Aims. The aim of this study was to investigate the incidence and characteristics of instrumentation failure (IF) after total en bloc spondylectomy (TES), and to analyze risk factors for IF. Methods. The medical records from 136 patients (65 male, 71 female) with a mean age of 52.7 years (14 to 80) who underwent TES were retrospectively reviewed. The mean follow-up period was 101 months (36 to 232). Analyzed factors included incidence of IF, age, sex, BMI, history of chemotherapy or radiotherapy, tumour histology (primary or metastasis; benign or malignant), surgical approach (posterior or combined), tumour location (thoracic or lumbar; junctional or non-junctional), number of resected vertebrae (single or multilevel), anterior resection line (disc-to-disc or intravertebra), type of bone graft (autograft or frozen autograft), cage subsidence (CS), and local alignment (LA). A survival analysis of the instrumentation was performed, and relationships between IF and other factors were investigated using the Cox regression model. Results. A total of 44 patients (32.4%) developed IF at a median of 31 months (interquartile range 23 to 74) following TES. Most IFs were rod fractures preceded by a mean CS of 6.1 mm (2 to 18) and LA kyphotic enhancement of 10.8° (-1 to 36). IF-free survival rates were 75.8% at five years and 56.9% at ten years. The interval from TES to IF peaked at two to three years postoperatively and continued to occur over a period of time thereafter; the early IF-developing group had greater CS at one month postoperatively (CS1M) and more lumbar TES. CS1M ≥ 3 mm and sole use of frozen autografts were identified as independent risk factors for IF. Conclusion. IF is a common complication following TES. We have demonstrated that robust spinal reconstruction preventing CS, and high-quality bone grafting are necessary for successful reconstruction. Cite this article: Bone Joint J 2023;105-B(2):172–179

The relationship between radiologic union and clinical outcome in thoracoscopic scoliosis surgery is not clear, as apparent non-union does not always correspond to a poor clinical result. Our aim was to evaluate CT fusion rates 2yrs after thoracoscopic surgery, and explore the relationship between fusion scores and; (i) rod diameter, (ii) graft type, (iii) fusion level, (iv) implant failure, and (v) lateral position in disc space. Between 2000 and 2006 a cohort of 44 patients had thoracoscopic scoliosis correction. Discectomies were performed and defect was packed with either autograft (n=14) or allograft (n=30). Instrumentation consisted of either 4.5mm (n=24) or 5.5mm (n=20) single titanium anterior rod and vertebral body screws. Fusion quality and implant integrity were evaluated 2yr following surgery using low-dose CT. At each disc space, left, right and mid-sagittal CT reconstructions were generated and graded using the Sucato 4-point scale (Sucato, 2004) which is based on calculated percentage of fusion across disc space. Fusion scores were measured for 259 disc spaces in 44 patients. Rod diameter had a strong effect on fusion score, with a mean score of 2.12±0.74 for 4.5mm Ti rod, decreasing to 1.41+0.55 for 5.5mm Ti rod, and to 1.09+0.36 for 5.5mm Ti-alloy rod. Mean fusion scores for autograft and allograft subgroups were 2.13±0.72 and 2.14±0.74 respectively. Fusion scores were highest in the middle of implant construct, dropping off by 20–30% toward the ends. Fusion scores adjacent to the rod (2.19±0.72) were significantly higher than on the contralateral side of the disc (1.24±0.85). Levels where rod fracture occurred (n=11) had lower fusion scores than those without fracture (1.09±0.67 vs 1.76±0.80). Levels where top screw pullout occurred (n=6) had lower CT fusion scores than those without (1.25±0.60 vs 1.83±0.76). Rod diameter (larger), intervertebral level (proximal or distal), lateral position in disc (further from rod) and rod fracture or screw pullout all reduce fusion scores, while graft type does not affect scores. The assumed link between higher fusion score and better clinical outcome must be treated with caution, because rod fractures did not necessarily occur in patients with lower fusion scores. It is possible that with a stiffer rod, less bony fusion mass is required for a stable construct. We propose that moderate fusion scores secure successful clinical outcomes in thoracoscopic scoliosis surgery

