Introduction. Growing rods are used in the treatment of early-onset scoliosis. The aim of this technique is to achieve deformity correction while maintaining spinal growth. Gradual stiffening or spontaneous fusion of the spine can interfere with the ability to lengthen. Furthermore, diminished acquired length with serial distraction is common and needs to be evaluated and quantified. The purpose of this prospective study was to measure the forces and amount of distraction over time in patients with early-onset scoliosis treated with growing rods. Methods. Distraction forces were measured prospectively during 60 consecutive lengthening procedures in 26 patients. All patients had single submuscular rod constructs with side-to-side connectors. For every measurement, output from a transducer on a dedicated pair of distraction calipers was recorded at zero load status, and the force was then recorded at every 1 mm lengthening; length was obtained at each event and was recorded in millimeters. Results. The force required to distract the spine doubled at the fifth lengthening procedure (mean 368 N [SD 54]), and the distraction force was significantly higher at the fifth lengthening than at previous lengthening (p<0·01). Mean length achieved at each distraction decreased over time, such that by the fifth lengthening, 8mm or less was consistently achieved. Conclusions. Distraction forces increase significantly after repeated lengthening of growing rod constructs, and the length obtained at each procedure decreases

Abstract. MAGnetic Expansion Control (MAGEC) rods are used in the surgical treatment of children with early onset scoliosis. The magnetically controlled lengthening mechanism enables rod distractions without the need for repeated invasive surgery. The CE certification of these devices was suspended in March 2021 due, primarily, to performance evidence gaps in the documents provided by the manufacturer to regulators and notified bodies. MAGEC rods are therefore not permitted for use in countries requiring CE marking. This was a survey of 18 MAGEC rod surgeons in the UK about their perception of the impact of the CE suspension on the clinical management of their patients. Unsurprisingly, virtually all perceived a negative impact, reflecting the complexity of this patient group. Reassuringly, these surgeons are highly experienced in alternative treatment methods. Cite this article: Bone Jt Open 2022;3(2):155–157

Objectives. Pedicle-lengthening osteotomy is a novel surgery for lumbar spinal stenosis (LSS), which achieves substantial enlargement of the spinal canal by expansion of the bilateral pedicle osteotomy sites. Few studies have evaluated the impact of this new surgery on spinal canal volume (SCV) and neural foramen dimension (NFD) in three different types of LSS patients. Methods. CT scans were performed on 36 LSS patients (12 central canal stenosis (CCS), 12 lateral recess stenosis (LRS), and 12 foraminal stenosis (FS)) at L4-L5, and on 12 normal (control) subjects. Mimics 14.01 workstation was used to reconstruct 3D models of the L4-L5 vertebrae and discs. SCV and NFD were measured after 1 mm, 2 mm, 3 mm, 4 mm, or 5 mm pedicle-lengthening osteotomies at L4 and/or L5. One-way analysis of variance was used to examine between-group differences. Results. In the intact state, SVC and NFD were significantly larger in the control group compared with the LSS groups (P<0.05). After lengthening at L4, the percentage increase in SCV (per millimetre) was LRS>CCS>FS>Control. After lengthening at L5 and L4-L5, the percentage increase in SCV (per millimetre) was LRS>FS>CCS>Control. After lengthening at L4 and L4-L5, the percentage increase in NFD (per millimetre) was FS>CCS>LRS>Control. After lengthening at L5, the percentage increase in NFD (per millimetre) was CCS>LRS>control>FS. Conclusions. LRS patients are the most suitable candidates for treatment with pedicle-lengthening osteotomy. Lengthening L4 pedicles produced larger percentage increases in NFD than lengthening L5 pedicles (p < 0.05). Lengthening L4 pedicles may be the most effective option for relieving foraminal compression in LSS patients. Cite this article: P. Li, L. Qian, W. D. Wu, C. F. Wu, J. Ouyang. Impact of pedicle-lengthening osteotomy on spinal canal volume and neural foramen size in three types of lumbar spinal stenosis. Bone Joint Res 2016;5:239–246. DOI: 10.1302/2046-3758.56.2000469

