1. Intra-wound Vancomycin Powder Significantly Reduces the Risk of Infection in Growth-friendly Surgery John T. Smith, MD Justin Haller, MD Angela Presson, Ph.D. Jessica Morgan John Heflin, MD University of Utah Department of Orthopedics Primary Children’s Hospital Salt Lake City, UT

2. Disclosures  JT Smith: Depuy-Synthes; Globus; Biomet; Spineguard. BOD CSF  J Haller: none  A Presson: none  J Morgan: none  J Heflin: Medtronic, Globus

3. Background  Management of Early Onset Scoliosis (EOS) using ‘Growth Friendly’ techniques is associated with a significant complication rate  Infection rates with repetitive surgery reported up to 6.2%  Infections require unplanned surgeries and significantly increase risk and the cost of care

4. Vancomycin Powder  Multiple studies in adults have shown that vancomycin powder sprinkled into wounds reduced the rate of post- operative infection  Few studies have shown a similar effect in children who have repetitive surgery

5. Hypothesis  Children requiring surgical treatment for Early Onset Scoliosis (EOS), treated with intra-wound Vancomycin powder (VP) at closure will have a lower rate of post- operative infection compared to those not treated with VP.

6. Study Design  IRB approved review of a prospectively collected database of EOS patients requiring surgery  Patients treated without intra-wound Vancomycin powder were compared to those who were.  Primary endpoint was a post-operative infection that required surgical or medical treatment

7. Methods  166 consecutive patients treated with rib-based distraction growth- friendly surgery  Single center (SLC)  1261 procedures – 1081 without intra-wound Vancomycin – 180 with intra-wound Vancomycin  Varied etiologies – Neuromuscular: 88 – Syndromic: 23 – Congenital: 55 – Idiopathic: 39  Average dose of Vancomycin Powder: 500 mg per wound  Database reviewed to determine if there was a difference in infection rates between the two groups

8. Results  Infection rate without Vancomycin powder 6.2% Infection rate with Vancomycin powder: 2.2%

9. Comparison of Groups

10. Statistical Analysis  There was a 64% decrease in risk of infection in Rib-based distraction procedures when using Vancomycin powder compared to procedures without VP. (relative risk: 0.36; 95% CI: 0.13, 0.97, Fisher Exact Test: p=0.03)

11. Discussion  Children with EOS requiring repetitive surgery have a high risk of infection  A risk ratio of 0.36 indicates that intra-wound vancomycin powder reduced this risk by 64% Conclusion  We recommend the routine use intra-wound Vancomycin powder in all growth-friendly procedures to manage EOS

12. Acknowledgements  The University of Utah  Study Design and Biostatistics Center  Center for Clinical and Translational Science  http://www.ccts.utah.edu/biostats/ http://www.ccts.utah.edu/biostats/  Hiroko Matsumoto, Ph.D.