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Complications of Growing Rods - has the Magec Rod overcome all of it ?

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Presentation on theme: "Complications of Growing Rods - has the Magec Rod overcome all of it ?"— Presentation transcript:

1 Complications of Growing Rods - has the Magec Rod overcome all of it ?
Kenneth Cheung Jessie Ho Professor in Spine Surgery President-Elect, Scoliosis Research Society Head, Department of Orthopaedics and Traumatology The University of Hong Kong

2 Growing instrumentations
Internal brace to achieve and maintain deformity correction during spinal growth Serial lengthening every 6 – 12 months J Am Acad Orthop Surg 2006

3 Clinical problem – spinal deformity in young child A growing internal brace
After Before Before

4 Traditional growing rods
Care with anchor placements Intraop imaging Cross-link Fusion PJK: Rod contouring Hooks vs screws Repeated surgical exposures Wound closure ?local vancomycin powder Akbarnia et al. Spine 2005

5 Lancet April 2012 First human clinical trial using MCGR with longest FU to date MCGR is safe and with good clinical outcomes Maintains spinal growth Shorter hospital stay, less psychological burden and pain Long term FU to maturity needed MCGR instrumentation costs more (HK$50,000) traditional GR (HK$25,000) but more frequent surgeries (twice per year until skeletal maturity) In the future… Home distractions Internal bracing limb deformity correction, thoracic insufficiency syndrome, limb lengthening, limb salvage procedures or any conditions in which slow progressive change is required.

6 Implantable Titanium rod with an internal magnet
Lancet April 2012 Implantable Titanium rod with an internal magnet External magnet to rotate the internal one and shorten or lengthen the attached rod Available rods are available in sizes (diameter) of: 6.35 mm, 5.5 mm and 4.5 mm. The actuator is 9 mm in diameter and 90 mm long.

7 Lenthenings Distract 1.8-2mm/mth Out-patient procedure
Awake distraction ~30 seconds

8 Out-patient lengthening Frequency of lengthening
TGR vs MCGR 41o Out-patient lengthening Frequency of lengthening

9 50th Anniversary of International Phillip Zorab Symposium
Traditional Growing Rods Versus Magnetically Controlled Growing Rods in Early Onset Scoliosis: A Case-Matched Two Year Study B. A. Akbarnia, K. Cheung, G. Demirkiran, H. Elsebaie J. Emans, C. Johnston, G. Mundis, H. Noordeen, J. Pawelek M. Shaw, D. Skaggs, P. Sponseller, G. Thompson, M. Yazici, Growing Spine Study Group 50th Anniversary of International Phillip Zorab Symposium June 20-21, 2013 – London, UK

10 Total # of Lengthenings
RESULTS (Procedures) Total # of Surgeries Total # of Lengthenings MCGR 16 137 TGR 78 49

11 Re-operation after magnetically controlled growing rod implantation: a review of 30 patients with minimum two-year follow-up KMC Cheung1, K Kwan1, A Alanay2, JAI Ferguson3, C Nnadi4, IJ Helenius5, M Yazici6, GH Demirkiran6, BA Akbarnia7 1The University of Hong Kong, Hong Kong 2Acibadem University School of Medicine, Turkey 3Starship Children’s Hospital, New Zealand 4Nuffield Orthopaedic Centre, Oxford, UK 5Turku University Central Hospital, Finland 6Hacettepe University, Turkey 7University of California, San Diego, USA

12 Mean age at surgery = 7.3 years (range: 4-14)
Mean follow-up = 37 months (range: 24-61) Revision surgeries in 15 cases 4 had single rods; 26 dual rods

13 Re-operation / unplanned return to OR
14 out of 30 patients (46.7%) Mean time to re-operation was 23 mths(range: 5 – 48 mths)

14 Failure of rod distraction
BMI of 28 Thick subcutaneous tissues Idiopathic scoliosis with MCGR implantation at aged 9

15 Failure to distract Dec 2011 – immediately after surgery
Short rods on either side of actuator

16 Failure of rod distraction
Calcified deposits at the housing-rod junction

17 Failure of proximal foundation
Failure of proximal fixation, lamina fracture and wound infection - 2 years post-op Inadequate fixation

18 Single MCGR rod in a revision case Design issue - rectified
Rod breakage Single MCGR rod in a revision case Design issue - rectified

19 Frequency of distraction vs re-operation
Group 1 (n=14) Distraction every 1 week-2 months Group 2 (n=16) Distraction every months Re-operation 10 patients (71%) 4 patients (25%) Causes of re-operation - Failure of rod distractions 60% - Foundation failure 20% - Infection 10% Coronal imbalance 10% Rod breakage 50% - Proximal foundation failure 50% PJK 3 patients (21%) 2 patients (12.5%)

20 Other risk factors for re-operation
No relationship between re-operation and Pre-operative diagnosis Re-operative coronal / sagittal Cobb angle Age at surgery Level of instrumentation (UIV / LIV) MCGR done as primary or revision cases

21 FU 12 to 46 mths (mean 34mths) 7 of 10 patients (70%) – unplanned return to OR

22 Discussion TGR system 6 monthly distraction: as many as 15 operations during whole treatment period Largest study with longest follow-up to look at re-operations in MCGR Re-operation rate is 46.7% Fewer procedures than TGR comparatively Re-operation associated with more frequent distractions Limitation of the study Heterogeneous nature of patient subgroups Not followed up to skeletal maturity currently

23 6San Diego Centre for Spinal Disorders, La Jolla CA, USA
Proximal Junctional Kyphosis Associated with Magnetically Controlled Growing Rod Surgery for Early Onset Scoliosis Kenneth Cheung1, Kenny Kwan1, John Ferguson2, Colin Nnadi3, Ahmet Alanay4, Muharrem Yazici5, Gokhan Demirikiran5, Behrooz Akbarnia6 1Queen Mary Hospital, The University of Hong Kong; 2Starship Children Hospital, New Zealand; 3Nuffield Department of Orthopaedics, Oxford, UK; 4Bilim University Faculty of Medicine, Istanbul, Turkey; 5Hacettepe University, Ankara, Turkey; 6San Diego Centre for Spinal Disorders, La Jolla CA, USA

24 PJK 5 of 23 patients (21.7%)

25 No relationship identified
Risk factors for PJK in TGR proximal thoracic scoliosis thoracic kyphosis proximal pedicle screws Frequency of distraction and PJK range, 1 to 3 months

26 Other complications (personal series)

27 Failure to distract Cheung et al. (2015)
Journal of Orthopaedic Surgery

28 Metallosis

29 Complications Of growing rod surgery Specific to MCGR Infection
Implant migration PJK Rod fracture Specific to MCGR Failure to distract Tissue/bone interposition Mechanism failure Metallosis

30 MCGR Non-invasive distraction is a definite advantage
Not the ONLY procedure for the child, but can reduce the number of procedures Long term follow-up needed A lot is unknown no standard technique no agreed best lengthening frequency

31 Journal of Orthopaedic Surgery (JOS)
now with impact factor!

32 The University of Hong Kong
Queen Mary Hospital The Duchess of Kent Children’s Hospital LKS Faculty of Medicine

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