Aims. This study aimed to determine the relationship between pedicle-lengthening distance and bulge-canal volume ratio in cases of lumbar spinal stenosis, to provide a theoretical basis for the extent of lengthening in pedicle-lengthening osteotomies. . Methods. Three-dimensional reconstructions of CT images were performed for 69 patients (33 men and 36 women) (mean age 49.96 years; 24 to 81). Simulated pedicle-lengthening osteotomies and disc bulge and spinal canal volume calculations were performed using Mimics software. . Results. The mean spinal canal volume of the two groups, L4 and L5, were 14 646.81 mm. 3. (5918.60 to 22 717.77) and 16 408.47 mm. 3. (8678.21 to 31 204.79), respectively. The mean lengthening distance was 2.17 mm (0.5 to 4.8) and the mean bulge-canal volume ratio was 0.23 (0.05 to 0.48). The pedicle-lengthening distance of the two groups were very strongly correlated with disc bulge volume and bulge-canal volume ratio (p < 0.001); the predictive equation was established as L = 0.06 + 9.06R (where L equals the pedicle-lengthening distance and R represents the bulge-canal volume ratio). . Discussion. Our findings indicated that lumbar pedicle-lengthening distance strongly correlates with bulge-canal volume ratio, which can be estimated before surgery from CT images. Take home message: The predictive equation could help surgeons to decide the pedicle lengthening distance according to individual's condition and guide the surgery effectively. Cite this article: Bone Joint J 2016;98-B:238–43

Aims. The aim of this study was to compare the outcomes of surgery using growing rods in patients with severe versus moderate early-onset scoliosis (EOS). Patients and Methods. A review of a multicentre EOS database identified 107 children with severe EOS (major curve ≥ 90°) treated with growing rods before the age of ten years with a minimum follow-up of two years and three or more lengthening procedures. From the same database, 107 matched controls with moderate EOS were identified. Results. The mean preoperative major curve was 101° (90 to 139) in the severe group and 67° (33° to 88°) in the moderate group (p < 0.001), which was corrected at final follow-up to 57° (10° to 96°) in the severe group and 40° (3° to 85°) in the moderate group (p < 0.001). T1-S1 height increased by a mean of 54 mm (-8 to 131) in the severe group and 27 mm (-4 to 131) in the moderate group at the initial surgery (p < 0.001), and by 50 mm (-17 to 200) and 54 mm (-11 to 212), respectively, during distraction (p = 0.84). The mean number of complications per patient was 2.6 (0 to 14) in the severe group and 1.9 (0 to 10) in the moderate group (p = 0.040). Five patients (4.7%) in the severe group and three (2.8%) in the moderate group developed a neurological deficit postoperatively (p = 0.47). Conclusion. Severe EOS can be treated effectively using growing rods, but the risk of complications is high. Cite this article: Bone Joint J 2018;100-B:772–9

Aims. The aim of this study was to compare the peak pull-out force (PPF) of pedicle-lengthening screws (PLS) and traditional pedicle screws (TPS) using instant and cyclic fatigue testing. Materials and Methods. A total of 60 lumbar vertebrae were divided into six groups: PLS submitted to instant pull-out and fatigue-resistance testing (groups A1 and A2, respectively), TPS submitted to instant pull-out and fatigue-resistance testing (groups B1 and B2, respectively) and PLS augmented with 2 ml polymethylmethacrylate, submitted to instant pull-out and fatigue-resistance testing (groups C1 and C2, respectively). The PPF and normalized PPF (PPFn) for bone mineral density (BMD) were compared within and between all groups. Results. In all groups, BMD was significantly correlated with PPF (r = 0.83, p < 0.001). The PPFn in A1 was significantly less than in B1 (p = 0.006) and C1 (p = 0.002). The PPFn of A2 was significantly less than in B2 (p < 0.001) and C2 (p < 0.001). The PPFn in A1, B1, and C1 was significantly greater than in A2 (p = 0.002), B2 (p = 0.027), and C2 (p = 0.003). There were no significant differences in PPFn between B1 and C1, or between B2 and C2. Conclusion. Pedicle lengthening screws with cement augmentation can provide the same fixation stability as traditional pedicle screws and may be a viable clinical option. Cite this article: Bone Joint J 2018;100-B:516–21

