Treatment of congenital thoracic scoliosis with associated rib fusions using VEPTR expansion thoracostomy: a surgical technique

Abstract : Introduction: Untreated growing patients with congenital scoliosis and fused ribs will develop finally thoracic insufficiency syndrome. The technique of expansion thoracoplasty with implantation of a vertical expandable prosthetic titanium rib (VEPTR) was introduced initially to treat these children. Methods: This article attempts to provide an overview of the surgical technique of opening-wedge thoracostomy and VEPTR instrumentation in children with congenital thoracic scoliosis and fused ribs. Results: Our modification of the surgical approach using a posterior midline incision rather than the modified thoracotomy incision initially described could potentially help to diminish wound dehiscence and secondary infection, while preserving a more acceptable esthetic appearance of the back. Conclusions: Vertical expandable prosthetic titanium rib-based treatments should be undertaken only with a good knowledge of its numerous specific complications. Every aspect of the treatment should be oriented to minimize these complications. At the same time it should be kept in mind that the ultimate step of this long-term fusionless treatment strategy will be a technically demanding spine fusion

Hémimélie tibiale : présentation de quatre cas

L'hémimélie tibiale est une anomalie congénitale rare, survenant environ chez une naissance pour un million. Elle consiste en une aplasie ou hypoplasie du tibia selon le type d'hémimélie ; la fibula est normale. La classification la plus largement utilisée dans la littérature est la classification Jones, basée sur la description radiologique. Cette anomalie peut être unilatérale et isolée, bilatérale et isolée, et finalement uni- ou bilatérale et associées à d'autres malformations, ceci habituellement dans le contexte d'un syndrome d'hémimélie tibiale. Ce travail porte sur 4 patients présentant cette pathologie: les deux premières patientes sont des jumelles monozygotiques, qui reflètent la variabilité d'expression "intragénotypique" du syndrome d'aplasie tibiale et d'ectrodactylie, les deux autres patients présentent des formes sporadiques. Les aspects embryologiques, génétiques et thérapeutiques de cette entité sont passés en revue. La dissection post-amputation des pièces opératoires issues du quatrième cas est présentée en appendice

Posterior Minimally Invasive Surgery for the Treatment of Adolescent Idiopathic Scoliosis

Adolescent idiopathic scoliosis (AIS) represents the most frequent indication for scoliosis surgery at the pediatric age. The current gold standard for the surgical treatment of AIS is spinal instrumentation and fusion through an open approach. Despite reproducible good outcomes, this standard approach necessitates significant soft-tissue disruption and extensive paravertebral muscle detachment. It is consequently associated with long-lasting paravertebral muscle injury and denervation, leading to persistent atrophy and decreased trunk extension muscle strength. Minimally invasive surgery (MIS) techniques have been increasingly used over the last two decades for the treatment of lumbar degenerative disorders and thoracolumbar fractures in the adult patient population. Over the last decade, MIS techniques have also been increasingly reported for the treatment of adult spinal deformity. These less invasive techniques have been shown to be useful tools for the treatment of adult spine deformity, with reduced complication rates when compared with conventional open techniques. But they also appear to be less effective for correction of severe and/or fixed sagittal and/or coronal plane deformities. Adolescent spine deformity is generally considered less rigid than adult, thus theoretically more amenable to standalone MIS techniques. The pediatric spine, because of its inherent flexibility and ability to fuse, is theoretically ideal for MIS. Given the positive results obtained with MIS to treat adult spine pathologies, including deformities, the next logical step is the application of less invasive surgical techniques to the treatment of spine deformity at the pediatric age, and in particular AIS. During the nineties, a first attempt to propose an MIS treatment for AIS has been made with the development of thoracoscopic anterior spinal fusion and instrumentation (TASF) for AIS. This technically demanding procedure, with an acceptable complication rate, including during the learning curve, is however restricted for thoracic curves, and offers similar good or excellent results for these patients when compared to the gold standard (open posterior spine fusion). Due to an expanded degree of correction and reduced risk of instrumentation failure associated with modern posterior technique, most spine surgeons, including the proponents of this technique, have currently converted almost entirely to the open posterior approach for the treatment of thoracic AIS. In order to try to decrease the approach-related morbidity associated with the conventional posterior approach, a MIS technique for posterior spinal fusion, using 3 skin incisions and muscle splitting approach, has been recently proposed for AIS. The limited available data suggest that the use of posterior MIS technique for AIS is associated with deformity correction and complication rates equivalent to open posterior spinal fusion, with potential benefits related to a less traumatizing exposure, with low blood loss and a diminished length of hospital stay. However these encouraging results are obtained at the expense of a prolonged surgical time, which could be related, at least partially, to a learning curve effect. The longer-term safety of this procedure needs to be documented in larger studies with long-term follow-up, before recommending its routine use. The impact of some surgical strategies, like dual attending surgeon to try to lessen operative time, and intraoperative traction to address stiff curves, also needs to be better precised

