Recombinant coagulation factor VIIa--a novel haemostatic agent in scoliosis surgery?

Spinal fusion surgery in children and adolescents with idiopathic scoliosis is often associated with severe haemorrhage. Recombinant coagulation factor VIIa (rFVIIa) has previously been shown to be an effective haemostatic treatment for severe bleeding associated with a variety of coagulopathic and non-coagulopathic indications. The aim of this retrospective study was to assess the safety and haemostatic efficacy of rFVIIa in a series of 26 consecutive adolescent patients with scoliosis (22 females; mean age 16.6 years) undergoing correctional surgery. A second series of 26 consecutive patients (20 females; mean age 16.2 years) who received standard therapy during surgery, represented historical controls. Blood loss, transfusion requirements, duration of surgery, and peri-operative measurements of coagulation parameters were compared between the two groups. Intra-operative and combined intra-operative and post-operative blood losses were significantly smaller in the rFVIIa-treatment group than in the historical controls (P=0.003 and 0.032, respectively); rFVIIa-treated patients also demonstrated significantly reduced blood loss per vertebral segment fused (P=0.032) and per hour of surgery (P<0.001). Intra-operative requirements for packed red blood cells were also significantly lower in the treatment group (P=0.042). Patients in the treatment group demonstrated rapid and maintained reduction of prothrombin time and international normalised ratio; values among rFVIIa-treated patients remained significantly lower than those in the control group at all time points evaluated (P<0.001). There were no deaths and no adverse events. These results suggest that rFVIIa is a safe and effective haemostatic agent for use during spinal fusion surgery in adolescent patients with idiopathic scoliosis; however, further research and randomised, placebo-controlled trials are needed to confirm these findings.

The use of the Ilizarov technique in the treatment of upper limb deformity in patients with Ollier's disease.

Between 1997 and 2001 three children with Ollier's disease underwent treatment of five upper limb segments using the Ilizarov technique. Average length discrepancy was 8.4 cm in the arm and 4.5 cm in the forearm, but coexisting large angular deformities were the major problem in all the children. Full correction of the axial deviations was achieved in all children. Restoration of length was achieved in all arms, but residual forearm length discrepancy persisted. In four segments conversion of the abnormal cartilage into normal regenerate was observed on radiograms. The problems, obstacles, and complications are similar to those met in more usual lengthening procedures. The Ilizarov technique should be the treatment of choice in restoring the correct axis and length of a limb in patients with Ollier's disease.

[Treatment results of triplanar correction of idiopathic scoliosis in relation to curve pattern and degree of scoliosis]. / Wyniki leczenia skoliozy idiopatycznej metoda trojplaszczyznowej korekcji w zaleznosci od typu i wielkosci znieksztalcenia.

Background. The King classification enables the surgeon to assess the curve pattern of scoliosis which determines the choice of operative technique as well as the extent of spinal fusion. The final outcome of operative treatment depends on the curve pattern and the degree of scoliosis. Material and methods. The aim of the study was to assess the relation between the correction of the deformity and the curve pattern. In this retrospective study, 97 patients were included who had undergone scoliosis surgery between 1999 and 2001, and for whom the follow-up period was at least 36 months. 12 patients were classified as type I according to the King classification, 26 as type II, 49 as type III, and 5 each as type IV and V. The mean Cobb angle in the whole group was 58 degrees in the thoracic region and 38 degrees in the lumbar region, while in the sagittal plane there was kyphosis of the thoraco-lumbar region of 3 degrees . Results. Postoperative values were as follows: thoracic region - 30.2 degrees , lumbar region - 27.6 degrees and thoraco-lumbar region - lordosis of 4 degrees . Conclusions. The Cotrel-Dubousset method makes it possible to achieve an average correction of 65% of the original deformity, the best result being achieved for type IV and V. Operative treatment should be applied to patients with scoliosis of an angle below 60 degrees , which enables compensation of trunk transposition.

[The use of recombinant coagulation factor VIIa in patients undergoing surgical correction of scoliosis with the C-D method]. / Zastosowani rekombinowanego czynnika krzepniecia VIIa u pacjentow z operacyjna korekcja skoliozy metoda C-D.

Background. Excessive intraoperative bleeding during scoliosis correction extends surgery time, and may increase the risk of complications during surgery and the postoperative period. Recombinant factor VIIa (rVIIa) is widely used to control hemorrhage in patients with hemophilia. Recent reports have examined the use of rVIIa for intraoperative bleeding in patients without coagulopathies. The aim of our study was to evaluate the influence of rVIIa on selected coagulation parameters and blood loss in patients undergoing surgical correction of scoliosis. Material and methods. 62 patients undergoing surgical correction of scoliosis were included in the study. The treatment group consisted of 29 patients who received rVIIa (20 g/kg). The coagulation parameters were evaluated at 15 minutes, 2 hours, 4 hours and 12 hours after the start of surgery. The control group consisted of 33 patients who underwent the same surgery without pharmacological blood loss control. Results. A single administration of rVIIa resulted in a reduction of prothrombin (PT) time and APTT. The effect was observed until the 4th hour of surgery, after which time the value of coagulation parameters increased and reached preoperative values after 12 hours. The volume of blood loss in the treatment group was 1046 ml, compared to 1393 ml in the control group. Conclusions. The use of small doses of rVIIa in healthy patients resulted in rapid thrombin activation at places of tissue damage caused by surgery. During extensive scoliosis surgery, the effect of rVIIa on coagulation process led to a reduction of the time spent in surgery.

