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

Is posterior vertebral arthrodesis at the end of the electromagnetic rod lengthening program necessary for all patients? Comparative analysis of sixty six patients who underwent definitive spinal arthrodesis and twenty four patients with in situ lengthening rods

PURPOSE

Magnetically controlled growing rods (MCGR) should be removed or changed at most two years after their implantation in the treatment of patients with early-onset scoliosis (EOS) (Safety notice July 2021). However, in the face of patients at high risk of intraoperative complications and relying on the principle of auto-fusion of the spine, some surgeons would prefer a more wait-and-see attitude. The aim of this study was to report on patients who did not undergo final fusion at the end of the lengthening program with MCGR and to compare them with those who did.

METHODS

This was a multicenter study with ten centres. We collected all graduate patients with EOS who had received MCGR between 2011 and 2022.

RESULTS

A total of 66 patients had final fusion at the end of the lengthening program and 24 patients kept MCGRs in situ. The mean total follow-up time was 66 months (range, 25.3-109), and the mean follow-up time after final lengthening was 24.9 months (range, 3-67.7). Regarding the main curve and thoracic height, there was no significant difference in the percentage of correction over the whole follow-up between the two groups (p = 0.099, p = 0.176) although there was a significant difference between the end of lengthening and the last follow-up (p < 0.001). After completion of the lengthening program, 18 patients who had final fusion developed 24 of the 26 recorded complications (92.3%).

CONCLUSION

Contrary to the manufacturer's published safety notice, not all patients systematically benefited from the removal of the MCGRs. Although arthrodesis significantly improved the scoliotic deformity, no significant difference was found in terms of radiographic outcome between patients who underwent spinal fusion and those who kept the MCGRs in situ.

Optimal timing of starting growing rod treatment for early-onset scoliosis

BACKGROUND CONTEXT

Growing rod (GR) systems require periodical surgical intervention and may cause associated complications, as well as worsened sagittal plane deformity. Generally, the risk of complications decreases with an increment in age at the time of the index surgery with GR construct placement. However, the optimal timing to begin GR treatment has not reached a consensus yet.

PURPOSE

This study was performed to investigate the effect of age at the index GR surgery on the complication rates and formulate clinical guidelines for the optimal timing to begin GR treatment for EOS patients.

STUDY DESIGN

Kaplan-Meier analysis was used to determine complication occurrence as a function of the age at the index surgery and to determine the survival rates for the procedures. The receiver operator characteristic (ROC) curve was used to determine optimal cut-off values for the optimal timing of index surgery based on whether complications occurred or not.

PATIENT SAMPLE

54 patients who met the criteria were enrolled in this study.

OUTCOME MEASURES

The following spinal parameters were measured: major coronal Cobb angle, global kyphosis (GK), and coronal balance (CB). CB was defined as the horizontal distance from the C7 plumb line to the center sacral vertical line.

METHODS

All patients had completed GR treatment and had a minimum 1-year follow-up duration after the final surgical intervention. Patient data were collected as follows: age at the index surgery, gender, diagnosis, type of GR construct, and the number of lengthening procedures. The standing full-spine radiographs were obtained before and after the index surgery, before and after each lengthening procedure, before and after the final surgical intervention, and at the latest follow-up. Complications were categorized as implant, alignment, and general.

RESULTS

Kaplan-Meier analysis of complications demonstrated a declining trend in complication rates with increasing age at the index surgery. The absence of perioperative complications was targeted, we constructed the ROC curve and the cut-off value was 71.0 months. Age at the index surgery was therefore categorized into two groups: younger-age group (≤ 71.0 months) and advanced-age group (> 71.0 months). There was a higher complication rate for the younger-age group than versus the advanced-age group (61.5% vs 22.0%, p=.011). PJK as a major alignment-related complication, was more frequent in the younger-age group than in the advanced-age group (30.8% vs 4.9%, p=.025). But the advanced-age group exhibited significantly more severe deformities before GR surgery compared to the younger-age group.