Introduction: The occurrence of non-union following instrumented scoliosis correction may predispose to pseudarthrosis and subsequent implant failure. Although non-union is often multifactorial, it is widely accepted that bone graft of adequate quality and quantity is fundamental to achieve solid fusion. Conventionally, autologous rib graft or iliac crest harvest has been utilised for endoscopic anterior instrumented scoliosis surgery. However, these techniques increase the operative duration and cause donor site morbidity, both of which may lengthen hospital stay. Alternatives such as allograft bone and bone morphogenetic proteins have gained more widespread use and may improve fusion rates although this remains controversial. The aim of this study was to compare two-year postoperative fusion rates for a series of patients who underwent endoscopic anterior instrumentation for thoracic scoliosis utilising various bone graft types. Methods: 19 patients who had undergone endoscopic anterior instrumented scoliosis correction using identical instrumentation (4.5mm diameter titanium anterior rod and vertebral body screws, Eclipse, Medtronic) between May 2000 and August 2005 were identified from a surgical database of 132 consecutively treated individuals. All patients received bone graft to supplement thoracic fusion. Discectomy was performed at the levels to be instrumented and intervertebral spaces were packed with autologous rib heads (8 patients), iliac crest (1 patient), or mulched femoral head allograft (10 patients). The quality of thoracic fusion and implant integrity were evaluated two years following scoliosis correction using low-dose CT performed in accordance with local ethical approval. The intervertebral fusion was assessed using a modified Sucato method (1). Each level was graded using a 4-point scale based on calculated percentage of fusion across the disc space. 0 points indicated no fusion; 1 point, fusion < 25%; 2 points, fusion between 25 and 50%; 3 points, fusion between 50 and 75%; 4 points > 75% or complete fusion. The fusion was considered solid with a score of 3 points or more. Data was analysed with non-parametric tests using a significance level of 0.05. Results: Of the cohort, nine had evidence of implant failure with rod fracture. All implant failures occurred in the group who received either rib head or iliac crest graft. No rod fractures were identified in the femoral allograft group. The mean fusion grade in the autologous bone graft group was 1.91 whereas in the allograft group this was 3.30 (95% confidence intervals 1.38–2.44 and 2.99–3.61 respectively) with a statistically significant difference in fusion rates between these two groups (p=0.001). Discussion: This study demonstrated significantly better rates of thoracic fusion in endoscopic anterior instrumented scoliosis correction using mulched femoral allograft compared with autologous rib heads and iliac crest graft. This could be partly explained by the difficulty obtaining sufficient quantities of autologous graft. The lower fusion rate seen in the autologous graft group appears to predispose to rod fracture although the longer-term clinical consequence of implant failure in this group is not clear and warrants further study

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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.

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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).

Aim:. To determine the efficacy and safety of the Magec system in early onset scoliosis (EOS). Methods:. In 2011, 6 males and 2 females had Magec rods, with an average age of 8.5 years (2.9–12.7 years), 7 patients had dual rods, and 1 had single. The main cause of EOS was idiopathic scoliosis (n=6), followed by Congenital (n=1), and Syndromic (n=1). Average follow up was 19.4 months (14–26 months). 4 of these patients had their previous Paediatric Isola growing rods exchanged to Magec, and 1 patient had an exchange from single to Dual Magec rods. Results:. In total, the cohort of patients underwent 65 extensions in clinic with an average 8 each (4–19). The first rod extension was performed at an average of 4.6 months following surgery. From there on extensions were done at two monthly intervals on an average. A total of 75 radiographs were taken after Magec insertion, ranging from 5 to 15 per patient. The mean pre-operative Cobb angle 59° improved to 41° at final follow up. This is a mean reduction of 31%. The mean pre-operative T1-S1 length was 305mm which improved to 349mm at final follow up. A mean increase in spinal length of 14%.m. During follow up, 5 complications were noted: 2 metalwork pullouts, 1 extension failure, 1 rod fracture and 1 patient had dermatitis at site of wound. Conclusion:. Our early results using the Magec magnetic growing rod system are encouraging with maintenance of curve correction and in achieving trunk growth in EOS. Conflict Of Interest Statement: No conflict of interest

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To determine the value of scoliosis surgery, it is necessary to evaluate outcomes in domains that matter to patients. Since randomized trials on adolescent idiopathic scoliosis (AIS) are scarce, prospective cohort studies with comparable outcome measures are important. To enhance comparison, a core set of patient-related outcome measures is available. The aim of this study was to evaluate the outcomes of AIS fusion surgery at two-year follow-up using the core outcomes set.