Conventional growing rods are the most commonly used distraction-based devices in the treatment of progressive early-onset scoliosis. This technique requires repeated lengthenings with the patient anaesthetised in the operating theatre. We describe the outcomes and complications of using a non-invasive magnetically controlled growing rod (MCGR) in children with early-onset scoliosis. Lengthening is performed on an outpatient basis using an external remote control with the patient awake. Between November 2009 and March 2011, 34 children with a mean age of eight years (5 to 12) underwent treatment. The mean length of follow-up was 15 months (12 to 18). In total, 22 children were treated with dual rod constructs and 12 with a single rod. The mean number of distractions per patient was 4.8 (3 to 6). The mean pre-operative Cobb angle was 69° (46° to 108°); this was corrected to a mean 47° (28° to 91°) post-operatively. The mean Cobb angle at final review was 41° (27° to 86°). The mean pre-operative distance from T1 to S1 was 304 mm (243 to 380) and increased to 335 mm (253 to 400) in the immediate post-operative period. At final review the mean distance from T1 to S1 had increased to 348 mm (260 to 420). Two patients developed a superficial wound infection and a further two patients in the single rod group developed a loss of distraction. In the dual rod group, one patient had pull-out of a hook and one developed prominent metalwork. Two patients had a rod breakage; one patient in the single rod group and one patient in the dual rod group. Our early results show that the MCGR is safe and effective in the treatment of progressive early-onset scoliosis with the avoidance of repeated surgical lengthenings. Cite this article: Bone Joint J 2013;95-B:75–80

Aims

The aim of this study was to compare outcomes after growth-friendly treatment for early-onset scoliosis (EOS) between patients with skeletal dysplasias versus those with other syndromes.

Aims. Magnetically controlled growing rods (MCGRs) allow non-invasive correction of the spinal deformity in the treatment of early-onset scoliosis. Conventional growing rod systems (CGRS) need repeated surgical distractions: these are associated with the effect of the ‘law of diminishing returns’. The primary aim of this study was to quantify this effect in MCGRs over sequential distractions. . Patients and Methods. A total of 35 patients with a maximum follow-up of 57 months were included in the study. There were 17 boys and 18 girls with a mean age of 7.4 years (2 to 14). True Distraction (TD) was determined by measuring the expansion gap on fluoroscopy. This was compared with Intended Distraction (ID) and expressed as the ‘T/I’ ratio. The T/I ratio and the Cobb angle were calculated at several time points during follow-up. Results. The mean follow-up was 30 months (6 to 57). There was a significant decrease in the mean T/I ratio over time (convex rod at 3 months 0.81, . sd. 0.58 vs 51 months 0.17, . sd . 0.16, p = 0.0001; concave rod at 3 months 0.93, . sd. 0.67 vs 51 months 0.18, . sd. 0.15, p = 0.0001). A linear decline of the mean T/I ratios was noted for both convex rods (r. 2. = 0.90, p = 0.004) and concave rods (r. 2. = 0.81, p = 0.015) over 51 months. At the 24-month follow-up stage, there was a significant negative correlation between the mean T/I ratio of the concave rod with weight (r = -0.59, p = 0.01), age (r = -0.59, p = 0.01), and BMI of the child (r = -0.54, p = 0.01). Conclusions. The ‘law of diminishing returns’ is also seen after serial distraction using MCGR. Compared to previously published data for CGRS, there is a gradual linear decline rather than a rapid initial decline in lengthening. In older, heavier children a reduced distraction ratio in the concave rod of the MCGR device is noted over time. Cite this article: Bone Joint J 2017;99-B:1658–64