CONCLUSIONS

This study shows that the elevated risk of complications observed in the younger-age group, which can be attributed to the younger age at the index surgery and the increased number of lengthening procedures during treatment. We suggest deferring the initiation of GR treatment until after the age of six years for EOS patients. We hope it will serve as a basis for GR technique in the treatment of EOS, with the ultimate goal of enhancing treatment outcomes for this challenging disorder.

Diagnostic and therapeutic strategies in early onset scoliosis: A current concept review

Substantial advances in the treatment of early onset scoliosis (EOS) over the past two to three decades have resulted in significant improvements in health-related quality of life of affected children. In addition to classifications that address the marked heterogeneity of this patient population, increasing understanding of the natural history of the disease, and new implants and treatment techniques have resulted in innovations unlike any other area of pediatric orthopedics. The growing understanding of the interaction between spinal and thoracic growth, as well as dependent lung maturation, has had a lasting impact on the treatment strategy of this potentially life-threatening disease. The previous treatment approach with early corrective fusion gave way to a growth-friendly concept. Despite the steady development of new growth-friendly surgical treatment options, whose efficacy still needs to be validated, as well as a revival of conservative growth control with serial casts and/or braces, the psychosocial burden of the long lasting and complication-prone treatments remains high. As a consequence, EOS still represents one of the greatest pediatric orthopedic challenges.

The Clinical and Imaging Outcome of the Tandem Growing Rod Technique in Early-Onset Scoliosis With the Proximal Upper Thoracic Curve Progression: A Modified Technique of Growing Rod

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The orthopaedic ability of traditional GR for severe EOS is limited. The proximal upper thoracic curve may progress during the lengthening procedure, which may lead to coronal imbalance and inhibit the longitudinal growth of the spine. In this retrospective cohort study, we investigated the clinical outcome of tandem GR.

METHODS

We modified the traditional technique by using two groups of GR devices to control the major and the proximal upper thoracic curve, connected the two groups of GR in series, and named it tandem GR. The clinical and imaging outcomes of the new technique were evaluated and compared with traditional technique.

RESULTS

Twenty one patients were enrolled in the tandem GR group, and 30 patients were treated with traditional GR as the control. The baseline parameters were consistent between the two groups. In the tandem GR group, the secondary curve progressed from 24.9 ± 3.9° to 31.4 ± 3.2° (P = .006) in the procedure with the traditional GR and improved to 18.4 ± 4.5° (P = .001) after the switch. Meanwhile, the clavicular angle aggravated from 1.6 ± 1.0° to 2.6 ± .7° (P = .041), and improved to 1.7 ± .8° after changed to the tandem GR (P = .033). At the final of the follow-up, the secondary curve was higher in the control group (27.1 ± 8.3° vs 18.4 ± 4.5°, P = .034), the clavicle angle was 2.4 ± 1.1° in control and 1.7 ± .8° in the tandem GR group (P = .028), the T1-S1 height was 28.2 ± 4.8 cm in the control and 33.3 ± 3.0 cm in the tandem GR group (P = .027). The average growth rate was 1.0 ± .3 cm/year in the control and 1.2 ± .4 cm/year in the tandem GR group (P = .046).

CONCLUSION

Tandem GR can effectively improve the proximal upper thoracic curve progression during the treatment of EOS. Compared with the traditional GR, tandem GR can achieve better curve correction, better shoulder balance, and retains more capacity for longitudinal spine growth.

Clinical and radiological results of final fusion in patients who underwent lengthening with magnetically controlled growing rods. About 66 patients with a mean follow-up of 5 years

PURPOSE

The aim of this study was to evaluate the effects of definitive arthrodesis on frontal and sagittal spine balance in EOS patients treated with MCGR, as well as the complications associated with this procedure and the outcome at last follow-up.

METHODS

This was a multicentre study in 10 French centres. All patients who underwent posterior spinal arthrodesis after completion of MCGR treatment, regardless of age, etiology of scoliosis between 2011 and 2022, were included.