Diagnosis of syringomyelia and Chiari malformations in patients with scoliosis.

Background. Syryngomyelia was first described by Olliver in 1824. Burwell and Williams reported a 50% incidence of scoliosis in patients with syringomyelia. Malformations of the central nervous system among patients with scoliosis are very difficult to diagnose on the basis of clinical and radiological examination. MRI examination is a useful tool in diagnosing neurogenic malformations. The aim of this study is to evaluate the prevalence of neurogenic malformations in a group of patients with scoliosis, and the evaluation of shared clinical symptoms in this group. Material and methods. Clinical, radiological and MRI assessment was performed on a group of 323 patients referred to the Clinic due to scoliosis with a Cobb angle > 20. Results. Four patients were diagnosed with syringomyelia, 1 had a Chiari malformation type I and 1 female patient aged 14 was diagnosed with tethered cord. Conclusions. In the group, the prevalence of neurogenic malformation was 1.9%. MRI examination in patients with scoliosis seems to be justified in the following cases: clinical findings suggests a neurogenic background of spine deformation; scoliosis with onset before 8 years of age; prior to the planned surgical correction of scoliosis.

Remodelling and congruency of the hip joint in children with Perthes' disease treated with varus-derotation subtrochanteric osteotomy.

Background. Dislocation of the femoral head to the front and to the side during the course of Perthes' disease is the main threat to the development of the hip. Containment of the femoral head into the acetabulum is the main goal of conservative and operative treatment. The spherical shape of the acetabulum is used as the modelling factor for the femoral head during the regeneration period, which enables the femoral head to rebuild its spherical shape. The aim of the study is to present the changes occurring within the hip joint during the course of Perthes' disease, before and after operative treatment with varus-derotation subtrochanteric osteotomy, based on objective radiological measurements. Material and methods. 53 patients, aged from 5 to 10 years, were treated operatively. The necrosis period was assessed on radiographic examination according to Reiberg and Catterall. All patients were treated with varus-derotation subtrochanteric osteotomy, decreasing the neck-shaft angle to an average value of 111 degrees . During the follow-up period of 6 years, a control examination was performed every 12 months. Measurements were compared with norms published in the literature. Various parameters were assessed in this study to assess the proximal end of the femur bone (neck-shaft angle, epiphyseal head index of Heyman and Herndon) and the position of the femoral head inside the acetabulum (centre-edge angle, distance angle, acetabular head index of Heyman-Herndon). Results. During the 6-year follow-up period, the value of the neck-shaft angle remained within the range of norms for the age and group, and for operated limbs the value was lower than the norm. The other assessed parameters showed substantial improvement, which led to the preservation of the correct shape of both the femoral head and acetabulum and improved the congruency of the joint. Conclusion. The value of parameters assessed post-operatively show a substantial improvement compared with preoperative measurements. Good results are obtained as a result of varus-derotation subtrochanteric osteotomy in patients with Perthes' disease type III and IV according to Catterall, and lead to improvement in the congruency of the joint.

Variability of the anteversion angle in children with Perthes' disease treated with varus-derotation subtrochanteric osteotomy.

Background. Despite extensive research, it is still unknown whether a 40% increase in the anteversion angle value is a primary or a secondary change in Perthes' disease. The aim of the study was to evaluate the variability of the anteversion angle in children with unilateral Perthes disease treated operatively with varus and derotation osteotomy. Material and methods. 53 patients between 5 and 10 years were included in this study. The stage and type of necrosis were classified using radiological examination according to the Reiberg and Cattarall classification. The value of anteversion was determined using clinical and ultrasound examination in addition to directly during surgery. After the operation, the anteversion angle was 11 degrees . During a 6-year follow-up period, ultrasound examination was performed every 12 months. Angle values obtained through direct measurements were compared with the norms published by Lanz and Wachsmuth, and ultrasound measurements were compared with the norms for the age groups. Results. 47 patients were found to be in stage III of the disease and 6 were in stage II. During the period up to 36 months after surgery, the value of the anteversion angle gradually reached the same value as in a limb considered as "healthy". During the following 36 months these values remained unchanged. Conclusions. An increased value of the anteversion angle in children with Perthes' disease is observed in a limb considered as "healthy". An increased value of the anteversion angle in children with Perthes' disease is a secondary deformation caused by the arrest of the physiological decrease of its value during development.