteotomies and thoracotomies, treatment with TGR or MCGR is minimally invasive, only exposing proximal and distal anchor points, leaving most of the spine including the apex undisturbed. Early mobilization is usually possible after 24-48 h. Braces may have to be prescribed for patients with osteopenia, noncompliance, or arisk to fall. Since 2005, more than 200patients were treated with the VEPTR technique, more than 200 patients with the MCGR technique, and about 30patients with the TGR technique in our department. Complication rates are high with all techniques including the law of diminishing returns, autofusion, bone anchor-related complications like loosening or migration of implants, failure to distract and proximal junctional kyphosis. In our own series of 13patients below age 3years, VEPTR proved to be effective for mixed deformities. In other studies, we were able to show that physiological growth with MCGR can be maintained for 2-3years but spinal growth declines after that period with acceptable complications. Complication rates in most studies are lower with MCGR compared to TGR and VEPTR. Therefore, it is currently the treatment of choice for most early onset scoliosis patients.

The effectiveness of growth-friendly systems in the treatment of early onset scoliosis: a systematic review

Objective. To perform a systematic analysis of the literature evaluating the effectiveness of growth-friendly systems in the treatment of early onset scoliosis.Material and Methods. A subject search was conducted in the Google Scholar database for the terms “growing rods”, “early onset scoliosis”, “treatment”, “surgery” and “growth-friendly” using AND or OR logical operators with a search depth of 10 years. At the first stage, 824 abstracts of publications were selected. The second stage of search was carried out in accordance with the PICOS criteria, 38 abstracts of original studies, case series and reviews of surgical techniques for spinal deformity correction with preservation of growth potential were selected. The evaluation criteria were divided into four groups: general data, correction of the frontal and sagittal components of the deformity, complications and unplanned scenarios.Results. In the analyzed studies, gender equality of distribution was observed, and the average age at the time of the primary operation was 6.6 years for patients with traditional growing rods (TGR) and Schilla/Luque trolley and 4.9 years for patients with Vertical Expandable Prosthetic Titanium Rib (VEPTR). From the point of view of the magnitude of spinal deformity correction, the VEPTR systems demonstrated the minimum result (18 % correction), and the TGR and Schilla results were comparable (42.1 and 53.1 %, respectively), as well as the indicators of the dynamics of body lengthening.Conclusion. The use of VEPTR systems is associated with a high risk of complications and a somewhat lower efficiency of spinal deformity correction, however, VEPTR is indispensable in the treatment of thoracic insufficiency syndrome, as well as severe deformities of the axial skeleton in young children using non-vertebral fixation points. Growth modulation systems (Schilla and Luque trolley) showed deformity correction results similar to those of TGR.

Surgical and Health-related Quality of life Outcomes in Children With Congenital Scoliosis During 5-year Follow-up. Comparison to Age and Sex-matched Healthy Controls.

Congenital spinal anomalies represent a heterogeneous group of spinal deformities, of which only progressive or severe curves warrant surgical management. Only a limited number of studies have investigated the impact of surgery on the health-related quality of life and very limited data exists comparing these outcomes to healthy controls. A single surgeon series of 67 consecutive children with congenital scoliosis (mean age at surgery 8.0 y, range: 1.0 to 18.3 y, 28 girls) undergoing hemivertebrectomy (n = 34), instrumented spinal fusion (n = 20), or vertical expandable prosthetic titanium rib procedure (n = 13) with a mean follow-up of 5.8 years (range: 2 to 13 y). The comparison was made to age and sex-matched healthy controls. Outcome measures included the Scoliosis Research Society questionnaire both pre and postoperatively, radiographic outcomes, and complications. The average major curve correction was significantly better in the hemivertebrectomy (60%) and instrumented spinal fusion (51%) than in the vertical expandable prosthetic titanium rib group (24%), respectively ( P < 0.001). Complications were noted in 8 of 67 (12%) children, but all patients recovered fully during follow-up. Pain, self-image, and function domains improved numerically from preoperative to final follow-up, but the pain score was the only one with a statistically significant change ( P = 0.033). The Scoliosis Research Society pain, self-image, and function domain scores remained at a significantly lower level at the final follow-up than in the healthy controls ( P ≤ 0.05), while activity scores improved to a similar level. Surgery for congenital scoliosis improved angular spinal deformities with a reasonable risk of complications. Health-related quality of life outcomes improved from preoperative to final follow-up, but especially pain and function domains remained at a significantly lower level than in the age and sex-matched healthy controls. Level III, therapeutic.