RESULTS

A total of 66 patients who had a final fusion after the lengthening programme were included in the study. The mean follow-up time was 5.5 ± 1.7 years (range: 2.1-9). The mean follow-up time after arthrodesis was 24 ± 18 months (range: 3-68) and the mean age at arthrodesis was 13.5 ± 1.5 years (range: 9.5-17). The main and secondary curves were significantly (p < 0.005 and p = 0.03) improved by arthrodesis (16.4° and 9° respectively) and stabilised at the last follow-up. The T1-T12 and T1-S1 distances increased by 8.4 mm and 14 mm with spinal fusion, with no significant difference (p = 0.096 and p = 0.068). There was no significant improvement in the rest of the parameters with arthrodesis, nor was there any significant deterioration at last follow-up. After final fusion, there were a total of 24 complications in 18 patients (27.3%) that routinely led to repeat surgery.

CONCLUSION

Final fusion after MCGR provides satisfactory additional correction of the main and secondary curves and a moderate increase in the T1-T12 distance but has no impact on sagittal balance and other radiological parameters. The post-operative complication rate is particularly high in patients at risk of complications.

LEVEL OF EVIDENCE

Level 4.

A Comparative Analysis of Revision Surgery Before or After 2 Years After Graduation From Growth-friendly Surgery for Early Onset Scoliosis

INTRODUCTION

After discontinuation of growth-friendly (GF) surgery for early onset scoliosis, patients are termed graduates: they undergo a spinal fusion, are observed after final lengthening with GF implant maintenance, or are observed after GF implant removal. The purpose of this study was to compare the rates of and reasons for revision surgery in two cohorts of GF graduates: before or after 2 years of follow-up from graduation.

METHODS

A pediatric spine registry was queried for patients who underwent GF spine surgery with a minimum of 2 years of follow-ups after graduation by clinical and/or radiographic evidence. Scoliosis etiology, graduation strategy, number of, and reasons for revision surgery were queried.

RESULTS

There were 834 patients with a minimum of 2-year follow-up after graduation who were analyzed. There were 241 (29%) congenital, 271 (33%) neuromuscular, 168 (20%) syndromic, and 154 (18%) idiopathic. 803 (96%) had traditional growing rod/vertical expandable titanium rib as their GF construct and 31 (4%) had magnetically controlled growing rod. Five hundred ninety-six patients (71%) underwent spinal fusion at graduation, 208 (25%) had GF implants retained, and 30 (4%) had GF implants removed.In the entire cohort, there were 108/834 (13%) patients who underwent revision surgery. Of the revisions, 71/108 (66%) occurred as acute revisions (ARs) between 0 and 2 years from graduation (mean 0.6 y), and the most common AR indication was infection (26/71, 37%). The remaining 37/108 (34%) patients underwent delayed revision (DR) surgery >2 years (mean 3.8 y) from graduation, and the most common DR indication was implant issues (17/37, 46%).Graduation strategy affected revision rates. Of the 596 patients with spinal fusion as a graduation strategy, 98/596 (16%) underwent revision, compared with only 8/208 (4%) patients who had their GF implants retained, and 2/30 (7%) that had their GF implants removed (P ≤ 0.001).A significantly higher percentage of the ARs had a spinal fusion as the graduation strategy (68/71, 96%) compared with 30/37 DRs, (81%, P = 0.015). In addition, the 71 patients who underwent AR undergo more revision surgeries (mean: 2, range: 1 to 7) than 37 patients who underwent DR (mean: 1, range: 1 to 2) (P = 0.001).

CONCLUSION

In this largest reported series of GF graduates to date, the overall risk of revision was 13%. Patients who undergo a revision at any time, as well as ARs in particular, are more likely to have a spinal fusion as their graduation strategy. Patients who underwent AR, on average, undergo more revision surgeries than patients who underwent DR.

LEVEL OF EVIDENCE

Level III, comparative.