Between 1969 and 1989, we performed posterior segmental instrumentation on 38 patients with thoracic Scheuermann's kyphosis. We used a dynamic system without sublaminar fixation, and a kyphosis of 50 degrees was the main indication for surgery. The mean initial angle was 68 degrees (50 to 100) and the mean final kyphosis was 43 degrees at five-year follow-up, with a mean final loss after surgery of 3.7 degrees. Reconstruction of the vertebral bodies, vertebral wedging and the anterior-body height ratio were observed even in skeletally mature patients. There were no medical complications. There were three cases of loss of correction by more than 10 degrees and one of rod fracture with pseudarthrosis. The role of non-operative treatment is evaluated and early surgical treatment is advocated

Purpose. 1. To evaluate how radiological parameters change during the first 3 years following anterior endoscopic surgery. 2. To report complications encountered in this period. Methods. Between April 2000 and June 2006,106 patients underwent an anterior endoscopic instrumented fusion. There were 95 females and 11 males. Average age was 16.1 years (range 10-46). 103 (97%) had right-sided idiopathic curves. The majority were Lenke type 1 (79%). Patients were assessed at 3, 6, 12, 24, and 36 months. 83 patients had 1 year follow-up, 69 had 2 years or more. The following were investigated; the structural curve, instrumented curve, non-structural curves, skeletal age at operation and sagittal profile (T5-T12). Results. The mean Cobb angle of the structural curve was 52.3 degrees. 2 months following surgery, it was 21.4 degrees, with a correction rate was 59%. There was a partial loss of correction thereafter (29.3 degrees at 3 years, P=<0.001). The instrumented curve did not change significantly. The mean post-operative Cobb angles of the proximal and distal non-structural curves (when present) at 2months were 19.6 and 19.7 degrees respectively. At 3 years they were 18.8 and 24.4. The change in the distal curve was significant (p=<0.05). The pre-operative sagittal profile was 19 degrees. At 2 months it was 28 degrees and 31 degrees at 3 years. Skeletal maturity at time of surgery was not found to influence the structural curve. There were 12 fractured rods. All were 4.5mm rods and all but 2 were using rib autograft. There were 8 cases of proximal screw pullout. Conclusion. Anterior endoscopic surgery is effective in restoring both sagittal and coronal balance. However, there is small loss of coronal correction in the structural curve. 11% of rods fractured, though none occurred in the 94 patients where a larger rod (5.5mm) and femoral allograft was used

Purpose: To describe the Halifax anterior-posterior kyphectomy, and report on a series consecutive patients. Method: Twenty-two patients received a Halifax kyphectomy over a 23 year period. Patient charts were examined, and radiographs measured pre- immediately post- and at final follow up. Cobb’s method was used to determine kyphosis angle. The procedure itself involves an apical kyphectomy, and cord transection if necessary, followed by the insertion of two rods distally and anteriorly in the vertebral bodies. This is followed by sublaminar wires superiorly and reduction of the kyphosis. Data was analysed to attempt to find a correlation between age, deformity, OR time, length of stay and maintainence of correction. Results: Mean age was 7.59 years (2–17); mean pre-op kyphosis was 123.19 degrees (79–163); post-op 40.43 degrees (13–92); mean correction of 82.29 (39–153). Mean follow-up was 6.38 years (0–14); mean kyphosis at follow-up was 60.24 degrees (14–126), mean final correction of 63.43 degrees (−37–162); mean loss of correction 19.33 degrees (−9–76). The average OR time was 247.86 minutes (180–345); EBL 765cc (140–2100) and length of stay 13.68 days (1–57). Eight patients required hardware removal, and two of these required revision surgery. The other six patients maintained correction without hardware, and did not require re-operation. One patient had a rod fracture, but did not require revision or removal. Twelve patients had no complications. There was one intra-operative mortality. Conclusion: The Halifax kyphectomy is a safe, effective treatment for kyphosis in myelomeningocele patients. Outcomes in this series are comparable to the available literature

Aims

Magnetically controlled growing rods (MCGR) have been gaining popularity in the management of early-onset scoliosis (EOS) over the past decade. We present our experience with the first 44 MCGR consecutive cases treated at our institution.

