1. Final Fusion in Patients Treated with Rib Based Distraction: A Review of Peri- operative Results THE UNIVERSITY OF UTAH Department of Orthopaedic Surgery John A Heflin, MD; John Smith, MD; Victoria Heagy, Jessica Morgan

2. Disclosures  John A. Heflin – paid consultant for Globus Spine, Medtronic  John T. Smith – paid consultant for Globus Spine, Depuy Synthes Spine, SpineGuard, Biomet, Ellipse; Board Member Children’s Spine Foundation; Royalties Synthes Spine  Victoria Heagy – none  Jessica Morgan - none

3. Background  Rib based distraction is commonly used in children with EOS  At cessation of growth, definitive fusion is often performed – Gain additional correction – Prevent further progression  As patients mature, more definitive procedures are now being performed

4. Study Objective  Review peri-operative outcomes for patients undergoing definitive fusion following rib-based distraction treatment for early onset scoliosis: – Coronal curve correction – Correction of kyphosis – Technical difficulty EBL Surgical time Complications Osteotomies

6.  Review of IRB approved CSSG registry database, patient charts  Single surgeon  Patients treated with rib based distraction  Previous implantation of rib-based distraction prior to definitive fusion  Definitive fusion performed with segmental instrumentation Study Methods

7.  27 Patients identified: – Age at initial surgery – Age at fusion – Number of lengthenings – Type of construct – Blood loss – Surgical time – Pre/post-op Cobb angles – Pre/post-op kyphosis – Osteotomies required – Total complications Data collection

8. Results 27 patients Average Range Age at initial implant (yrs.) 7.451.78 – 11.78 Age at fusion (yrs.) 13.519.21 – 18.51 Lengthenings 10.50 -18 Total surgical procedures 13.353 - 21 Fusion data: EBL (cc) 534180 - 1280 Surgical time (min.) 256115 - 520 Osteotomies 11 total Complications 12 total Repeat procedures 9 total Pre-fusion Cobb 67.4240 - 107 Pre-fusion Kyphosis 61.088 - 113 Post-fusion Cobb 50.1732 - 82 Post-fusion Kyphosis 50.0020 - 85

9. Results Complications – 11 patientsRequired Surgery Neck pain No Crouched gait No Hardware Failure (broken rod) Yes Prominent hardware, wound dehiscence Yes Infection / wound dehiscence Yes Pseudarthrosis Yes Infection Yes Pseudarthrosis, hardware failure, wound dehiscence Yes Wound dehiscence Yes Wound dehiscence Yes Prominent hardware Yes

10. Conclusion  Definitive fusion in patients treated with rib-based distraction : – Technically challenging – Longer surgical times – Higher blood loss – Less correction – More surgical complications (44%)

11. Conclusion  Despite technical challenges, definitive fusion does improve pre-operative coronal Cobb angles and kyphosis  Longer follow-up will be needed to determine if correction maintained

12. Thank You