Intraoperative Antibiotic Use in Patients With Early-onset Scoliosis: Current Practices and Trends.

Best Practice Guidelines (BPGs) regarding antibiotic prophylaxis in early-onset scoliosis (EOS) patients were published in September 2019. Recommendations included using intravenous cefazolin and topical vancomycin for all index procedures, plus gram-negative coverage for neuromuscular patients. Guideline adherence is unknown. This study aimed to characterize antibiotic prophylaxis at the time of index growth-friendly procedures and assess changes in practice patterns over time. This retrospective review of data collected through a multicenter study group included EOS patients undergoing index growth-friendly procedures between January 2018 and March 2021, excluding revisions, lengthenings, and tetherings. Demographics, clinical measurements, intraoperative antibiotics, and 90-day complications were recorded. Descriptive and univariate statistics were utilized. Antibiotic prophylaxis from April 2018 through September 2019 and October 2019 through March 2021 were compared with evaluate change after BPG publication. A total of 562 patients undergoing growth-friendly procedures were included. The most common scoliosis types included neuromuscular (167, 29.7%), syndromic (134, 23.8%), and congenital (97, 17.3%). Most index procedures involved magnetically controlled growing rods (417, 74%) followed by vertical expandable prosthetic titanium rib or traditional growing rods (105, 19%). Most patients received cefazolin alone at index procedure (310, 55.2%) or cefazolin with an aminoglycoside (113, 20.1%). Topical antibiotics were used in 327 patients (58.2%), with most receiving vancomycin powder. There was increased use of cefazolin with an aminoglycoside after BPG publication (16% vs. 25%) (P=0.01). Surgical site infections occurred in 12 patients (2.1%) within 90 days of index procedure, 10 pre-BPGs (3%), and 2 post-BPGs (0.9%), with no significant difference in surgical site infection rate by type of antibiotic administered (P>0.05). Historical variability exists regarding antibiotic prophylaxis during index growth-friendly procedures for EOS. There continues to be variability following BPG publication; however, this study found a significant increase in antibiotic prophylaxis against gram-negative bacteria after BPG publication. Overall, greater emphasis is needed to decrease variability in practice, improve compliance with consensus guidelines, and evaluate BPG efficacy. Level III-retrospective.

Trends in the Utilization of Implants in Index Procedures for Early Onset Scoliosis From the Pediatric Spine Study Group.

Because of the relative rarity of Early Onset Scoliosis (EOS) cases, patient registries were developed to combine clinical information from multiple institutions to maximize patient care and outcomes. This study examines the history and trends regarding the use of growth-friendly devices for index surgical procedures in EOS patients within the Pediatric Spine Study Group database. All index growth-friendly implants were queried from registry inception until October 2020. EOS etiology, device/implant type, and geographic area/institution for each procedure were recorded. From 1994 to 2020, 2786 patients underwent index surgery at a mean age of 6.2±2.9 years. There were 908 traditional growing rods (TGR) (32.3%), 922 vertical expandable prosthetic titanium rib devices (VEPTR) (33.1%), 5 hybrid VEPTR/TGR (0.18%), and 951 magnetically controlled growing rods (MCGR) (34.2%) index implants. Fifty-six different institutions reported an index implant, and 5 accounted for 823 (30%) of the cases during the study period. Institutions in the Northeast accounted for more index implants than other regions of the United States. There was a 40% increase in index implant insertions annually when comparing 1994 (3 implants/1 center) to 2018 (234 implants/56 centers), ( P <0.001). Beginning in 2009, there was a 90.9% decrease in the number of TGR/VEPTR procedures (2009: 156 implants/32 centers; 2019: 22 implants/49 centers P =0.001), and a 479% increase in MCGR (2009: 1 implant/1 center; 2018: 197 implants/34 centers ( P =0.005). The overall number of growth-friendly index procedures performed in 2019 (150/49 centers) decreased 34.5% when compared to 2018 (234/48 centers). The number of growth-friendly implants reported in the Pediatric Spine Study Group registry as the initial surgical management of EOS increased markedly over the past 20 years. MCGR is currently the predominant type of device utilized for index surgical procedures by group members, surpassing the use of VEPTR and TGR in 2014. There was a significant decrease in index growth-friendly procedures in 2019 compared to 2018. Level IV.