Aims. Significant correction of an adolescent idiopathic scoliosis in the coronal plane through a posterior approach is associated with hypokyphosis. Factors such as the magnitude of the preoperative coronal curve, the use of hooks, number of levels fused, preoperative kyphosis, screw density, and rod type have all been implicated. Maintaining the normal thoracic kyphosis is important as hypokyphosis is associated with proximal junctional failure (PJF) and early onset degeneration of the spine. The aim of this study was to determine if coronal correction per se was the most relevant factor in generating hypokyphosis. Methods. A total of 95 patients (87% female) with a median age of 14 years were included in our study. Pre- and postoperative radiographs were measured and the operative data including upper instrumented vertebra (UIV), lower instrumented vertebra (LIV), metal density, and thoracic flexibility noted. Further analysis of the post-surgical coronal outcome (group 1 < 60% correction and group 2 ≥ 60%) were studied for their association with the postoperative kyphosis in the sagittal plane using univariate and multivariate logistic regression. Results. Of the 95 patients, 71.6% (68) had a thoracic correction of > 60%. Most (97.8%) had metal density < 80%, while thoracic flexibility > 50% was found in 30.5% (29). Preoperative hypokyphosis (< 20°) was present in 25.3%. A postoperative thoracic hypokyphosis was four times more likely to occur in patients with thoracic correction ≥ 60% (odds ratio (OR) 4.08; p = 0.005), after adjusting for confounding variables. This association was not affected by metal density, thoracic flexibility, LIV, UIV, age, or sex. Conclusion. Our study supports the ‘essential lordosis’ hypothesis of Roaf and Dickson, i.e. with a greater ability to translate the apical vertebra towards the midline, there is a commensurate lengthening of the anterior column due to the vertebral wedging. Cite this article: Bone Joint J 2020;102-B(4):513–518

Aims

The aim of this study was to compare the clinical and radiological outcomes of patients with early-onset scoliosis (EOS), who had undergone spinal fusion after distraction-based spinal growth modulation using either traditional growing rods (TGRs) or magnetically controlled growing rods (MCGRs).

Aims. Magnetically controlled growing rod (MCGR) systems use non-invasive spinal lengthening for the surgical treatment of early-onset scoliosis (EOS). The primary aim of this study was to evaluate the performance of these devices in the prevention of progression of the deformity. A secondary aim was to record the rate of complications. Patients and Methods. An observational study of 31 consecutive children with EOS, of whom 15 were male, who were treated between December 2011 and October 2017 was undertaken. Their mean age was 7.7 years (2 to 14). The mean follow-up was 47 months (24 to 69). Distractions were completed using the tailgating technique. The primary outcome measure was correction of the radiographic deformity. Secondary outcomes were growth, functional outcomes and complication rates. Results. The mean Cobb angle was 54° (14° to 91°) preoperatively and 37° (11° to 69°) at the latest follow-up (p < 0.001). The mean thoracic kyphosis (TK) was 45° (10° to 89°) preoperatively and 42° (9° to 84°) at the latest follow-up. The mean T1–S1 height increased from 287 mm (209 to 378) to 338 mm (240 to 427) (p < 0.001) and the mean sagittal balance reduced from 68 mm (-76 to 1470) preoperatively to 18 mm (-32 to 166) at the latest follow-up. The mean coronal balance was 3 mm (-336 to 64) preoperatively and 8 mm (-144 to 64) at the latest follow-up. The mean increase in weight and sitting and standing height at the latest follow-up was 45%, 10% and 15%, respectively. The mean Activity Scale for Kids (ASKp) scores increased in all domains, with only personal care and standing skills being significant at the latest follow-up (p = 0.02, p = 0.03). The improvements in Cobb angle, TK and T1-S1 heights were not related to gender, the aetiology of the EOS, or whether the procedure was primary or conversion from a conventional growing rod system. A total of 21 children developed 23 complications at a rate of 0.23 per patient per year. Seven developed MCGR-specific complications. Complications developed at a mean of 38 months (3 to 67) after the initial surgery and required 22 further procedures. Children who developed a complication were more likely to be younger, have syndromic EOS, and have a single-rod construct (6.9 versus 9.3 years, p = 0.034). Conclusion. The progression of EOS can be controlled using MCGRs allowing growth and improved function. Younger and syndromic children are more likely to develop complications following surgery. Cite this article: Bone Joint J 2018;100-B:1187–1200