Pulling Exercises for Strength Training and Rehabilitation: Movements and Loading Conditions

The back is an extremely common site of injury among both athletes and sedentary people. Furthermore, low back pain has become prevalent in our society. Maintaining strong back muscles can help prevent future pain or injuries. Here, the aim is therefore to assess the kinetic and kinematic movements of four pulling exercises with different external loading directions. Fifteen healthy subjects were analyzed using a 3D motion capture system. The pulley machine was equipped with a load cell for force data acquisition. The exercises consisted of 8 repetitions each of the lat pulldown (25% and 50% body weight (BW) extra load), the lat pulldown with 45° incline (10% and 25% BW), the seated cable row (25% and 50% BW) and the upright row (standing, 10% and 25% BW). The minimum and maximum curvature angle in the thoracic as well as the lumbar spine was larger during the upright row than during the other exercises. Furthermore, during the upright row, the sagittal moment in the shoulder joint is opposed to the other exercises in the direction of retroversion. Due to the higher lumbar curvature observed in low back patients, to avoid overload, it is not advisable for patients with back pain to perform upright rows

Casting in infantile idiopathic scoliosis as a temporising measure: A systematic review and meta-analysis

Objective: Treatment of infantile idiopathic scoliosis remains vague. Because implantation of temporary telescopic devices carries a high risk of complications, interest in the older technique of serial casting is growing as a temporising measure before invasive procedures. The goal of this review was to meta-analyse studies examining the effect and safety of casting in infantile idiopathic scoliosis.Methods: Two reviewers independently searched for relevant studies in PubMed and Embase databases through November 2018. The studies included were limited to infantile idiopathic scoliosis patients who underwent casting, had a mean Cobb angle of 20 or more and written in English. The methodological quality of the chosen studies was assessed. The primary outcome was the difference in Cobb angle means from before and after casting. The secondary outcome was adverse events of casting. Heterogeneity was explored and a funnel plot was drawn.Results: Of the 366 studies screened, 10 studies were included in the meta-analysis (243 subjects) and all were non-randomised. The casting was consistently associated with a reduction in the mean Cobb angle. The pooled mean difference was 24.85° (95% confidence interval: 19.25 to 30.46, p Conclusion: Casting seems to be effective and safe in decreasing Cobb angle even in high curve magnitudes. In older patients, casting showed less Cobb angle correction.</p

Pelvic fixation for neuromuscular scoliosis deformity correction

Pelvic fixation is most frequently indicated in the pediatric population for the treatment of neuromuscular scoliosis with significant pelvic obliquity. Neuromuscular scoliosis surgery is associated with a high risk of complications, and this is further increased by extension of fusion to the sacrum. Numerous techniques have been described for pelvic fixation associated with a long spine fusion each with its own set of specific benefits and risks. This article reviews the contemporary surgical techniques of pelvic fixation used to extend a spine fusion to the sacrum and pelvis focusing on the management of neuromuscular scoliosis, including their biomechanical rationale, results, and complications

Tibial aplasia-hypoplasia and ectrodactyly in monozygotic twins with a discordant phenotype

Tibial hemimelia with ectrodactyly is reported for the first time in monozygotic female twins with a positive family history for limb anomalies. This very rare autosomal dominant condition is known to be associated with a highly variable phenotype, as illustrated by the distinct clinical presentations, despite identical genotype