Risk of ventriculoperitoneal shunt malfunction in operatively treated early onset spinal deformity.

Ventriculoperitoneal (VP) shunt placement is a common neurosurgical procedure performed in patients with early onset scoliosis (EOS). To provide insight into the risks of spine lengthening operations, we investigate the rate of VP shunt complications in patients with EOS undergoing spinal deformity correction interventions. A retrospective review was performed of all patients with EOS at a single institution undergoing spinal deformity correction procedures from 2007 to 2018. Patients having undergone VP shunt implantation prior to deformity correction were included. A minimum of 2-year follow-up was required for inclusion. Clinical records and imaging studies were reviewed. Nineteen patients with VP shunts underwent Vertical Expandable Prosthetic Titanium Rib (VEPTR) implantation for treatment of early onset spinal deformity. The mean age at shunt placement and spine instrumentation surgery was 13.7months (1day to 13years) and 6.1years (0.5-15.1) respectively. The diagnoses associated with shunt implantation were: 12 spina bifida, 3 structural defects or obstructions, 2 intraventricular hemorrhage, 1 cerebral palsy, and 1 campomelic dwarfism. During the first 2years following rib-based insertion, there was a mean of 2.5 expansion/revision procedures (0-5) with no shunt-related complications. The mean length of follow-up in this series was 7.0years (2.6-13.2). A total of three (16%) patients required shunt revision following their rib-based device insertion, two patients with proximal shunt malfunctions and one with a mid-catheter breakage, at 2.4, 2.6, and 5.6years, respectively, after rod implantation (Fig.2). Each of these shunt revisions occurred more than 50days following an expansion procedure (1.9, 2.9, and 5.7months, respectively). Growing instrumentation procedures in EOS are associated with low risk for post-operative shunt complications in patients with ventriculoperitoneal shunts. There were no shunt revision procedures performed in the first 2years following rib-based device insertion. Sixteen percent of patients went on to require a shunt revision at some point during their follow-up, which is comparable to the baseline rate of shunt revision in non-EOS patients. IV, Case series.

Surgical and Nonsurgical Factors Associated with Salvaging Exposed Vertical Expandable Prosthetic Titanium Rib Hardware.

Vertical expandable prosthetic titanium rib (VEPTR) devices were designed to treat childhood scoliosis and thoracic insufficiency syndrome. Although they have drastically reduced patient mortality, they present a profound subcutaneous hardware burden. The authors examined the surgical and nonsurgical factors associated with salvage of VEPTR hardware exposures. Between 2014 and 2020, a prospective institutional database was queried for patients with VEPTR hardware complications who required soft-tissue reconstruction. Hardware salvage was considered successful if reconstruction allowed the hardware to be retained until the next VEPTR expansion. Fifty-eight patients required VEPTR hardware salvage. Hardware complications were successfully salvaged in 62.1 percent of patients at 60.0 percent of operative sites. Neuromuscular scoliosis (p = 0.041) and nonambulatory status (p = 0.018) were factors associated with VEPTR hardware salvage failure, whereas congenital scoliosis was associated with successful hardware salvage (p = 0.012) and preventing need for immediate hardware removal (p = 0.049). Exposed hardware, as compared to threatened exposure, was more likely to require immediate removal (p = 0.045) and result in unsuccessful hardware salvage (p = 0.015). Local and regional muscle flaps were able to prevent VEPTR hardware removal in the majority of patients, even in the setting of infection, immobility, incontinence, and multiple systemic comorbidities. Patients with neuromuscular scoliosis and nonambulatory status were at increased risk for failure, whereas those with incontinence and low body mass index trended toward increased risk of failure. Threatened exposure was associated with higher rates of salvage than exposed hardware, and thus earlier referral to plastic surgeons for soft-tissue salvage may be advised. Risk, III.