Is Final Fusion Necessary for Growing-Rod Graduates: A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVES

The need for definitive fusion for growing rod graduates is a controversial topic in the management of Early-onset scoliosis (EOS) patients. The authors performed a systematic review and meta-analysis on the available literature to evaluate the outcomes of growing rod graduates undergoing final fusion or observation with implants in-situ.

METHODS

An extensive literature search was carried out aimed at identifying articles reporting outcomes in growing rod graduates. Apart from the study characteristics and demographic details, the extracted data included Cobb's correction, trunk height parameters, and revision rate. The extracted data was analyzed and forest plots were generated to draw comparisons between the observation and fusion groups.

RESULTS

Of the 11 included studies, 6 were case-control and 5 were case series. The authors did not find any significant difference between the 2 groups with respect to the pre-index and final Cobb's correction, T1-T12 or T1-S1 height gain in either over-all, or sub-analysis with case-control studies. The meta-analysis showed a significantly higher revision rate in patients undergoing a definitive fusion procedure.

CONCLUSION

The current analysis revealed comparable outcomes in terms of correction rate and gain in the trunk height but a lesser need of revisions in observation sub-group. The lack of good quality evidence and the need for prospective and randomized trials was also propounded by this review.

Relook into the Risk Factors of Proximal Junctional Kyphosis in Early Onset Scoliosis Patients: Does the Location of Upper Instrumented Vertebra in Relation to the Sagittal Apex Matter?

OBJECTIVE

Growing rods surgery is the mainstay of treatment for early-onset scoliosis (EOS) while proximal junctional kyphosis (PJK) is one of the most commonly reported postoperative complications. We sought to investigate the impact of the location of upper instrumented vertebra (UIV) in relation to the sagittal apex on proximal junctional kyphosis in EOS after traditional growing rods (GRs) treatment.

METHODS

A total of 102 EOS patients who received traditional growing rods treatment with a follow-up of at least 2 years between 2009 and 2020 were retrospectively reviewed. Radiographic measurements were performed before and after the index surgery and at the latest follow-up. We investigated the coronal Cobb angle and spinopelvic parameters of the whole spine. The location of the UIV, apex, lower instrumented vertebra (LIV), inflection vertebra (IV), the number and distance of UIV-apex, LIV-apex and IV-apex were also recorded. Risk factors for PJK were analyzed by logistic regression analysis.

RESULTS

PJK was observed in 21 patients (20.6%) during the follow-up period. The PJK group showed a younger age at the index surgery (5.9 vs. 7.1 years, P = 0.042), more lengthening procedure times (5.0 vs. 4.0, P = 0.032), larger preoperative coronal Cobb angle (82.0 vs. 75.6°, P = 0.038), higher correction rate (51.2% vs. 44.4%, P = 0.047) and larger postoperative proximal junctional angle (PJA) (13.9 vs. 5.5°, P < 0.001) than the non-PJK group. The ratio of the number and distance from UIV-apex to IV-apex also differed significantly between the two groups. The logistic regression revealed that age at the index surgery ≤ 7 years, the ratio of the number from UIV- apex to IV- apex ≤ 0.6 and the ratio of the distance from UIV- apex to IV- apex ≤ 0.6 were independent risk factors for postoperative PJK.

CONCLUSION

Besides younger age, a closer location of UIV relative to the sagittal apex is identified to be an independent risk factor of postoperative PJK. Selection of UIV at a relatively farther location away from the sagittal apex might help prevent occurrence of PJK.

Evaluation of shoulder balance in early onset scoliosis after definitive fusion and comparison with adolescent idiopathic scoliosis shoulder balance

STUDY DESIGN

The Children Spine Study Group registry was queried for early onset scoliosis (EOS) patients who had final definitive spinal fusion after their scoliosis was managed with either growing rods or VEPTR. The Harms Study Group registry was queried for adolescent idiopathic scoliosis (AIS) patients who had definitive fusion OBJECTIVE: The goal is to assess shoulder alignment in EOS patients after a definitive fusion and how these radiographic outcomes relate to the more familiar situation of post-definitive fusions shoulder alignment in AIS patients.

