ADOLESCENT
A PROSPECTIVE
IDIOPATHIC
TRIAL
A.
G.
WITH
AND
Fifty
patients
with
instrumentation
augmented
to ascertain
the need
Twenty-five
without
H.
two
years
was
7
significant.
PRINCE,
the University
for postoperative
wore
The mean
later
statistically
G.
BRACING
J.
Hospital,
adolescent
idiopathic
scoliosis
by a Cotrel bar or by sublaminal
patients
a brace.
WITHOUT
CHRISTODOULOU,
From
THORACIC
DURING
K.
WEBB,
POSTOPERATIVE
R.
G.
CARE
BURWELL
Nottingham
treated
Luque
by posterior
fusion
and Harrington
wires were studied
in a prospective
trial
bracing.
a plaster
brace
loss of correction
in the braced
We conclude
SCOLIOSIS
from
group,
that
postoperatively
for six months,
while 25 were managed
the first standing postoperative
radiograph
to one obtained
and 6.3 in the unbraced
group, the difference
not being
postoperative
bracing
is unnecessary
after
augmented
Harrington
instrumentation.
Treatment
of
idiopathic
scoliosis
fusion
was first described
nique
has
been
modified
by
by posterior
in 1924. The
Hibbs
subsequently
bone
fusion
bony
tech-
by two innovaand
the improved
described
by Moe
tions,
the use of autograft
technique
of posterior
spinal
(1958).
geon.
The pseudarthrosis
loss of correction
varied
rate
from
and
transverse
siderable
time before
operation.
using Harrington
instrumentation
with
bar (Cotrel
1978) and sublaminal
wires at the
the curve
tightened
around
the distraction
rod
a further
sublaminal
wire at either
end to secure
the
of
hooks
(Guadagni,
In the early
instrumentation,
Drummond
and Breed 1984).
reports
of posterior
fusions
without
correction
of the curve
was achieved
postoperatively
by a carefully
moulded
plaster
brace
with rest in bed for four to six months
before
allowing
the patient
to walk
in a further
protective
brace.
The
papers
describing
scoliosis
the
reported
an
use
and a loss of correction
Hibbs,
Risser
and Ferguson
al. 1958;
Moe
the
A. G. Christodoulou,
General
Hospital
has
rapidly
brace
duration
allowed
being
MD, Lecturer
George
Papanicolou,
for reprints
should
be sent
I 987 British
030l620X/87
Editorial
Society
I 155 52.00
VOL.
I. JANUARY
(‘
determined
in Orthopaedic
Thessaloniki,
69-B.
No.
1987
to Miss
of Bone
removal
for three
and
by the
of
to
sur-
a Cotrel
bar
both
ends,
Boulevard,
patients
posterior
Surgery
________
with
spinal
more
measured
included
in our
and
being
were
and
in the
Gillespie
the
various
paper
wires
operation
we report
AND
adolescent
surgery
by the Cobb
prospective
38 females
in the
14 years
42 thoracic
group,
to us that by
either with
at the apex and at
was
probably
a prospective
idiopathic
for
burden
to
for a con-
trial
scoliosis
thoracic
curves
having
of
35
or
method
(Cobb
1948) were
trial. The surgery
was per-
the
and all patients
were
There
were I 2 males
mean
age
at operation
4 months
(range
10 to 26 years).
and eight double
curves;
in the
was considered
to be secondary
curve
was fused.
Overall
the
from 35 to 80.
operations
were
to
METHODS
between
1979 and
1982
two years after operation.
or one ofhis
tenor
spinal
1981).
It occurred
augmented
sublaminal
after
MATERIAL
ranged
Nott-
Tolo
or with
bracing
the lumbar
curve
only
the thoracic
and
5%, and
to
10
to
is a physical
and psychological
many
of whom
have worn
one
unnecessary.
In this
test this hypothesis.
The
Morphology
l976
The brace
these patients,
formed
reviewed
Surgery
Greece.
H. G. Prince.
Joint
Harrington
Fifty
of 7%
the patient
(usually
after
which
is worn
H. G. Prince,
FRCS,
Senior
Orthopaedic
Registrar
J. K. Webb,
FRCS,
Consultant
Orthopaedic
Surgeon
R. G. Burwell,
MD,
FRCS,
Professor
of Human
Experimental
Orthopaedics
University
Hospital,
Queen’s
Medical
Centre,
Clifton
ingham
NG7 2UH,
England.
Requests
in idiopathic
up to 3 1 % (Hibbs
I 924;
1931; Cobb
1952; Blount
et
instrumentation
to be mobilised
more
sutures)
in a moulded
months,
of
method
of pseudarthrosis
1958).
Harrington
nine
of this
incidence
4%
5
series which
have been reported
(Tambornino,
Armbrust
and Moe
1964; Dickson
and Harrington
1973; Leider,
Moe and Winter
1973: Mir et al. 1975; Erwin,
Dickson
The next advance
was the introduction
of the
Harrington
instrumentation
(1962).
More
recently
two
methods
have been used to augment
correction,
namely
a
apex
was
performed
by one
There
latter,
and
curves
of us (JKW)
senior
fusion
assistants.