Early outcomes of growth friendly instrumentation in children with Williams syndrome.

Although scoliosis and kyphosis have been associated with Williams Syndrome (WS), no previous literature has reported on surgical treatment for early onset scoliosis (EOS) in WS. The aim of this case series is to report on the outcomes of spine deformity surgery in patients with EOS and WS and any perioperative anesthetic or cardiovascular complications. One multicenter database was queried for all patients with WS who underwent growth-friendly (GF) treatment before age 12 between 2000 and 2017. Demographics, surgical, and growth-friendly data were queried. Radiographs were measured for curve magnitude, T1-T12 length, and T1-S1 length. Seven patients were analyzed (3 males, 4 females). Patients were at a median age of 2.8years at initial surgery with median follow-up 3.6years (range 2.0-12years) after index surgery. The initial surgical treatments were as follows: 2 traditional growing rods (TGR), 2 magnetically controlled growing rods (MCGR), and 3 vertical expandable prosthetic titanium ribs (VEPTR). The median duration of growth-friendly treatment was 5.0years (range, 2.6-10.4years) with a median number of 9 device lengthenings. The median improvement in coronal curve magnitude from preoperative to most recent follow-up was 19° (range, 54°-9°). Three patients have completed GF treatment: one underwent definitive fusion, and two are under observation with apparent spontaneous fusion and retain the original GF implants. No peri-operative anesthetic or cardiovascular complications occurred. Few studies have reported on surgical outcomes in WS patients with EOS. In this case series, 6/7 patients experienced curve improvement with growth-friendly spine instrumentation. This study suggests that growth-friendly instrumentation for severe EOS in WS can be used for control of spinal deformity while allowing for further growth. Associated complications were typical of distraction-based EOS surgical treatment. There were 62 total procedures with general anesthesia, but no perioperative cardiac complications occurred.

Use of Vancomycin Powder in the Surgical Treatment of Early Onset Scoliosis Is Associated With Different Microbiology Cultures After Surgical Site Infection.

The use of vancomycin powder has been shown to decrease risk of surgical site infection (SSI) in early onset scoliosis (EOS). While there is potential benefit in SSI reduction, there is also theoretical risk in creating increased bacterial resistance to standard treatment regimens. However, the effects of topical vancomycin powder on microbiology in these patients has not been studied. A multicenter database for EOS patients was retrospectively analyzed. All patients that underwent surgical treatment with traditional growing rods, magnetically controlled growing rods, vertical expandable prosthetic titanium rib, and Shilla for EOS performed after 2010 were identified (n=1115). Patients that sustained at least 1 SSI after guided growth surgery were assessed (n=104, 9.3%). Patients with culture and antibiotic details were included (n=55). Patients that received vancomycin powder at index surgery were compared with patients that did not. A multivariate regression model was used to control for potential confounders. There were 55 patients included in this study, including 26 males (47%) and 29 females (53%). Mean age at index surgery was 7.2±6.9 years. Vancomycin powder was utilized in 18 cases (33%). Mean time from index surgery to SSI was 2.0±1.3 years. There were 2 cases of wound dehiscence (4%), 7 cases of superficial infection (13%), and 46 cases of deep infection (84%).There were significant differences in overall microbiology results between vancomycin and no vancomycin cohorts (P=0.047). On univariate analysis, the vancomycin powder cohort had a significantly high incidence of cultures without growth (n=7, 39% vs. n=4, 11%, relative risk: 2.063, 95% confidence interval: 0.927-4.591, P=0.028). This association remained significant on multivariate analysis (adjusted odds ratio: 9.656, 95% confidence interval: 1.743-53.494, P=0.009). In EOS patients undergoing procedures complicated by SSI, the use of vancomycin powder was independently associated with increased risk of no culture growth. Surgeons and infectious disease physicians should be aware and adjust diagnostic and treatment strategies appropriately. Level III-retrospective cohort study.