BACKGROUND

EOS is a challenging pathology to manage. Numerous components are important in the success of spinal surgery for this population. Shoulder balance is a one of the components that is easily seen by the patient. Recently, the importance of its relationship to patient satisfaction has received greater attention.

METHODS

Sample size: n = 145 (EOS (n = 34) and AIS (n = 111)). Shoulder balance parameters (SBP) of clavicular angle (CA), coracoid height difference (CHD), clavicular tilt angle difference (CTAD), and clavicle-rib cage intersection difference (CRID) measurements were measured from the reviewed radiographs and documented pre-definitive, post-definitive and 2-year follow-up measures. Shoulder balance parameters were compared between EOS and AIS cohorts at documented intervals.

RESULTS

EOS mean pre-definitive fusion SBPs (CA, CTAD, CRID, CHD) were significantly higher compared to AIS, p = 0.004, 0.003, < 0.001, < 0.001, respectively. Significant post-definitive fusion corrections were noticed for CTAD (0.01), CHD (0.01), nearly significant CA (0.07), non-significant CRID in EOS patients. In AIS patients, no significant corrections were noticed for CA, CTAD, CHD and but significant for CRID (0.02). At post-definitive and 2-year follow-up, CA, CRID, CHD were not significant between cohorts, but CTAD (< 0.01) was significantly higher in EOS cohort at final follow-up.

CONCLUSION

Post-definitive and 2-year follow-up shoulder balance for EOS patients was not significantly different from AIS patients.

LEVEL OF EVIDENCE

III.

Clinical Outcomes of 3-column Osteotomy at Growing Rod Graduation

BACKGROUND

Several different strategies were described on how to graduate a patient when skeletal maturity is reached after growing rod treatment. A final instrumentation and fusion is commonly performed, but the stiffness of the spine after numerous lenghthenings can be a major problem. When correction is needed in a severe and rigid curve, 3-column osteotomies (3CO) can be used as a method of bringing the spine back to a well-balanced position. This study aims to evaluate the clinical outcomes of 3CO osteotomies at growing rod graduation.

METHODS

A retrospective search of the database was performed between 1996 and 2018. Inclusion criteria were: diagnosis of early-onset scoliosis, underwent 3CO at the final fusion procedure, and ≥1 year of follow-up. Indications for this osteotomy were: significant sagittal and/or coronal off-balance or severe crankshaft deformity or significant distal and/or proximal adding-on. Clinical, radiographic, and operative data were analyzed. Complications were classified according to the modified Clavien-Dindo-Sink system.

RESULTS

Eight patients were included in the study with a mean age of 13.5 at graduation (male/female: 2/6). The mean scoliosis angle significantly reduced from 65.6 to 39 degrees (P=0.012). Mean T1-T12 height increased from 19 to 20.5 (P=0.084) and T1-S1 from 29.6 to 31.6 (P=0.144). Five patients had a staged surgery. Average operative time was 338 minutes and blood loss was 1321 mL. Four grade 1, 1 grade 2, and 1 grade 3 complications occurred.

CONCLUSIONS

This is the first case-series in the literature reporting on the use of 3CO at growing rod graduation. These procedures can be safely and effectively used to overcome significant multiplanar deformity and/or off-balance in the graduation of patients with early-onset scoliosis and significant correction can be achieved on these severe and rigid curves.

LEVEL OF EVIDENCE

Level IV-case series.

Prevalence of junctional kyphosis in early-onset scoliosis: can it be corrected at final fusion?

PURPOSE

To investigate the risk and predictive factors of junctional issues after conversion from Traditional growing rod (TGR) to definitive spinal fusion in Early-onset scoliosis (EOS).