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

STUDY DESIGN. Retrospective study of 8 children treated with vertical expandable prosthetic titanium rib (VEPTR) for correction of early onset spinal scoliotic deformities. METHODS. 8 children with progressive scoliosis due to a variety of conditions, 6 congenital (2 Goldenhar syndrome, 2 VACTERL syndrome, 2 congenital thoracic abnormalities), 1 spondyloepiphyseal dysplasia, 1 early onset of scoliosis, underwent the index procedure and subsequent lengthening procedures at 6 months intervals (1 patient had 11 lengthening procedures). Mean age was 4 years (2-6 years) and mean follow up 3.8 years (2-6 years). Mean preoperative Cobb angle was 64,8° (51-108) and mean postoperative angle 40° (31-50). RESULTS. There were no neurological complications. Three patients developed infection with wound breakdown. One patient underwent removal of one of the two VEPTR rods. In the other two patients the rods were removed followed by antibiotics and the VEPTR converted to another growing rod system. Overall, patients tolerated the multiple procedures well. Three patients experienced significant distress with multiple surgical procedures. CONCLUSION. VEPTR offers a viable treatment option for children with severe congenital and early onset scoliosis where there are no viable alternatives. It achieves and maintains spinal deformity correction, while allowing for continued spine and chest-wall growth. Complication rate is acceptable in view of the benefits. None of the complications have lead to long term complications to date, but the repeated lengthening have resulted in psychological disturbance which we are investigating further. An implantable driver would offer very significant advantages and would avoid some of the repeated operations

The management of spinal deformity in children with univentricular cardiac pathology poses significant challenges to the surgical and anaesthetic teams. To date, only posterior instrumented fusion techniques have been used in these children and these are associated with a high rate of complications. We reviewed our experience of both growing rod instrumentation and posterior instrumented fusion in children with a univentricular circulation. Six children underwent spinal corrective surgery, two with cavopulmonary shunts and four following completion of a Fontan procedure. Three underwent growing rod instrumentation, two had a posterior fusion and one had spinal growth arrest. There were no complications following surgery, and the children undergoing growing rod instrumentation were successfully lengthened. We noted a trend for greater blood loss and haemodynamic instability in those whose surgery was undertaken following completion of a Fontan procedure. At a median follow-up of 87.6 months (interquartile range (IQR) 62.9 to 96.5) the median correction of deformity was 24.2% (64.5° (IQR 46° to 80°) vs 50.5° (IQR 36° to 63°)). We believe that early surgical intervention with growing rod instrumentation systems allows staged correction of the spinal deformity and reduces the haemodynamic insult to these physiologically compromised children. Due to the haemodynamic changes that occur with the completed Fontan circulation, the initial scoliosis surgery should ideally be undertaken when in the cavopulmonary shunt stage. Cite this article: Bone Joint J 2014;96-B:94–9