Outcomes and Complications in Management of Congenital Myopathy Early-Onset Scoliosis.

Congenital myopathies (CMs) are complex conditions often associated with early-onset scoliosis (EOS). The purpose of this study was to investigate radiographic outcomes in CM patients undergoing EOS instrumentation as well as complications. Secondarily, we sought to compare these patients to a population with higher prevalence, cerebral palsy (CP) EOS patients. This is a retrospective study of a prospectively collected multicenter registry. The registry was queried for EOS patients with growth-sparing instrumentation (vertical expandable prosthetic titanium ribs, magnetically controlled growing rods, traditional growing rod, or Shilla) and a CM or CP diagnosis with minimum 2 years follow-up. Outcomes included major curve magnitude, T1-S1 height, kyphosis, and complications. Sixteen patients with CM were included. Six (37.5%) children with CM experienced 11 complications by 2 years. Mean major curve magnitude for CM patients was improved postoperatively and maintained at 2 years (P<0.01), with no significant increase in T1-S1 height or maximum kyphosis(P>0.05). Ninety-seven patients with CP EOS were included as a comparative cohort. Fewer CP patients required baseline respiratory support compared with CM patients (20.0% vs. 92.9%, P<0.01). Fifty-four (55.7%) CP patients experienced a total of 105 complications at 2 years. There was no evidence that the risk of complication or radiographic outcomes differs between cohorts at 2 years, though CP EOS patients experienced significant improvement in all measurements at 2 years. EOS CM children face a high risk of complication after growing instrumentation, with similar curve correction and risk of complication to CP patients. Level III.

Nonfusion procedures in pediatric scoliosis

The treatment of early onset scoliosis (EOS) in children is acomplex and demanding challenge in the treatment of spinal deformities. Conservative treatment with physiotherapy is indicated in mild forms with a Cobb angle from 10°and additionally a corset treatment with a Cobb angle of more than 20°. After exhaustion of the conservative measures or a progression of spinal scoliosis of 10° or deformities of more than 35°, asurgical approach should be considered in order to prevent respiratory insufficiency as well as severe postural and thoracic deformities. In situations where growth is still ongoing fusion operations can lead to stunted growth, a crankshaft phenomenon or degeneration of alignment. Meaningful alternatives to a fusion are so-called growing rods as a distraction-based nonfusion technique, e.g. traditional growing rods (TGR) and magnetically controlled growing rods (MCGR) or as a further method a vertical expandable prosthetic titanium rib (VEPTR) device. The advantages and disadvantages of each operative procedure must be considered with respect to the risk profile of each patient and the experience of the surgeon in order to guarantee the best possible treatment.

Early Complications in Vertical Expandable Prosthetic Titanium Rib and Magnetically Controlled Growing Rods to Manage Early Onset Scoliosis.

The aim of this study is to examine whether surgical treatment of early onset scoliosis (EOS) with magnetically controlled growing rods (MCGRs) or a vertical expandable prosthetic titanium rib (VEPTR) resulted in fewer short-term (24 months) complications and reoperations. EOS is a challenging problem for spine surgeons that has been managed with different growth-friendly instrumentation systems. Although rib-based devices encourage spinal growth via regular lengthening, the high rate of complications and reoperations leads us to use spine-based devices such as MCGRs to mitigate this concern. A total of 35 EOS patients were included in the study. Twenty patients were included in the VEPTR group, and 15 patients were included in the MCGR group. Demographic data and 2 years of postoperative complications and reoperations were reviewed retrospectively. As secondary outcomes, radiographic outcomes were reported preoperatively and 1 year after surgery. Indications for this technique and complications were collected from the charts. Demographic data showed no significant differences between the 2 groups. Significant differences were found in the complications rate at 2 years, with 65% complications in the VEPTR group and 13.3% complications in the MCGR group (P < .001). The reoperation rate at 2 years was also significantly higher in the VEPTR group, with 50% versus 13.3% in the MCGR group (P = .0009). As secondary outcomes, radiological parameters such as main curve Cobb angle correction (P = .001) and apical vertebral translation (P = .002) were significantly higher in the MCGR group. Significant differences were also found in sagittal profile parameters; T1-T12 and T1-S1 were significantly higher in the MCGR group (P < .001). According to our results, VEPTR has significantly higher complication and reoperation rates at 2 years postsurgery compared with MCGR. 4.

