VCR or not? Complication rates in major deformity surgeries Kostuik - - PDF document

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VCR or not? Complication rates in major deformity surgeries Kostuik - - PDF document

Disclosures Alternatives to VCR in major deformity AOSpine (a, d) Avalon Spinecare (a) correction Medtronic (d) NuVasive (d) OrthoSmart (g) Kenneth Cheung Jessie Ho Professor in Spine Surgery Conflicts of Interest Key: a


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SLIDE 1

Alternatives to VCR in major deformity correction

Kenneth Cheung Jessie Ho Professor in Spine Surgery Head, Department of Orthopaedics & Traumatology

Disclosures

  • AOSpine (a, d)
  • Avalon Spinecare (a)
  • Medtronic (d)
  • NuVasive (d)
  • OrthoSmart (g)

Conflicts of Interest Key: a – grants/research support; b – consultant; c – stock/shareholder (self- managed); d – speaker honoraria; e – advisory board or panel; f – employee, salary (commercial interest); g – other financial or material support (royalties, patents, etc.)

VCR or not?

Complication rates in major deformity surgeries

  • Kostuik and Hall 1983

– 78%

  • Simmonds et al. 1993

– 41%

  • Daubs et al. 2007

– 37%

  • Charovsky et al. 2012
  • 39%

Prospective, Multicenter Assessment of Complications Following Complex Adult Spinal Deformity Surgery:

The Scoli-RISK-1 Trial

LAWRENCE G. LENKE, MD MICHAEL G. FEHLINGS, MD, PHD CHRISTOPHER I. SHAFFREY, MD KENNETH MC CHEUNG, MD LEAH CARREON, MD, MSC

Kenneth Cheung1, Mark Dekutoski2, Frank Schwab3, Oheneba Boachie-adjei4, Khaled Kebaish5, Christopher Ames6, Yong Qiu 7, Yukihiro Matsuyama8, Benny Dahl9, Hossein Mehdian10, Ferran Pellisé-Urquiza11, Leah Carreon 12, Christopher Shaffrey13, Michael Fehlings14, Lawrence Lenke15 Affiliations:

1 The University of Hong Kong, Hong Kong 2 The CORE Institute, Roschester, U.S.A. 3 New York University, U.S.A. 4 Hospital for Special Surgery, New York, U.S.A. 5 Johns Hopkins University, U.S.A. 6 University of California, San Francisco, U.S.A. 7 Nanjing University Medical School, China 8 Hamamatsu University School of Medicine, Japan 9 SpineUnit, Rigshospitalet, Copenhagen, Denmark 10 University Hospital, Nottingham, U.K. 11 Hospital Universitari Vall d’Hebron, Spain 12 Norton Leatherman Spine Center, Louiseville, U.S.A. 13 University of Virginia, U.S.A. 14 University of Toronto, Canada 15 Washington University, U.S.A.

1 2 3 4 5 6

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  • At discharge – 25.76%
  • At 6 weeks – 18.18%
  • At 6 months - 6.06%
  • Total with complications = 163 (60.6%)
  • Intra-operative event = 29.4% (n=79)
  • Post-op complications = 49.8% (n=134)
  • Major = 21.6% (n=58)
  • Minor = 42.0% (n=112)
  • Number of patients with ≥ 1 complications = 37% (n=99)

How to minimise complications?

Summary of risk factors

  • Age
  • Obesity and medical comorbidities
  • Smoking status and nutrition
  • Bone quality – evaluation, agonists (Teriparatide), fixation strategies
  • Magnitude of surgery
  • osteotomies
  • Length of fusion
  • Fusion to sacrum
  • Blood transfusion and excessive blood loss
  • Poor postop sagittal balance

Alternatives to VCR in big deformities

  • Accurate flexibility assessment
  • Implant density
  • Correction techniques
  • Posterior column osteotomies
  • Spinal traction – external / internal
  • Salvage
  • Partial correction
  • In-situ fusion

Accurate flexibility assessment

7 8 9 10 11 12

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SLIDE 3

93°

62o

Case 1 Case 2

AIS

34°

Flexibility index= 15% Flexibility index= 64%

53°

Big curves are not necessarily stiff.. And stiff curves are not always big!