Post traumatic stress disorder (PTSD) is well recognised in children having repeated medical/surgical procedures. It has been suggested that it is common in young children undergoing growing rod treatment with ongoing lengthening and the inevitable accompanying complications. We present an index case history, review the literature in order to infer a correlation for the incidence of PTSD and discuss diagnosis and management. We present an index case history of PTSD in a young child undergoing growing rod treatment for scoliosis. The literature was reviewed for PTSD in paediatric surgery and pathologies requiring multiple treatments. Spinal surgery is compared with paediatric cancer, burns, organ failure/transplant, cardiopulmonary disease, inflammatory bowel disease, cystic fibrosis and limb lengthening. No published studies examine PTSD in children undergoing multiple spinal surgeries. One paper reports that children undergoing growing rod treatments show “behavioural alterations” and changes in psychosocial behaviour, including anxiety on entering the operating room and broken rod worries. A recent spine meeting presentation referred to this. Psychosocial problems occur in up to 30% of children with chronic or life-threatening illnesses which involve ongoing treatments. Factors such as age, parental anxiety and previous adverse medical experiences influence anxiety, depression and PTSD. Based on our index case and methodological correlation with similar pathologies, we fell that PTSD is a genuine concern in children who have repeated spinal operations. This paper is part of an ongoing study, but we believe that the spinal community should be aware of this diagnosis and its management. Ethics approval: Audit Interest Statement: None

Spinal Deformity Service, Royal Orthopaedic Hospital, Birmingham, UK. To describe the technique of nonfusion annulotomy and nuclectomy with posterior growing rod instrumentation for the treatment of non-congenital early onset scoliosis. To present our results of the application of this technique in a consecutive series of nine patients with mean follow up of 76 months (range 16 to 123 months). We undertook retrospective observational casenote and radiograph study of patients with noncongenital early onset scoliosis having annulotomy and nuclectomy at the apex of their respective curves with standard posterior growing rod instrumentation between 1998 and 2009. 10 patients were identified with one excluded due to short follow up period. Of the nine patients included mean follow up was 76 months. Mean age at primary surgery was 71.7 months (range 29- 97 months). We measured pre and post operative Cobb angle, T1-S1 height change and change in height over the apical segments. Mean pre op cobb angle was 74° (range 62- 81°). Mean post op cobb angle was 38°. Three patients have completed their treatment programme with a mean number of 9 lengthenings achieved. Six patients are still undergoing lengthenings. CT demonstrates that the annulotmized segment does not fuse at a mean 3.5 years postoperatively. All patients demonstrated growth over total spinal height and also over apical segments which had undergone annultomy/ nuclectomy. We also report complications. We have demonstrated that anterior annulotomy and nuclectomy with posterior growing rod construct does allow for spinal growth over released segments without autofusion

Introduction. Many methods are available for distal anchoring of spine-based and rib-based growing rod systems for early-onset scoliosis. One of these methods, pelvic S-hooks, was initially recommended for patients with spina bifida or for those with severe thoracolumbar curves. No study has yet analysed the clinical and radiographic effects of S-hooks on patients with rib-based instrumentation. The purpose of this study is to retrospectively review the results of S-hook pelvic fixation in patients with rib-based instrumentation. Methods. A multicentre, retrospective study, approved by the institutional review board, was undetaken in all patients treated with rib-based constructs using S-hooks for pelvic fixation. Preoperative and postoperative clinical variables, radiological measurements, and the incidence and management of complications were evaluated in patients with a minimum follow-up of 2 years. Results. 44 patients, 26 of whom were girls, were studied and had a mean age at surgery of 71 months. The most common surgical indication was progressive neuromuscular scoliosis. The average preoperative Cobb angle was 64° and at most recent follow-up (mean 45 months) was 53°. The most common construct was dual rods resting over the iliac crest without suture to the iliac crest extending from T3/T4 ribs to the pelvis using domino connectors. 45% of the patients had complications, of which S-hook migration after the initial procedures was the most common. S-hook migration was corrected at the next lengthening with repositioning of the hook to the iliac crest. No correlation was detected between the complication rates and the clinical, radiographic, and surgical technique variables evaluated. Conclusions. Control of spinal deformities without fusion presents several challenges. S-hooks can migrate off the iliac crest, requiring repositioning of implants during subsequent lengthening. This finding highlights the need to explore different fixation techniques with a stronger attachment to the iliac crest

Aims

To report the mid-term results of a modified self-growing rod (SGR) technique for the treatment of idiopathic and neuromuscular early-onset scoliosis (EOS).

Aims

To report the outcome of spinal deformity correction through anterior spinal fusion in wheelchair-bound patients with myelomeningocele.