1. The Rib Construct (RC) has provided secure proximal fixation for management of patients with EOS and severe thoracic hyperkyphosis Alaa Azmi Ahmad – MD Associate Professor of Orthopedic Surgery –Annajah Medical School – Nablus- Palestine Disclosure –NON Richard H. Gross –MD Professor of Orthopedic Surgery – Clemson University –USA Disclosure -NON

2. Thoracic hyperkyphosis Greater than 20 degrees of kyphosis from T1-5 Greater than 40 degrees from T5-12 Greater than 50 degrees of maximum total kyphosis Treating EOS associated with thoracic kyphosis 1- has poor outcome 2- decision making between spine based and rib based proximal fixation has been graded as being among the areas of greatest clinical uncertainty at present for surgeons treating EOS

3. Implant complication of the growing rod Implant prominence Screw pullout ( minimal fixation points ) Hook dislodgment in small weak bones Growing spine study group has put some contraindications for the growing rod use mainly severe kyphosis and Myelodysplasia

4. To have success with the growing rod with kyphosis ( Yazici, ICEOS 2009 ) Apical 360 degrees fusion Increase level of fixation from 2 to 3 or 4 Add sublaminar wires to laminar hooks proximally Put Halovest preop. And a brace post op Do anterior annulotomy to increase flexibility

5. VEPTR Can it be a solution ? It is 7.3 mm in diameter and bulky for small children Away from the spine with less control of the deformity Rod contouring cannot be done for correction of kyphosis with cantilever effect

6. Methods Ongoing data collection of surgical management of 13 children with EOS and greater than 20 degrees of kyphosis between T1-5 and/or 70 degrees between T5-12, and at least 24 months of followup was compiled. The (RC) was used for proximal fixation in all cases.

7. 5 syndromic 5 congenital/structural 3idiopathic 9 had prior spine surgery Average age at initial surgery 84 months followup averaged 47 months (24-77)

8. Pre-OpPost-Op T1-5 sagital kyphosis2926 T5-12 sagital kyphosis9656 Thoracic Scoliosis6844 Lumbar Scoliosis3938 Spine Length22.9 cm29.2 cm Sagital Balance39 mm27 mm

9. Pre-Operative Post-Operative

10. Complications Dislodgments: 3 proximal hook, 5 distal anchors 1 delayed deep wound infection with removal and subsequent replacement of instrumentation 3 rod failures 1 PJK As a group, there were 63 subsequent planned procedures, and 18 unplanned.

11. Advantages minimal neurologic risk, as distraction is not necessary for kyphosis correction, and gentle compression of rib hooks reduces kyphogenic effect reliable correction of >100 degree kyphosis without anterior release ability to correct coronal plane malalignment by manipulation of the construct improved alignment of previously fused thoracic spine without osteotomy osteoporosis is not a contraindication to instrumentation with the rib construct

12. Conclusions The RC provides reliable proximal fixation for EOS patients with severe thoracic hyperkyphosis, especially for those with hyperkyphosis from T5-12.