Pedicle screw instrumentation with or without pelvic fixation in neuromuscular scoliosis: Outcome and complications in a series of 37 patients with a minimum 2-year follow-up.

OBJECTIVE: Neuromuscular scoliosis (NMS) is often associated with rapid progressive spinal deformities. Indications, when to extend the instrumentation to the pelvis for pelvic obliquity are not generally accepted at this time. This study reports on the indications, surgical technique and results using pedicle screw instrumentation exclusively with or without pelvic fixation for spine fusion in patients with NMS. PATIENTS AND METHODS: Thirty-seven NMS patients were treated with pedicle screw instrumentation (PSI) between 2007 and 2013 with a minimum follow-up of 24 months. The mean age at the time of operation was 14.91 ± 2.03 years (range, 11.17-18.58). Posterior spine fusion (PSF) was conducted in 33 patients; 4 patients underwent a combined anterior spinal release followed by PSF during one-stage surgery. Pelvic fixation was achieved by ilium screws combined with S-1 screws in 4 cases and by sacral-alar-iliac (SAI) technique by Sponseller in 9 cases, respectively. RESULTS: The mean primary Cobb angle was 65.5° (range, 14-103°) and improved significantly to 19.8° (range, 1-50°, p < 0.001) after surgery and 20.5° (range, 3-57, p = 0.47) at 2 years FU, respectively. Besides, an improvement of pelvic obliquity and T1 tilt angle could be detected. Major complications occurred in 19% and minor complications in 32%. CONCLUSION: Pedicle screw fixation only for spine fusion in patients with NMS can be applied safely with reasonable complication rates. An excellent correction in all planes, a significant improvement of the pelvic obliquity and almost no loss of correction at 2 years FU were observed.

Treatment of pediatric spinal deformity with use of recombinant human bone morphogenetic protein-2.

In pediatric spine surgery nonunion is a challenging issue. Instability may cause neurological impairment and lead to numerous surgeries in order to achieve fusion. The use of rhBMP-2 for pediatric spinal fusion has not been widely reported. In this study, a series of 13 children (14 procedures) that underwent spinal rhBMP-2 application were analyzed in order to measure clinical and radiographic outcome. Therefore, patient data, diagnosis, construct of instrumentation, type of bone graft, quantity of BMP used, and fusion outcome were reviewed. The study cohort included four female and nine male patients with a mean age of 11.2 years (range 2.6-19.2 years) at the time of rhBMP-2 application. Rh-BMP-2 was used in both primary (n = 6) and revision surgery (n = 8) in patients with a high risk for the development of nonunion. The mean follow-up was 51 months (range 12-108 months). Fusion occurred in 11 patients. Complications that may be due to application of rhBMP-2 were seen after four operations. Three patients had an increased body temperature and in one case prolonged wound secretion was evident, treated by local wound care or observation. In one of these patients an extensive postoperative hematoma occurred, necessitating surgical treatment. In conclusion, we could detect high fusion rates following the use of rhBMP-2 in pediatric spine surgery without an increased complication rate attributable to its application. Therefore we consider recombinant human BMP-2 to be an option in selected pediatric spinal procedures, especially in cases with compromised bone healing due to congenital, systemic, or local conditions.

Strategies for Treating Scoliosis in Early Childhood.

BACKGROUND: Scoliosis in early childhood is defined as abnormal curvature of the spine of any etiology that arises before age 10. The affected children are at high risk of developing restrictive pulmonary dysfunction. The treatment presents major challenges because of the complexity and high morbidity of the disease. METHODS: This article is based on pertinent articles retrieved by a selective literature search, and on the results of a retrospective study by the authors. RESULTS: In addition to conservative treatment methods including physiotherapy, casts, and corsets, progressive scoliosis usually requires early surgical intervention. In recent years, many different so-called non-fusion techniques have been developed for the surgical treatment of early childhood scoliosis. The goal of this new strategy is to avoid early fusion procedures and to enable further growth of the rib cage, lungs, and spine in addition to correcting the scoliosis. The authors also present their own intermediate-term results with a novel growth-preserving spinal operation that exploits magnet technology. CONCLUSION: Because of the low prevalence and heterogeneous etiology of early childhood scoliosis, the literature to date contains no randomized controlled therapeutic trials concerning this small group of high-risk patients. For the treatment to succeed, it is essential for specialists from all of the involved medical disciplines to work closely together. Conservative measures such as physiotherapy, casts, and corsets can delay the (frequent) need for surgery or even make surgery unneces - sary, particularly in the idiopathic types of early childhood scoliosis. The new non-fusion techniques enable continued growth of the spine, rib cage, and lung in addition to correcting the scoliosis.

Recombinant Human Bone Morphogenetic Protein-2 (rhBMP-2) for the Treatment of Nonunion of the Femur in Children and Adolescents: A Retrospective Analysis.

