Can Infection Associated with Rib Distraction Instrumentation be Managed without Implant Removal? A Multi-Center Study John T. Smith, MD* Patrick Cahill,

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Management of Implant Related Infections:

Presentation transcript:

Can Infection Associated with Rib Distraction Instrumentation be Managed without Implant Removal? A Multi-Center Study John T. Smith, MD* Patrick Cahill, MD Jennie B. Mickelson, BS, CCRP** University of Utah and Primary Children’s Medical Center (PCMC) Salt Lake City, Utah Shriners Hospital for Children, Philadelphia Philadelphia, Pennsylvania

Disclosures *Paid Consultant Synthes Spine, USA *Royalties: VEPTR 2 device **Nothing to disclose

Background Rib Distraction Techniques (i.e. VEPTR) are widely used for management of: Thoracic Insufficiency Syndrome (TIS) Progressive scoliosis with chest wall constriction Hypoplastic thorax syndromes Complications remain problematic Migration Wound slough Infection (~15%)

Infectious Disease Literature Established infection following spinal instrumentation and fusion usually requires implant removal Infection demands prolonged antibiotic management

Smith et.al. SRS 2009 Single institution review of infections associated with Rib-based Distraction 19 infections in 16 patients All managed with I&D, antibiotics and resolved No patient required implant removal Spine 2010, in press

Research Question: Can infection associated with Rib Distraction Techniques managed without implant removal be validated at multiple institutions? Are infections associated with non-fusion technology (Growing Instrumentation) different than infections after spinal fusion?

Methods IRB approved Retrospective chart review All VEPTR patients at Sites 3,6,& 7 2002-2009

Diagnosis: Infection Group Jeunes Syndrome (1) Jarcho-Levine Syndrome (1) Congenital Myopathy (2) Progressive scoliosis (2) Spina Bifida (2) Congenital Scoliosis (11) Cerebral Palsy (3) Poland Syndrome (1) OI (1) Arthrogrposis (1) Beals Syndrome (1) Spondylo epiphyseal dysplasia (1) Rib Fusion after TEF repair (1)

Results 176 patients treated with Rib Distraction Techniques at 3 participating institutions 31 infections in 28 patients Superficial: 19 Deep: 12 16% of patients experienced at least one infection 2.3% of patients had instrumentation removed due to infection

Infection Group Average age: 6 years Average BMI: 16.6 (low) Average ANC: 7.32 (low) Procedure associated with infection: Initial implant: 12.45% Expansion: 61.17% Exchange: 7.92% Revision: 12.45% 22/31 infections were associated with a wound dehiscence

Management 24 patients were treated with irrigation, debridement, and closure of the wound. 27 patients received IV antibiotics Median duration of IV therapy: 37* days Median of oral suppressive therapy: 23** days 6 patients required more than one debridement to control the infection 2 patients initially managed with oral antibiotics alone failed. * 2 patients length IV therapy was unknown ** 4 patients length of oral therapy was unknown

6 patients required implant removal to resolve infection

Conclusions This population of children are at high risk for infection due to the need for multiple procedures, significant co-morbidities, poor nutrition, etc Improved techniques for management of soft tissues and implant coverage may reduce the incidence of infection

Conclusion Most infections associated with rib distraction techniques can be managed WITHOUT removal of the devices. This differs significantly from the known experience with established infections in spinal fusion patients. These data may be useful in educating our infectious disease colleagues for future patients

Conclusions This Multicenter experience did not replicate our Utah experience at consistently managing infection without implant removal Further study is needed

Thank You