An NIHR-approved two-year observational study on magnetically controlled growth rods in the treatment of early onset scoliosis.

Aims: The primary aim of this study was to evaluate the performance and safety of magnetically controlled growth rods in the treatment of early onset scoliosis. Secondary aims were to evaluate the clinical outcome, the rate of further surgery, the rate of complications, and the durability of correction. Patients and Methods: We undertook an observational prospective cohort study of children with early onset scoliosis, who were recruited over a one-year period and followed up for a minimum of two years. Magnetically controlled rods were introduced in a standardized manner with distractions performed three-monthly thereafter. Adverse events which were both related and unrelated to the device were recorded. Ten children, for whom relevant key data points (such as demographic information, growth parameters, Cobb angles, and functional outcomes) were available, were recruited and followed up over the period of the study. There were five boys and five girls. Their mean age was 6.2 years (2.5 to 10). Results: The mean coronal Cobb angle improved from 57.6° (40° to 81°) preoperatively, 32.8° (28° to 46°) postoperatively, and 41° (19° to 57°) at two years. Five children had an adverse event, with four requiring return to theatre, but none were related to the device. There were no neurological complications or infections. No devices failed. One child developed a proximal junctional kyphosis. The mean gain in spinal column height from T1 to S1 was 45.4 mm (24 to 81) over the period of the study. Conclusion: Magnetically controlled growth rods provide an alternative solution to traditional growing rods in the surgical management of children with early onset scoliosis, supporting growth of the spine while controlling curve progression. Their use has clear psychosocial and economic benefits, with the reduction of the need for repeat surgery as required with traditional growing rods. Cite this article: Bone Joint J 2018;100-B:507-15.

The use of magnetically-controlled growing rods to treat children with early-onset scoliosis: early radiological results in 19 children.

AIMS: We undertook a prospective non-randomised radiological study to evaluate the preliminary results of using magnetically-controlled growing rods (MAGEC System, Ellipse technology) to treat children with early-onset scoliosis. PATIENTS AND METHODS: Between January 2011 and January 2015, 19 children were treated with magnetically-controlled growing rods (MCGRs) and underwent distraction at three-monthly intervals. The mean age of our cohort was 9.1 years (4 to 14) and the mean follow-up 22.4 months (5.1 to 35.2). Of the 19 children, eight underwent conversion from traditional growing rods. Whole spine radiographs were carried out pre- and post-operatively: image intensification was used during each lengthening in the outpatient department. The measurements evaluated were Cobb angle, thoracic kyphosis, proximal junctional kyphosis and spinal growth from T1 to S1. RESULTS: The mean pre-, post-operative and latest follow-up Cobb angles were 62° (37.4 to 95.8), 45.1° (16.6 to 96.2) and 43.2° (11.9 to 90.5), respectively (p < 0.05). The mean pre-, post-operative and latest follow-up T1-S1 lengths were 288.1 mm (223.2 to 351.7), 298.8 mm (251 to 355.7) and 331.1 mm (275 to 391.9), respectively (p < 0.05). In all, three patients developed proximal pull-out of their fixation and required revision surgery: there were no subsequent complications. There were no complications of outpatient distraction. CONCLUSIONS: Our study shows that MCGRs provide stable correction of the deformity in early-onset scoliosis in both primary and revision procedures. They have the potential to reduce the need for multiple operations and thereby minimise the potential complications associated with traditional growing rod systems. Cite this article: Bone Joint J 2016;98-B:1240-47.

Incidence of proximal junctional kyphosis with magnetic expansion control rods in early onset scoliosis.

BACKGROUND: The introduction of magnetic expansion control growth rods for the surgical management of EOS has gained popularity. However, there are no published studies on the incidence of proximal junctional kyphosis (PJK) using this technique. PURPOSE: The aim of this study is to report the incidence of PJK following treatment with magnetic growth rods in EOS. METHODS: Retrospective review of data from 21 cases (12 males, 9 females) over 3 years. PJK was obtained from whole spine X-rays pre-op, immediate post-op and last follow-up. Cobb angle was measured between the superior end plate of vertebra two levels above the upper instrumented vertebra (UIV) and the inferior end plate of the UIV. A difference of >10° between the pre-operative x-rays and the last follow-up X-rays was recorded as PJK. RESULTS: 6/21 (28.6 %) had proximal junctional kyphosis of more than 10° at last follow-up. Average age was 5.3. Average follow-up was 32.5 months. All the patients with PJK were syndromic. Four out of these six patients were males (66 %). Average PJK angle was 25.55°. Average pre-operative kyphosis was 52.5°. Average number of distractions was 7.4. All six patients had syndromic association. 3/6 patients (50 %) were conversion cases treated with traditional growth rods previously (TGR). None of the patients required unplanned surgery for PJK. CONCLUSION: The incidence of PJK in EOS patients treated with magnetic rods is favourably comparable to that reported with traditional growth rods. Also, children who are male, syndromic, hyperkyphotic, and younger must be monitored closely.

Radiological and clinical assessment of the distraction achieved with remotely expandable growing rods in early onset scoliosis.