Background. The aim of this study was to examine clinical and radiographic healing after rhBMP-2 application in children and adolescents presenting with nonunion of the femur and to investigate the safety of rhBMP-2 use in these cases. Materials and Methods. We reviewed the medical records of five patients with a mean age of 11 years (5.4 to 16.2) with nonunion of the femur who were treated with rhBMP-2 and internal fixation using a locking plate at a single institution. Particular attention was paid to identify all adverse events that may be due to rhBMP-2 use. Results. Union occurred in four of five patients at a mean of 12.1 months (7.9 to 18.9). The locking plates were removed after a mean of 16 months (11 to 23). One patient had nonunion due to deep infection. After a mean follow-up of 62.5 months (17 to 100), union was still evident in all four patients and they were fully weight-bearing without pain. Discussion. In this retrospective study, rhBMP-2 combined with a locking plate has been used successfully to treat children and adolescents with nonunion of the femur in four of five cases. One major complication was thought to be possibly related to its use.

Posterior Only Vertebral Column Resection for the Treatment of Severe Spinal Deformities in Pediatric Patients: A Retrospective Case Series.

OBJECTIVE: The treatment of severe spinal deformities in pediatric patients is very challenging. Posterior only vertebral column resection (PVCR) allows for correcting of severe deformities of the vertebral column via a posterior only procedure. We analyzed radiologic outcome of PVCR performed on a series of pediatric patients with severe congenital and acquired spinal deformities. METHODS: A case series of 11 pediatric patients with severe spinal deformity who were treated by PVCR between 2009 and 2013 were retrospectively analyzed. All patients had posterior instrumentation and reconstruction of the anterior column with titanium cages filled with autologous bone. Seven patients had pure kyphosis or kyphoscoliosis, whereas 4 patients were treated because of scoliotic deformities. The patient records were reviewed for demographic and general clinical data. Complications and adverse events, transfusion rates, and surgical time were recorded. Radiologic analysis included Cobb angles and percentage of correction, analysis of sagittal profile, time to fusion, and possible complications related to instrumentation. RESULTS: Average preoperative scoliosis of 61° was corrected to 32°, resulting in a 50% correction at final follow-up. Coronal imbalance was improved to 36% at the most recent follow-up. Mean preoperative kyphotic deformity was 90° and was corrected to 43° at the last follow-up evaluation. Intraoperative complications included loss of the neuromonitoring signals in 2 cases and pleural laceration in 1 case. CONCLUSIONS: PVCR for children is an effective and safe technique providing a successful correction of complex pediatric spinal deformities. Nevertheless, it remains a technically highly demanding procedure, implying the possibility of severe complications.

Preliminary Results of Magnetically Controlled Growing Rods for Early Onset Scoliosis.

BACKGROUND: Growth-sparing techniques for the treatment of early onset scoliosis (EOS) have developed significantly over the last years. Traditional growing rods (GRs) require repeated surgical lengthening under anesthesia. Since June 2011 we have been using the magnetically controlled growing rods (MCGR) to treat patients with progressive EOS. METHODS: Thirty-five patients with EOS of different etiologies underwent treatment with MCGR. We record about our preliminary results of 24 patients who fulfilled the inclusion criteria of a minimum follow-up (FU) of 12 month and >3 lengthenings. The mean age at surgery was 8.9±2.5 years. Correction of the primary curve after the index surgery and after lengthenings was measured on standing radiographs using the Cobb technique. T1-T12 and T1-S1 spinal length were also measured. Intraoperative and postoperative complications were recorded. RESULTS: The mean FU was 21.1±7.3 months. All patients had a minimum of 3 outpatient lengthenings [mean, 4.6±1.5 (range, 3 to 8)]. The mean primary curve was 63±15 degrees (range, 40 to 96 degrees) and improved to 29±11 degrees (range, 11 to 53 degrees; P<0.001) after MCGR. The mean major curve after most recent lengthening was 26 degrees (range, 8 to 60 degrees; P<0.07). The T1-T12 as well as the T1-S1 length increased significantly (P<0.001). The mean preoperative thoracic kyphosis decreased from 43±24 degrees (range, -32 to 86 degrees) to 27±12 degrees (range, 9 to 50 degrees; P<0.001) after surgery, respectively, and measured 32±12 degrees (range, 12 to 64 degrees; P<0.05) at last FU. In 1 patient a loss of distraction occurred making rod exchange necessary. Three patients developed a proximal junctional kyphosis and in another patient a screw pull out occurred that required revision surgery. CONCLUSIONS: Our results demonstrate that MCGR is a safe and effective nonfusion technique in the treatment of progressive EOS avoiding repeated surgical lengthening procedures. It provides adequate distraction similar to standard GR. The magnetically induced transcutaneous lengthening allows noninvasive distraction achieving spinal growth comparable to conventional GR techniques. LEVEL OF EVIDENCE: Level IV-retrospective nonrandomized objective study.

Growth modulation with a medial malleolar screw for ankle valgus deformity. 79 children with 125 affected ankles followed until correction or physeal closure.

