5/11/2013 Financial Disclosures Vertebral body stapling in children with idiopathic • Theologis: none scoliosis < 10 years of age with curve magnitude • Cahill: DePuy Synthes Spine 30-39 degrees • Auriemma: none Alexander A. Theologis, MD; Patrick Cahill, MD; Mike • Betz: Medtronic, DePuy Synthes Spine, Auriemma, BS; Randal Betz, MD; Mohammad Diab, MD Orthocon, SpineGuard, MiMedx • Diab: none 58 th Annual LeRoy C. Abbott Society Scientific Program 34 th Annual Verne T. Inman Lectureships Department of Orthopaedic Surgery, UCSF March 11, 2013 The Unpredictable Early Onset Idiopathic Scoliosis • Skeletally immature child Mild Moderate Severe – Infantile: < 3 years <25 25 – 45 degrees > 45 degrees – Juvenile: 3-10 years Management? • Challenging - Prevent curve progression – Growth potential? - Prevent surgical fusion – Age – Curve magnitude – Unpredictable 1
5/11/2013 Nonoperative The Dilemma • Observation vs. Bracing • < 10 years old with curves > 30 degrees – Conflicting data – Curve too severe to be controlled with a brace – No difference in surgical rates (22% vs. 23%) (Dolan et – Patient too young to be fused al. 2007) • Crankshaft phenomenon • Limit growth of spine • Curve magnitude at onset of puberty is the only important factor ( DiMeglio 2011 ) • Fusionless surgical alternatives? – Improve curve Cobb angle < 20 20 - 30 > 30 – Prevent progression & fusion Risk of fusion 16% 75% 100% VBS Evolution • Vertebral body stapling • Nitinol staples – Adopted from long bone growth – Shape memory alloy – Cold: straight prongs modulation (Blount) – First use 1954: congenital scoliosis ( Smith ) – Warm: curved prongs • Indications – Age < 13 (girls); < 15 (boys) – Thoracic curves: < 35 degrees – Lumbar curves: 25-45 degrees 2
5/11/2013 Literature Objective • Betz et al. 2003 – 21 pts (11.9 yrs; 10-14 years) – Thoracic: 60% success for 18° to 55° curves (minimum 1 year f/u) • To determine whether VBS may arrest or slow • curve progression in order to avoid fusion in Betz et al. 2010 – 28 pts (9.4 yrs; 4-13); minimum 2 year f/u children < 10 years of age with scoliosis 30 to – Lumbar: 87% success for 25° to 45° curves 39° – Thoracic: 79% success for 25° to 35° curves • 30° to 39°. • Laituri et al. – Thoracic: 71.4% success for curves 25° to 41° – Thoracoscopic only – 7 children (8-11 years old) Improved success with narrower curve magnitudes and/or age criteria? Methods Surgical technique • Open • Retrospective case series – UCSF – Shriner’s Philadelphia • Inclusion – < 10 years old – Idiopathic scoliosis – Cobb angle 30 – 39 degrees – Minimum 2 year follow-up • Thoracoscopic • Outcome variables – Intra-operative and hospital data – Complications – Definitive fusion for curve progression (greater than 10 degrees) – Need for re-operation for any indication 3
5/11/2013 Patients Results Operative Data • Curve progression – Thoracic: 0% – Lumbar: 0% • Need for fusion: 0% • Revision surgery: 0% 4
5/11/2013 Conclusions Larger curves • Children < 10 years old with idiopathic scoliosis 30° to 39° may significantly benefit from immediate VBS • Vertebral tethering without observation or bracing. – Original use in the lumbar spine as a • This treatment may ultimately prevent the need for “dynamic stabilizer” – Titanium pedicle screws surgical fusion at a later age. – Polyethylene flexible tether: • Unknowns! compresses adjacent screws when – Lower age limit? tightened – Children between 10 and puberty? – Effect on growth? – Overcorrection? – Larger curves (>40-45°)? Vertebral tethering Future Directions 48° 17° 43° 20° • Exciting! 4 yo 58° • The future – Biomechanical comparisons – Surgical indications? (age, curves, etc) – Larger cohorts – Longer follow-up – Patient outcomes 5
5/11/2013 References 1. Smith AD, Von Lackum WH, Wylie R. An operation for stapling vertebral bodies in congenital scoliosis. J Bone Joint Surg Am 1954;36:342-8. 2. Dolan LA, Weinstein SL. Surgical rates after observation and bracing for adolescent idiopathic scoliosis: an evidence-based review. Spine (Phila Pa 1976) 2007;32:S91-S100. 3. Charles YP, Daures JP, de Rosa V, et al. Progression risk of idiopathic juvenile scoliosis during pubertal growth. Spine (Phila Pa 1976) 2006;31:1933-42. 4. DiMeglio A, Canavese F, Charles YP. Growth and adolescent idiopathic scoliosis: when and how much? J Pediatr Orthop 2011;31:S28-36. 5. Zuege RC, Kempken TG, Blount WP. Epiphyseal stapling for angular deformityat the knee. J Bone Joint Surg Am 1979;61:320–9. 6. Laituri CA, Schwend RM, Holcomb GW, 3rd. Thoracoscopic vertebral body stapling for treatment of scoliosis in young children. J Laparoendosc Adv Surg Tech A 2012;22:830-3. 7. Betz RR, Ranade A, Samdani AF, et al. Vertebral body stapling: a fusionless treatment option for a growing child with moderate idiopathic scoliosis. Spine (Phila Pa 1976) 2010;35:169-76. 8. Betz RR, D'Andrea LP, Mulcahey MJ, et al. Vertebral body stapling procedure for the treatment of scoliosis in the growing child. Clin Orthop Relat Res 2005:55-60. 9. Betz RR, Kim J, D'Andrea LP, et al. An innovative technique of vertebral body stapling for the treatment of patients with adolescent idiopathic scoliosis: a feasibility, safety, and utility study. Spine (Phila Pa 1976) 2003;28:S255-65. 10. Lavelle WF, Samdani AF, Cahill PJ, et al. Clinical outcomes of nitinol staples for preventing curve progression in idiopathic scoliosis. J Pediatr Orthop 2011;31:S107-13. 11. Trobisch PD, Samdani A, Cahill P, et al. Vertebral body stapling as an alternative in the treatment of idiopathic scoliosis. Oper Orthop Traumatol 2011;23:227-31. 12. Betz et al. Fusionless Alternatives VBS Biomechanics • Growing rods • Shilla • VEPTR • High complication rate – Broken rods 1) Staple placement restricts ROM in axial rotation and lateral bending – Infection 2) There is no mechanical difference between one double-prong staple and 2 single-prong staples – Multiple surgeries 3) An anterior staple significantly reduces the overall flexion-extension ROM of the thoracic spine. – Cost 4) Staple fixation does not result in significantly elevated adjacent segment motion. 6
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