Bilateral rib-to-pelvis technique for managing early-onset scoliosis

Abstract

Background: Early-onset scoliosis describes progressive spinal deformity of varying etiologies in the growing child. The management of early-onset scoliosis is challenging, with many treatment options but no conclusive evidence for the best treatment method.

Questions/purposes: We describe a bilateral percutaneous rib-to-pelvis technique, present our early experience with this technique in patients with early-onset scoliosis, identify adverse events, and determine whether these are comparable to those for other current techniques.

Description of technique: The VEPTR(®) device is placed through three small incisions that allow for attachment of rib hooks bilaterally at the upper end and through pelvic hooks at the distal end, providing distraction forces to correct the deformity while allowing for growth.

Patients and methods: We retrospectively reviewed all 37 patients with early-onset scoliosis treated with the bilateral rib-to-pelvis VEPTR(®) technique from 2003 and 2009. Patients were evaluated for demographics, diagnosis, curve correction, and adverse events and divided into two groups: ambulatory and nonambulatory. The 18 ambulatory patients underwent 139 procedures and the 19 nonambulatory patients underwent 100 procedures. Average followups were 84 and 64 months in the ambulatory and nonambulatory groups, respectively.

Results: The rate of adverse events per procedure was 13%. Thirty-nine percent of ambulatory patients developed a marked crouched gait over time. The rate of adverse events in the nonambulatory group was 15%.

Conclusions: This technique appears a reasonable alternative to growing rods for the management of early-onset scoliosis in nonambulatory children due to the low rate of adverse events. Due to the increased incidence of crouched gait, we have abandoned this technique in ambulatory children unless there is no option to attach the distal fixation to the spine.

Fig. 1

A photograph shows a patient prone on the operating table and carefully padded. A midline incision at the level of the second to fourth ribs is made for proximal rib fixation. Distal incisions 1 cm lateral to the posterosuperior iliac spine are used for pelvic fixation.

Fig. 2

A photograph shows how the second through fourth ribs are generally used for proximal rib fixation. A stacked rib cradle construct using the VEPTR^® 2 device is preferred.

Fig. 3

A photograph illustrates how the stacked rib cradles allow for multiple points of fixation on the ribs.

Fig. 4

A photograph shows how iliac fixation is placed over the apex of the ilium, which is generally about 1 cm lateral to the posterosuperior iliac spine.

Fig. 5

A photograph shows an appropriately sized VEPTR^® implant being selected and contoured. The surgeon should anticipate the extra length needed after insertion of the device for initial correction of the curve as demonstrated in Figure 6.

Fig. 6A–B

(A) A photograph shows the distal end of the VEPTR^® device being engaged in the connector for the iliac fixation, after which a c-ring is attached and used for distraction of the implant against the pelvic fixation. (B) A photograph demonstrates the distraction technique using the 5.0/6.0 connector and the c-ring.

Fig. 7

A photograph shows the simple dressing used. No bracing is used postoperatively.

Fig. 8A–D

(A) A radiograph shows the spine of a 15-month-old child with Williams syndrome and kyphoscoliosis. (B) A lateral radiograph of the spine shows substantial kyphosis in the sitting position. (C) A postoperative AP radiograph of the spine shows correction of the coronal deformity with the VEPTR^® 2 devices in place. (D) A lateral radiograph shows correction of the deformity in the sagittal plane.