Purpose: We analysed retrospectively 32 cases of posterior cervicothoracic fixation for spinal tumours. We evaluated spinal stability, spinal alignment, and associated complications. Material and methods: Thirty-two patients underwent surgery: 27 men and five women, mean age 52 years, age range 17–72 years. We implanted 96 articular screws in C4 to C6, 54 screws in C7 and 180 pedicular screws in T1 to T8. Nineteen patients had primary lung cancer with spinal invasion, eleven had spinal metastases, one had a chondrosarcoma and one had a myeloma. For the first group of 19 patients, en bloc resection of the tumour with the vertebra was performed: four total vertebrectomies, 15 partial vertebrectomies. In a second group of 15 patients, palliative posterior fixation was performed with laminectomy decompression. Results: Follow-up ranged from three to 54 months with a mean of 15 months. Mean survival after total or partial vertebrectomy was 16 months (range 3 – 54 months). Survival after palliative decompression was eleven months with a range from five to 19 months. There were no changes in the sagittal alignment in 30 patients: two patients developed mechanical complications late after surgery requiring revision. We did not have any case of screw, plate or rod fracture. There were no neurological complications related to screw insertion either at the thoracic level (180 screws) or the cervical level (96 screws in C4C5C6 and 54 screws in C7). A control scan was available for 21 patients and revealed a malposition of the implanted screws for 2.5% of the screws with no clinical impact. Discussion: Posterior screw fixation is a good method to stabilise the cervicothoracic spine during tumour surgery. Articular cervical screws and transpedicular thoracic screws provide effective stability postoperatively. In addition, this type of instrumentation does not interfere should subsequent laminectomy or wider resection be necessary

Aims. The Fassier Duval (FD) rod is a third-generation telescopic implant for children with osteogenesis imperfecta (OI). Threaded fixation enables proximal insertion without opening the knee or ankle joint. We have reviewed our combined two-centre experience with this implant. Methods. In total, 34 children with a mean age of five years (1 to 14) with severe OI have undergone rodding of 72 lower limb long bones (27 tibial, 45 femoral) for recurrent fractures with progressive deformity despite optimized bone health and bisphosphonate therapy. Data were collected prospectively, with 1.5 to 11 years follow-up. Results. A total of 24 patients (33%) required exchange of implants (14 femora and ten tibiae) including 11 rods bending with refracture. Four (5%) required reoperation with implant retention. Loss of proximal fixation in the femur and distal fixation in the tibia were common. Four patients developed coxa vara requiring surgical correction. In total, 13 patients experienced further fractures without rod bending; eight required implant revision. There was one deep infection. The five-year survival rate, with rod revision as the endpoint, was 63% (95% confidence interval (CI) 44% to 77%) for femoral rods, with a mean age at implantation of 4.8 years (1.3 to 14.8), and 64% (95% CI 36% to 82%) for tibial rods, with a mean age at implantation of 5.2 years (2.0 to 13.8). Conclusion. FD rods are easier to implant but do not improve on the revision rates reported for second generation T-piece rods. Proximal femoral fixation is problematic in younger children with a partially ossified greater trochanter. Distal tibial fixation typically fails after two years. Future generation implants should address proximal femoral and distal tibial fixation to avoid the majority of complications in this series. Cite this article: Bone Joint J 2020;102-B(8):1048–1055