METHODS

Retrospective review of a multicenter EOS database. TGR patients who received final fusion with at least two-year follow-up were included. Proximal (PJA) and Distal junctional angles (DJA) on pre-final fusion, post-final fusion (within one year of surgery), and at latest follow-up were measured on lateral upright spinal radiographs. Differences in values among designated time points and predictive factors of junctional issues were evaluated statistically.

RESULTS

Forty-six of 251 patients (28 females, 18 males and mean age at final fusion: 12 ± 2 [9-17] years) met the inclusion criteria. Mean follow-up between first postoperative measurement and latest follow-up was 49 ± 22 (24-112) months. No statistical differences in PJA and DJA values were available at pre-fusion, first post-fusion, or latest follow-up (p = 0.827, p = 0.076). Fifty percent of patients had extension of TGR instrumentation at fusion, either proximal or distal. No factor including sex and etiology, lumbar lordosis, thoracic kyphosis, major curve magnitude, PJA, and DJA at pre-fusion was found to be a predictive issue for extension of index TGR instrumentation, except the history of at least one implant-related complication during the period from index surgery to the definitive fusion.

CONCLUSION

PJA and DJA remained stable when transitioning from TGR to final posterior spinal fusion. But 50% of patients had extension of construction at fusion, either proximal or distal.

Risk Factors for Reoperation Following Final Fusion After the Treatment of Early-Onset Scoliosis with Traditional Growing Rods

BACKGROUND

Although there is a high rate of reoperation after final fusion following the treatment of early-onset scoliosis with use of traditional growing rods, the risk factors for reoperation are unknown. The purpose of the present study was to identify risk factors associated with the need for reoperation after final fusion for the treatment of early-onset scoliosis.

METHODS

A multicenter database for patients with early-onset scoliosis was retrospectively analyzed. Patients managed with traditional growing rods and final fusion were identified (n = 248). The inclusion criteria were ≥1 lengthening procedure with traditional growing rods and ≥2 years of follow-up after final fusion or revision surgery within 2 years after final fusion (167 patients; 67%). Patients requiring reoperation following final fusion were compared with patients who did not require reoperation. The data that were analyzed included demographic characteristics, comorbidities, spinal deformity characteristics, radiographic measurements, perioperative details, and complications during all stages of treatment. A multivariate regression model was used to identify independent risk factors.

RESULTS

The mean duration of follow-up from the initial visit to the latest visit was 10.7 ± 4.1 years, and the mean duration of follow-up after final fusion was 4.9 ± 3.1 years. Thirty-two (19%) of the 167 patients required reoperation following final fusion. Curve progression requiring revision surgery during lengthening with traditional growing rods (adjusted odds ratio [aOR], 21.137 per event; p = 0.028), the number of levels spanned with traditional growing rods (aOR, 1.378 per level; p = 0.007), and the duration of treatment with traditional growing rods (aOR, 1.220 per year; p = 0.035) were independently associated with revision surgery after final fusion.

CONCLUSIONS

Independent risk factors for curve progression requiring reoperation during lengthening with traditional growing rods that require operative intervention include increasing number of levels spanned with traditional growing rods and longer duration of treatment with traditional growing rods. These findings may help with patient counseling and potentially guide surgeon decision-making.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Characterizing Use of Growth-friendly Implants for Early-onset Scoliosis: A 10-Year Update

BACKGROUND

Growth-friendly treatment of early-onset scoliosis (EOS) has changed with the development and evolution of multiple devices. This study was designed to characterize changes in the use of growth-friendly implants for EOS from 2007 to 2017.

METHODS

We queried the Pediatric Spine Study Group database for patients who underwent index surgery with growth-friendly implants from July 2007 to June 2017. In 1298 patients, we assessed causes of EOS; preoperative curve magnitude; age at first surgery; patient sex; construct type; lengthening interval; incidence of "final" fusion for definitive treatment; and age at definitive treatment. α=0.05.