BACKGROUND AND PURPOSE: Growth modulation with a medial malleolar screw is used to correct ankle valgus deformity in children with a wide spectrum of underlying etiologies. It is unclear whether the etiology of the deformity affects the angular correction rate with this procedure. PATIENTS AND METHODS: 79 children (20 girls) with ankle valgus deformity had growth modulation by a medial malleolar screw (125 ankles). To be included, patients had to have undergone screw removal at the time of skeletal maturity or deformity correction, or a minimum follow-up of 18 months, and consistent radiographs preoperatively and at the time of screw removal and/or follow-up. The patients were assigned to 1 of 7 groups according to their underlying diagnoses. The lateral distal tibial angle (LDTA) was analyzed preoperatively, at screw removal, and at follow-up. RESULTS: Mean age at operation was 11.7 (7.4-16.5) years. The average lateral distal tibial angle normalized from 80° (67-85) preoperatively to 89° (73-97) at screw removal. The screws were removed after an average time of 18 (6-46) months, according to an average rate of correction of 0.65° (0.1-2.2) per month. No significant differences in the correction rate per month were found between the groups (p = 0.3). INTERPRETATION: Growth modulation with a medial malleolar screw is effective for the treatment of ankle valgus deformity in patients with a wide spectrum of underlying diagnoses. The individual etiology of the ankle valgus does not appear to affect the correction rate after growth modulation. Thus, the optimal timing of growth modulation mainly depends on the remaining individual growth and on the extent of the deformity.

Rebound of ankle valgus deformity in patients with hereditary multiple exostosis.

BACKGROUND: Temporary screw epiphysiodesis of the distal tibia is employed to correct ankle valgus deformity in patients with a wide spectrum of underlying etiologies. For patients with hereditary multiple exostosis it is unclear whether a rebound phenomenon may play a role after screw removal (SR) and successful management of ankle valgus deformity. METHODS: From January 2002 to July 2013, 10 boys and 2 girls with HME and an ankle valgus deformity were included in this study. To be included the following criteria had to be met: patients had to have undergone temporary medial malleolar screw epiphysiodesis, SR at the time of skeletal maturity or correction of the deformity, a follow-up (FU) at least 6 months after SR, and consistent radiographs obtained preoperatively at the time of SR as well at FU. The average age at the time of operation was 11.6±1.5 years (range, 9.6 to 14.7 y). The tibiotalar tilt (TT) was analyzed preoperatively, at SR and at FU. RESULTS: The average preoperative TT was 13.2±4.9 degrees. Twenty-four months (±10) after epiphysiodesis all screws were removed. At SR, the TT was normalized to 0.8±4.8 degrees (P<0.001), according to an average rate of correction of 0.63±0.28 degrees per month. Twenty-two months (±13) after SR, the TT increased up to 3.2±4.9 degrees (P<0.05), a rebound (>5 degrees) occurred in 43%, managed by repeated epiphysiodesis. No deep infections or implant complications occurred. No permanent damage of the physis was observed in any case. CONCLUSIONS: Medial malleolar screw epiphysiodesis is a successful treatment for the correction of ankle valgus deformity in patients with HME. A rebound after SR in the growing child or adolescent occurs in almost 50% of patients with HME, which can easily be managed by repeated epiphysiodesis. Therefore, we do not recommend overcorrection into a slight varus deformity. Because of the varying correction and recurrence rates, close FUs are of paramount importance. LEVEL OF EVIDENCE: Level IV.

Temporary epiphyseodesis for limb-length discrepancy. 8- to 15-year follow-up of 34 children.

BACKGROUND AND PURPOSE: For the treatment of leg-length discrepancies (LLDs) of between 2 and 5 cm in adolescent patients, several epiphyseodesis options exist and various complications have been reported. We reviewed the 8- to 15-year outcome after temporary epiphyseodesis in patients with LLD. PATIENTS AND METHODS: 34 children with LLD of up to 5 cm were included in the study. Mean age at epiphyseodesis was 12.8 (10-16) years. Temporary epiphyseodesis was performed with Blount staples or 8-plates. The LLD was reviewed preoperatively, at the time of implant removal, and at follow-up. Every child had reached skeletal maturity at follow-up. Long-standing anteroposterior radiographs were analyzed with respect to the mechanical axis and remaining LLD at the time of follow-up. Possible complications were noted. RESULTS: The mean LLD changed from 2.3 (0.9-4.5) cm to 0.8 (-1.0 to 2.6) cm at follow-up (p<0.001). 21 patients had a final LLD of <1 cm, and 10 had LLD of <0.5 cm. At the time of follow-up, in 32 patients the mechanical axis crossed within Steven's zone 1. No deep infections or neurovascular lesions were seen. 4 implant failures occurred, which were managed by revision. INTERPRETATION: Temporary epiphyseodesis is an effective and safe option for the treatment of LLD. The timing of the procedure has to be chosen according to the remaining growth, facilitating a full correction of the LLD. If inaccurate placement of staples is avoided, substantial differences between the mechanical axes of both legs at skeletal maturity are rare.