JBJS-A 79 (8), August 1997 FBCI -122% FBCI -230%

Eur Spine Journal December 2014, Volume 23, Issue 12, pp 2603–2618

FBCI

  • 100% flexible curves
  • 200% for stiff curves

JBJS-A, Jan 2010

13 15 16 17 18 19

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SLIDE 4
  • Curve correction can be predicted
  • FBCI
  • 122% flexible curves
  • 203% for stiff curves

FBCI is correlated with flexibility

Flexible curves : FBCI = 100% regardless of screw strategy

FBCI is correlated with flexibility

Stiff curves : FBCI >150%

KVSS up to 155% CMSS and ALSS up to 200%

Curve of <20 deg on the FBR More screws for stiff curves

Alternatives to VCR in big deformities

  • Accurate flexibility assessment
  • Implant density
  • Correction techniques
  • Posterior column osteotomies
  • Spinal traction – external / internal
  • Salvage
  • Partial correction
  • In-situ fusion

Posterior column osteotomies

From AO Surgery reference

From AOSpine Surgery Reference

20 21 22 23 24 25

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SLIDE 5

Cantilever correction technique with concave reduction screws

Spinal distraction

6 years old Suspected Mucopolysaccharidosis

4 months of traction / 50% body weight 4 months of traction / 50% body weight 4 months of traction / 50% body weight

26 27 28 29 30 31

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Halo Gravity Traction in Osteogenesis Imperfecta

Michael To, Jason Cheung, Eric Yeung, YL Fan, DH Zhong, Kenneth Cheung

Spinal deformities in OI

  • HKU Shenzhen Hospital 2014-2016
  • 300 OI patients treated
  • 105 have scoliosis (35%)
  • Age 8.3 +/- 6.1
  • 27% have Cobb’s angles > 10 degrees
  • Type III (11.4%) > Type IV (7.6%)/V (7.6%) > Type I (<1%)
  • 5 patients had severe scoliosis – treated by halo traction prior

to surgery

  • M. To et al. 2017 : Unpublished data

Halo traction

  • 6-8 pins inserted
  • CT scan skull
  • Traction started from 3Kg
  • Weekly increase by 0.5-1kg and XR monitoring

Results

  • 3 type IV and 2 type V
  • Mean age 15.2 (12-18)
  • 3 patients require exchange of pins during traction

Results

Subjects OI Type Pre- traction Cobb angle 1st month traction Cobb angle Max traction Cobb angle % Cobb angle correction Days of traction % Body weight

  • f

traction 1 V 140 110 110 21.4 17 40 2 IV 72 68 63 12.5 75 35 3 IV 97 88 87 10.3 60 24.1 4 IV 85 65 55 35.3 120 45.5 5 V 110 109 106 3.6 62 42

2/5 patients have Cobb angle correction above 20% With 40% of body weight

2.5 months traction at 40% body weight

85º 74º 55º

Case 4

32 33 34 35 36 37

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SLIDE 7

Conclusion

  • Pre-operative halo traction seems safe
  • Significant correction occurs within one month
  • Poor responders have more thoracic and rib deformities

Internal halo distraction

40

105

14yo with syrinx and severe kyphoscoliosis

41

97.1°

43

Prior to Definitive Fusion

45.6°

38 39 40 41 43 44

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SLIDE 8

36° 115°

Halo traction combined with VCR

  • 15/F student
  • Neurofibromatosis
  • Progressive spinal deformity
  • Bilateral lower limb weakness (grade 0-1)
  • No lower limb sensation
  • Bladder and bowel intact

NO traction 2017/03/14 Start traction from 2017/03/17 2017/04/01 2017/04/07 2017/04/14 2017/04/21 2017/04/28 2017/05/05 2017/05/12

Deformity improved over 6 weeks

Hip flexion: Gd 2 Knee extension: Gd 3 Ankle and toes: Gd 0 Light touch & pinprick: return to normal Temperature sense improved: 50%. Oct 2017 No further improvement

45 46 47 48 49 50

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Patient and family opted for VCR

  • Preoperative planning
  • Riluzole - 50 mg bd PO for 14 days preop and continue for 14 days

postop

  • 3D printed model and pedicle screw guidance templates

Intraop

  • Neuromonitoring
  • Detailed preop time out
  • Blood salvage
  • Tranexamic acid (10mg/kg body wt loading; 1 mg/kg/hr)
  • Hypotensive during dissection
  • Normotensive during VCR
  • IV steroid before VCR
  • Use of ultrasonic bone scalpel for osteotomy
  • Planned 1st stage dissection and screw insertion and 2nd stage VCR

and correction 24 hours later.

53 54 55 56 57 58

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SLIDE 10

Salvage

19yo male Achondroplasia Severe anaemia and recurrent GI bleeds from oesophageal varices

104

59 60 63 64 65 67

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SLIDE 11

13yo severe scoliosis (Cambodia)

90 90

In–Situ Fusion Alternatives to VCR in big deformities

  • Accurate flexibility assessment
  • Implant density
  • Correction techniques
  • Posterior column osteotomies
  • Spinal traction – external / internal
  • Salvage
  • Partial correction
  • In-situ fusion

Thank You!!

The University of Hong Kong

Queen Mary Hospital The Duchess of Kent Children’s Hospital Faculty of Medicine

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