RESULTS

From 2007 to 2017, the annual proportion of patients with idiopathic EOS increased from 12% to 33% (R=0.58, P=0.006). Neuromuscular EOS was the most common type at all time points (range, 33% to 44%). By year, mean preoperative curve magnitude ranged from 67 to 77 degrees, with no significant temporal changes. Mean (±SD) age at first surgery increased from 6.1±2.9 years in 2007 to 7.8±2.5 years in 2017 (R=0.78, P<0.001). As a proportion of new implants, magnetically controlled growing rods increased from <5% during the first 2 years to 83% in the last 2 years of the study. Vertically expandable prosthetic titanium ribs decreased from a peak of 48% to 6%; growth-guidance devices decreased from 10% to 3%. No change was seen in mean surgical lengthening intervals (range, 6 to 9 mo) for the 614 patients with recorded lengthenings. Final fusion was performed in 88% of patients who had undergone definitive treatment, occurring at a mean age of 13.4±2.4 years.

CONCLUSIONS

From 2007 to 2017, neuromuscular EOS was the most common diagnosis for patients treated with growth-friendly implants. Patient age at first surgery and the use of magnetically controlled growing rods increased during this time. Preoperative curve magnitude, traditional growing rod lengthening intervals, and rates of final fusion did not change.

LEVEL OF EVIDENCE

Level II.

Prospectively collected surgeon indications for discontinuation of a lengthening program for early-onset scoliosis

INTRODUCTION

At some point after children with early-onset scoliosis (EOS) undergo implantation of a distraction construct to control deformity and promote growth, a decision is made to discontinue lengthening. The purpose of this study was to evaluate surgeon indications for discontinuation of a lengthening program and to evaluate patient outcomes.

METHODS

As a part of a multicenter database, surgeons prospectively completed a questionnaire at the completion of growth-friendly treatment. Surgeon indications for discontinuation included patient age, pain/functional status, implant status, and spinal deformity parameters. Patient demographics, scoliosis type, deformity parameters, and length of time in a growing program were queried. Patients were treated with a final fusion or observation, and rate of secondary surgeries was analyzed.

RESULTS

Questionnaires were completed on 121 patients (61% female). EOS etiology was 31% neuromuscular, 43% congenital, 16% idiopathic, and 10% syndromic. Average age at initiation of growing program was 6.8 ± 3.1 years, and average age at discontinuation was 12.7 ± 2.5 years. The most commonly cited indications for discontinuation of a lengthening program included bone age/skeletal maturity (n = 46), patient age (n = 33), and diminishing returns with expansions (n = 33). A larger coronal Cobb angle was found in patients who underwent definitive fusion (65°) when compared with continued observation (55°, p = 0.001). Twenty-nine (24%) patients were initially treated with observation after completion of a growing construct. In this subgroup, at a minimum of 2 years' (average 3.8 years') follow-up, 26/29 (90%) patients remained stable with observation alone; whereas, three (10%) underwent delayed final fusion surgery.

CONCLUSIONS

The most common surgeon-cited indications for discontinuation of a lengthening program in EOS patients are skeletal maturity and patient age. The majority of patients (76%) underwent definitive spinal fusion after discontinuation of a lengthening program; whereas, those treated with observation alone had a survivorship of 90% at a minimum follow-up of two years.

Radiographic Outcome and Complication Rate of 34 Graduates After Treatment With Vertical Expandable Prosthetic Titanium Rib (VEPTR): A Single Center Report

BACKGROUND

The final strategy for graduates from growth-sparing surgery is challenging. The purpose of this study was to evaluate the radiographic outcome and complications of patients with early onset scoliosis (EOS) who have graduated from vertical expandable prosthetic titanium rib (VEPTR) treatment, either undergoing final fusion surgery or following a nonfusion approach.

METHODS

Final treatment for VEPTR graduates was divided in "VEPTR in situ without final fusion," "removal of VEPTR without final fusion," and "removal of VEPTR with instrumented final fusion." Radiographic evaluations included main coronal Cobb angle and main kyphosis pre and post VEPTR implantation, at the end of implant lengthening, after final fusion (if applicable), and at latest follow-up. Complications during VEPTR treatment and in case of final fusion were reported.