Bone fracture healing is regulated by a series of complex physicochemical and biochemical processes. One of these processes is bone mineralisation, which is vital for normal bone development, its biomechanical competence and fracture healing. Phosphatase, orphan 1 (PHOSPHO1), a bone-specific phosphatase, has been shown to be involved in the mineralisation of the extracellular matrix in bone. It can hydrolyse phosphoethanolamine and phosphocholine to generate inorganic phosphate, which is crucial for bone mineralisation. Phospho1−/− mice show hypomineralised bone and spontaneous fractures. All these data led to the hypothesis that PHOSPHO1 is essential for bone mineralisation and its structural integrity. However, no study to our knowledge has shown the effects of PHOSPHO1 on bone fracture healing. In this study, we examined how PHOSPHO1-deficiency might affect the healing and quality of the fractured bones in Phospho1−/− mice. We performed rodded immobilised fracture surgery on the right tibia of control wild type (WT) and Phospho1−/− mice (n=16 for each group) at eight weeks of age. Bone was left to heal for four weeks and then the mice were euthanised and their tibias were analysed using Faxitron X-ray analyses, microCT, histology and histomorphometry and three-point bending test. Our microCT and X-ray analyses revealed that the appearance of the callus and several static parameters of bone remodeling at the fracture sites were markedly different in WT and Phospho1−/− mice. We observed a significant increase of BS/BV, BS/TV and trabecular number and decrease in trabecular thickness and separation in Phospho1−/− callus in comparison to the WT callus. These observations were further confirmed by histomorphometry. The increased bone mass at the fracture sites of Phospho1−/− mice appears to be caused by increased bone formation as there is a significant increase of osteoblast number, while osteoclast numbers remained unchanged. There was a marked increase of osteoid volume over bone volume (OV/BV) in the Phospho−/− callus. Interestingly, the amount of osteoid was markedly higher at the fracture sites than that of normal trabecular bones. The three-point bending test showed that Phospho 1 −/− fractured bone had more of an elastic characteristics than the WT bone as they underwent more of a plastic deformity before the breakage point compare to the WT. Our work suggests that PHOSPHO1 plays an integral role during bone fracture repair. PHOSPHO1 can be an interesting target to improve the fracture healing process

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The aim of this study was to compare the surgical and quality-of-life outcomes of children with skeletal dysplasia to those in children with idiopathic early-onset scoliosis (EOS) undergoing growth-friendly management.

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It is uncertain whether instrumented spinal fixation in nonambulatory children with neuromuscular scoliosis should finish at L5 or be extended to the pelvis. Pelvic fixation has been shown to be associated with up to 30% complication rates, but is regarded by some as the standard for correction of deformity in these conditions. The incidence of failure when comparing the most caudal level of instrumentation, either L5 or the pelvis, using all-pedicle screw instrumentation has not previously been reported. In this retrospective study, we compared nonambulatory patients undergoing surgery at two centres: one that routinely instrumented to L5 and the other to the pelvis.

Aim. A retrospective study was undertaken to evaluate and compare the results of telescoping (group I) versus non-telescoping rods (group II) in the treatment of osteogenesis imperfecta. Materials and Methods. Thirty-three lower limb segments in ten patients were studied (14 segments in group I and 19 segments in group II). The surgical techniques of Sofield and Miller (1959) and Lang-Stevenson and Sharrard (1984) for rod insertion were used. All cases were assessed clinically regarding mobility status, growth and limb-length, refracture, and infection. They were also assessed radiologically regarding rod migration, bone outgrowing the rod, incorrect T-piece placement, breakage and bending of rods. Results. The average duration of follow-up was 86.2 months (range : 6 to 8 years). Mobility status and bone growth were better in group I than in group II patients. The overall implant related complication rate was 28.6% in group I in comparison to 68.4% in group II. Rod migration was twice more common in group II than in group I. Bone outgrowing the rod and breakage of rods with fracture was seen in group II only. The three-year survival rate for telescoping rods was 92.9% in contrast to 68.4% for non-telescoping rods. The reoperation rate was 7.2% in group I and 31.6% in group II. Conclusions. From this comparative study it was clear that the results were significantly better after Sheffield rods with regard to mobility status, longevity of the rod, and the frequency of complications requiring reoperations. Also most of the complications were related to the technique of rod insertion and the type of rod

Pathological fractures due to metastasis with destruction of the acetabulum and central dislocation of the hip present a difficult surgical challenge. We describe a series using a single technique in which a stable and long-lasting reconstruction was obtained using standard primary hip replacement implants augmented by strong, fully-threaded steel rods with cement and steel mesh, where required. Between 1997 and 2006, 19 patients with a mean age of 66 years (48 to 83) were treated using a modified Harrington technique. Acetabular destruction was graded as Harrington class II in six cases and class III in 13. Reconstruction was achieved using three 6.5 mm rods inserted through a separate incision in the iliac crest followed by augmentation with cement and a conventional cemented Charnley or Exeter primary hip replacement. There were no peri-operative deaths. At the final follow-up (mean 25 months (5 to 110)) one rod had fractured and one construct required revision. Of the 18 patients who did not require revision, 13 had died. The mean time to death was 16 months (5 to 55). The mean follow-up of the five survivors was 31 months (18 to 47). There were no cases of dislocation, deep infection or injury to a nerve, the blood vessels or the bladder

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).