Rib-based Distraction Device Implantation Before Age 3 Associated With Higher Unplanned Rate of Return to the Operating Room.

Surgical treatment of early-onset scoliosis (EOS) with rib-based implants such as the vertical expandable prosthetic titanium rib (VEPTR) is associated with a high rate of complications including surgical site infection, skin breakdown, and implant migration. Many of these complications warrant the need for unplanned reoperations, increasing the burden on an already vulnerable patient population, and introducing the further risk of infection. To provide insight into the risks of early intervention, we investigate the relationship between initial device implantation before the age of 3 and the rate of unplanned reoperation. A retrospective review was performed of all patients at a single institution who had undergone VEPTR insertion for EOS with at least a 2-year follow-up from 2007 to 2016. Patients were stratified into the case-cohort (0 to 2 y of age) or the comparison cohort (3 to 10 y of age) based on age at the time of device implantation. Multivariate regression accounting for age and scoliosis etiology was performed to identify factors predictive of unplanned reoperation. A total of 137 of 185 patients treated with VEPTR were identified with 76 (56%) undergoing at least 1 unplanned reoperation during the study time period. There were 68 and 69 patients in the age 0- to 2-year and 3- to 10-year cohorts, respectively. Patients aged 0 to 2 years underwent a higher number of total procedures compared with those aged 3 to 10 (13.1±6.5 vs. 10.6±4.8, P=0.032). A significant difference was found in the rate of unplanned reoperation between the 2 cohorts with 44 (65%) patients aged 0 to 2 and 32 (46%) patients aged 3 to 10 undergoing at least 1 unplanned reoperation (P=0.031). Binary logistic multivariate regression accounting for age and scoliosis etiology demonstrated that patients aged 0 to 2 had a significantly greater odds of undergoing an unplanned reoperation (odds ratio=3.050; 95% confidence interval: 1.285-7.241; P=0.011) compared with patients aged 3 to 10 years. Overall, EOS patients aged 0 to 2 at initial VEPTR implantation are up to 3 times higher risk of undergoing an unplanned reoperation compared with those aged 3 to 10. Level III.

Outcomes of Vertical Expandable Prosthetic Titanium Ribs in Children With Early-Onset Scoliosis Secondary to Cerebral Palsy

PurposePatients who have neuromuscular scoliosis, such as cerebral palsy (CP), often develop spinal deformities that negatively impact quality of life. The vertical expandable prosthetic titanium rib (VEPTR) was designed for thoracic insufficiency syndrome (TIS), but it has also been utilized in patients with CP with restrictive lung disease and spine deformity. Few studies report on VEPTRs in neuromuscular scoliosis; however, none reports on their utilization specifically in patients with CP. Our purpose was to assess if VEPTRs can improve spinal deformity and TIS in these patients.MethodsA retrospective chart review was performed of all patients with CP and scoliosis treated with a VEPTR between 2008 and 2017. Eight patients were eligible for this study. The mean follow-up was four years. Outcomes evaluated were Cobb angle, pelvic obliquity, space available for lung ratio (SAL), T1-S1 height, and complication rates. A p-value of less than 0.05 was used for statistical significance.ResultsThere were significant postoperative improvements in Cobb angle, pelvic obliquity, and T1-S1 height, but no statistical difference in SAL. Prior to final fusion, the mean number of VEPTR lengthening procedures was 3. The mean time from index surgery to final fusion was 3.7 years. The most common complications were infection (62.5%) and wound dehiscence (25%). Only 25% of patients did not have a complication.ConclusionVEPTRs demonstrated significant improvement in almost all parameters and may be valuable in improving TIS in patients with CP. The complication and reoperation rates were similar to those of VEPTRs used for other pathological conditions.

Chest wall reconstruction for sarcoma with vertical expandable prosthetic titanium ribs. First reported use in an adult patient.

ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Kostopanagiotou K, A. Steimer D, E. Wojtyś M, O. Wee J. Chest wall reconstruction for sarcoma with vertical expandable prosthetic titanium ribs. First reported use in an adult patient. Kardiochirurgia i Torakochirurgia Polska/Polish Journal of Thoracic and Cardiovascular Surgery. 2021;18(4):262-264. doi:10.5114/kitp.2021.112196. APA Kostopanagiotou, K., A. Steimer, D., E. Wojtyś, M., & O. Wee, J. (2021). Chest wall reconstruction for sarcoma with vertical expandable prosthetic titanium ribs. First reported use in an adult patient. Kardiochirurgia i Torakochirurgia Polska/Polish Journal of Thoracic and Cardiovascular Surgery, 18(4), 262-264. https://doi.org/10.5114/kitp.2021.112196 Chicago Kostopanagiotou, Konstantinos, Desiree A. Steimer, Małgorzata E. Wojtyś, and Jon O. Wee. 2021. "Chest wall reconstruction for sarcoma with vertical expandable prosthetic titanium ribs. First reported use in an adult patient". Kardiochirurgia i Torakochirurgia Polska/Polish Journal of Thoracic and Cardiovascular Surgery 18 (4): 262-264. doi:10.5114/kitp.2021.112196. Harvard Kostopanagiotou, K., A. Steimer, D., E. Wojtyś, M., and O. Wee, J. (2021). Chest wall reconstruction for sarcoma with vertical expandable prosthetic titanium ribs. First reported use in an adult patient. Kardiochirurgia i Torakochirurgia Polska/Polish Journal of Thoracic and Cardiovascular Surgery, 18(4), pp.262-264. https://doi.org/10.5114/kitp.2021.112196 MLA Kostopanagiotou, Konstantinos et al. "Chest wall reconstruction for sarcoma with vertical expandable prosthetic titanium ribs. First reported use in an adult patient." Kardiochirurgia i Torakochirurgia Polska/Polish Journal of Thoracic and Cardiovascular Surgery, vol. 18, no. 4, 2021, pp. 262-264. doi:10.5114/kitp.2021.112196. Vancouver Kostopanagiotou K, A. Steimer D, E. Wojtyś M, O. Wee J. Chest wall reconstruction for sarcoma with vertical expandable prosthetic titanium ribs. First reported use in an adult patient. Kardiochirurgia i Torakochirurgia Polska/Polish Journal of Thoracic and Cardiovascular Surgery. 2021;18(4):262-264. doi:10.5114/kitp.2021.112196.

Impact of growth friendly interventions on spine and pulmonary outcomes of patients with spinal muscular atrophy

Patients with spinal muscular atrophy (SMA) are often treated with growth friendly devices such as vertical expandable prosthetic titanium rib(VEPTR) and magnetically controlled growing rods(MCGR) to correct spinal deformity and improve pulmonary function. There is limited data on this topic, and the purpose of this study was to assess the effect of these constructs and the addition of chest wall support (CWS) on spinal deformity, thorax morphology and pulmonary outcomes. This is a retrospective analysis of prospectively collected data. We included patients with chest wall deformity and scoliosis secondary to SMA who were treated with growth friendly interventions and had two-year follow-up. Descriptive statistics and univariate analyses were performed. This study included 66 patients (25% MCGR, 73% VEPTR, 2% unknown). Approximately 23% of constructs included CWS. The average Cobb angle improved from 67° (SD: 27°) to 50° (SD: 26°) at 2 years in patients with CWS (p = 0.02), and from 59° (SD: 20°) to 46° (SD: 15°) at 2 years in patients without CWS (p < 0.01). Hemithorax height improved in patients treated with and without CWS (p = 0.01), but hemithorax width only improved in patients with CWS (p = 0.01). One patient with CWS and two patients without CWS required additional respiratory support at 2 years. The rates of postoperative complications were not significantly different in patients treated with and without CWS (p = 0.31). Growth friendly constructs improve spinal deformity and may be effective in altering the progression toward respiratory failure in patients with SMA. Patients treated with CWS have significant improvements in thorax morphology compared to patients without CWS.