RESULTS

In total, 34 VEPTR graduates were included; 17 underwent final fusion surgery, and 17 followed a nonfusion strategy. Average coronal Cobb angle before VEPTR implantation was 70±23 degrees (range, 21 to 121 degrees), and 65±22 degrees (range, 17 to 119 degrees) at latest follow-up. Average main kyphosis angle was 53±27 degrees (range, 6 to 137 degrees) before VEPTR, and 69±34 degrees (range, 10 to 150 degrees) at latest follow-up. There was a 41% complication rate with final fusion surgery.

CONCLUSIONS

There is a high complication rate during VEPTR treatment and with final fusion surgery. The stiffness of the spine and thorax allow for only limited correction when performing a final instrumented spondylodesis. Avoiding final fusion may be a viable alternative in case of good coronal and sagittal alignment.

LEVEL OF EVIDENCE

Level IV-therapeutic.

Long term outcome of vertical expandable prosthetic titanium rib treatment in children with early onset scoliosis

The vertical expandable prosthetic titanium rib (VEPTR) device was originally developed for the treatment of thoracic insufficiency syndrome with the aim of improving respiratory function of affected patients. Although clinically obvious, the changes in pulmonary function of VEPTR-treated patients are difficult to assess when using common lung function tests, and newer techniques based on functional magnetic resonance imaging (MRI) are currently being evaluated. The potential of improving lung function and simultaneously controlling the spinal deformity has continuously broadened the spectrum of indications for VEPTR, not least due to the frequent reports of complications with spine-based traditional growing rods (tGR). However, the initial enthusiasm of spine-sparing deformity correction has progressively subsided with the increasing number of reports on complications, including the detection of extraspinal ossifications along the implants and across ribs. The avoidance of repetitive surgical implant lengthening with the availability of motorized distraction-based implants has further diminished the use of VEPTR, especially in the absence of volume-depletion deformities of the thorax. In view of the still scarce reporting on the ultimate strategy of VEPTR treatment and the lack of long-term follow-up of patients receiving growth-sparing surgery, only limited conclusions can be drawn so far. Based on the available reports, however, the intended deformity corrections with final fusion surgeries can be achieved to a rather limited extent, while the complication and reoperation rates are still very high.

Treatment of early onset spinal deformities with magnetically controlled growing rods: a single centre experience of 30 cases

PURPOSE

The treatment of early onset scoliosis continues to be a major challenge, even when using motorized growth-sparing implants. We report on 30 cases operated on with magnetically controlled growing rods (MCGRs) at our institution, analyzing radiological parameters and complications, comparing our results with the literature and presenting a special implant fixation technique. A separate focus highlights the challenges of conversion from previous non-motorized implants.

METHODS

Consecutive case series. The nature and effects of complications were recorded for all patients. Radiographic evaluations were performed for patients with a minimum follow-up of two years. Separate analyses were carried out for patients who were previously treated with non-motorized growth-sparing implants.

RESULTS

There were 12 documented complications in 11/30 (37%) patients leading to 13 unplanned returns to the operating room. In all, 18/30 patients had a minimum follow-up of two years. Major curve and main kyphosis, as well as T1 to T12 and T1 to S1 distances significantly improved with MCGR implantation, however, less in patients converted from previous growth-sparing surgical treatment. While the achieved correction of the major curve was maintained, there was a loss of kyphosis correction with subsequent implant lengthening. Gain in implant length decreased with increasing number of extensions.

CONCLUSION

Despite improved patient's comfort, MCGR show a considerable complication rate. Coronal plane deformities can be well controlled, but diminished implant lengthening is already apparent within two years after MCGR implantation. Central databases should help to clarify unresolved aspects and optimize the treatment of these young patients.

LEVEL OF EVIDENCE

IV.