PURPOSES: Magnetically controlled growing rods (MCGR) allow controlled distraction of the immature spine for the treatment of early onset scoliosis. This study's primary aim was to determine the disparity between 'true' (TD) and 'intended' (ID) distraction. The secondary aim was to assess truncal growth and development during sequential lengthening. METHODS: Twenty-one patients with a maximum follow up of 37 months were included in the study. Patients in the study underwent three monthly distractions. The amount of TD was determined by measuring the expansion gap on dedicated fluoroscopic images of the actuator. The total TD to date was compared to the ID measurement reported on the external adjustment device (EAD). Weight, sitting and standing heights were recorded at each distraction. RESULTS: The average number of three monthly distractions was 8. The true to intended distraction ratio was calculated as 0.33. Patients who had undergone previous surgery gained less distraction with a ratio of 0.30 compared to patients undergoing MCGR as a primary procedure with a ratio of 0.35. Weight, sitting and standing heights increased in all patients by an average of 3.1 kg, 2.3 and 5.2 cm per year. The Cobb angle following surgical correction was maintained in 19 of 21 patients at the latest follow-up. CONCLUSIONS: The TI ratio of 0.33 suggests that for every unit of distraction registered on the EAD approximately 33 % of true distraction occurs in vivo. Increases in sitting and standing heights were observed in all patients in the study.

Treatment of post-operative infections following proximal femoral fractures: our institutional experience.

Proximal femoral fractures (PFFs) are a major health concern in the elderly population. Improvements made in implants and surgical techniques resulted in faster rehabilitation and shorter length of hospital stay. Despite this, the reduced physiological reserve, associated co-morbidities and polypharmacy intake of the elderly population put them at high risk of postoperative complications particularly of infectious origin. Out of 10061 patients with proximal femoral fractures 105 (1.05%) developed surgical site infection; 76 (72%) infections occurred in patients who had sustained intracapsular (IC) fractures with the remaining 29 (28%) infections occurring in patients with extracapsular (EC) neck of femur fractures. The median number of additional surgical debridements was 2 (range 1-7). MRSA was isolated in 49 (47%) of the cases; 38 patients (36%) ultimately underwent a Girdlestone's excisional arthroplasty. Mortality at 30 days and 3 months was 10% and 31%, respectively. It was noted that post-operative hip infection predisposed to a prolonged length of stay in the acute unit and subsequently to a more dependent destination after discharge.

The cost and consequences of proximal femoral fractures which require further surgery following initial fixation.

We evaluated the cost and consequences of proximal femoral fractures requiring further surgery because of complications. The data were collected prospectively in a standard manner from all patients with a proximal femoral fracture presenting to the trauma unit at the John Radcliffe Hospital over a five-year period. The total cost of treatment for each patient was calculated by separating it into its various components. The risk factors for the complications that arose, the location of their discharge and the mortality rates for these patients were compared to those of a matched control group. There were 2360 proximal femoral fractures in 2257 patients, of which 144 (6.1%) required further surgery. The mean cost of treatment in patients with complications was £18,709 (£2606.30 to £60,827.10), compared with £8610 (£918.54 to £45,601.30) for uncomplicated cases (p < 0.01), with a mean length of stay of 62.8 (44.5 to 79.3) and 32.7 (23.8 to 35.0) days, respectively. The probability of mortality after one month in these cases was significantly higher than in the control group, with a mean survival of 209 days, compared with 496 days for the controls. Patients with complications were statistically less likely to return to their own home (p < 0.01). Greater awareness and understanding are required to minimise the complications of proximal femoral fractures and consequently their cost.

The Hoffa fracture--a fracture not to miss.

The Hoffa fracture is a rare unicondylar fracture of the lower femur that occurs in the coronal plane. The nature of the fracture pattern makes it both radiologically and clinically difficult to diagnose. The mechanism of injury is usually high energy, often associated with multiple injuries and so can easily be overlooked. A high degree of suspicion is warranted to avoid missing these fractures which have a propensity to displace if not fixed. This report highlights the clinical presentation and management of a Hoffa fracture in a patient presenting with polytrauma and reviews the current literature.

Treatment of acute neurological deficit after cervical laminectomy with lumbar cerebrospinal fluid drainage.

Spinal cord ischaemia is a rare, but reported cause of acute deterioration following cervical laminectomies. Various adjuncts have been reported to protect against and treat cord ischaemia, including CSF diversion. We present a case of a patient who experienced an acute neurological deterioration following cervical laminectomies that improved following CSF drainage.

Horner's syndrome in a patient presenting with a spontaneous pneumothorax.

Spontaneous pneumothoraces are a common thoracic problem presenting to an Accident and Emergency (A&E) department. The symptoms and signs are well described and a chest x-ray examination is usually diagnostic. However the neurological signs, specifically a Horner's syndrome on the ipsilateral side, are not widely recognised. This case illustrates the association and emphasises that when assessing a patient with a suspected spontaneous pneumothorax, an ipsilateral Horner's syndrome supports the clinical diagnosis. Further, its presence makes a tensioning pneumothorax, or as in this case a pneumothorax with significant collapse and apical adhesions, more likely. No previous case reporting the association has had the opportunity for thorascopic assessment and demonstration of likely cause.