The technique
for the poswas similar
to that described
by Moe
(1958) and included
decortication
of spinous
processes,
laminae
and transverse
processes
together
with excision
and fusion
of facet joints.
Autograft
bone was harvested
from the posterior
iliac crest and packed
into the excised
13
14
A. G. CHRISTODOULOU,
Fig. 1
Radiographs
years.
Figure
ofa
2
Fig.
Radiographs
12 years.
-
H. G. PRINCE,
J. K. WEBB,
Fig. 2
patient
treated
with bracing.
Figure
Two weeks
after
operation
during
operation.
4
of a patient
treated
Figure
5 - Two weeks
Fig.
without
bracing.
after operation.
-
R. G. BURWELL
Fig. 3
1 Pre-operatively,
bracing.
Figure
3
5
-
at the age
Two years
Fig.
Figure
Figure
4
6
-
Pre-operatively,
Two years after
THE
of 14
after
6
at the age
operation.
JOURNAL
of
OF BONE
AND
JOINT
SURGERY
ADOLESCENT
facet
joints
and
also
along
the
rod
and
on
IDIOPATHIC
the
concave
aspect
of the spine.
A square-ended
Harrington
distraction
rod and hooks
were
inserted
in all 50 cases,
the
upper
hook
being bifid. In 30 patients
the Cotrel
apparatus was added
to the apical
three vertebrae
on the convex
side and connected
to the Harrington
rod. One patient
had
a Harrington
compression
rod
applied
opposite
the
operation
and at seven
days had their sutures
and a plaster
body
cast applied.
They
were
as soon as the plaster
was dry. A spinal
radio-
six months.
The
standing
and the spinal curve measured.
then allowed
home.
A cast was worn for
patient
was then
plaster
and provided
there
sis was allowed
to mobilise
Twenty-five
had
wounds
resolved.
discharge
The
out
I).
The
largest
loss
(Group
as soon
a brace.
were healed
A standing
from hospital.
patients
in both
II)
were
raised
was
were
6.3#{176}
(range
correction
relatively
in
minor.
overall
1#{176}
to 14#{176})
both
groups
was no sig(Table
II).
Two
patients
despite
the routine
use of
were aspirated
in theatre
under
local anaesthesia.
Three
patients
developed
superficial wound
infection:
prophylactic
antibiotic
cover was
extended
from the routine
48-hour
period
to seven days,
and infection
settled
within
10 days.
In one patient
in
Group
I the
lodged
Cotrel
tion had been
The mean
(range
2 to 4
after
operation
Table
I. Overall
radiograph
apparatus,
lost and the
operating
hours).
The
was
results
at six months
showed
a disbut only 5#{176}
of the initial correcposition
was stable.
time was 2 hours
50 minutes
mean
blood
loss during
and
900 ml (range
in each
Mean
700 to I 300 ml).
group
to
when
to re-
turn
to school
at three
weeks.
Group
II patients
were
permitted
to swim three months
after operation
and after
six months
both groups
were encouraged
to cycle and to
swim. Contact
sports
were not permitted
for 12 months.
Further
radiographs
were obtained
at I 2 months
and at
years.
Figures
1 to 3 and 4 to 6 show
the pre-operative
radiographs
and the postoperative
results
in two patients
treated
by a Harrington
distraction
rod and the Cotrel
apparatus,
one
treated
with
a brace
and
the other
(degrees)
curves
Preoperative
Postoperative
At 2 years
Mean loss of
correction
Group
I
(braced)
58.0
23.0
30.0
7.0
Groupll
(unbraced)
54.0
22.8
29.1
6.3
to
temperature
taken
before
encouraged
was
of the
allowed
as it was comfortable
They went home
and any
radiograph
groups
were
of
to 47#{176}).
The mean
during
the first six months
but there
difference
between
the end-results
was no sign of a pseudarthrofree of support.
patients
mobilise
postoperatively
do so, and did not wear
their
radiographed
(Table
was 25. 1 (6
in this group
developed
an early haematoma
suction
drainage;
their wounds
of the apical
two
to four
vertebrae
both
to
improve
correction
and
to decrease
rotation.
The
method
ofpassing
the wires was that described
by Luque
(1982).
Spinal
cord monitoring
was used in all patients.
Twenty-five
patients
(Group
I) were nursed
prone
in
taken
was
at two years
ofcorrection
Complications
aspect
graph
was
The patient
15
SCOLIOSIS
tion
loss
occurred
nificant
distraction
rod because
of a significant
kyphosis.
In the
other
19 patients
the Harrington
distraction
rods were
secured
by sublaminal
wires at their proximal
and distal
levels;
sublaminal
wires were also placed
on the concave
bed after
removed
mobilised
THORACIC
Table
II. Loss
ofcorrection
Mean
during
further
two
years
loss of correction
after
operation
(degrees)
3 months
6 months
1 year
2 years
Total
Groupl
(braced)
3.0
1.6
1.3
1.1
7.0
Group
II
(unbraced)
2.9
2.0
1 .0
0.4
6.3
two
DISCUSSION
without.
The aim of surgical
treatment
of idiopathic
thoracic
lescent
scoliosis
is to achieve
good
correction
RESULTS
of
adothe
spinal curve
with a balanced
spine and to maintain
this
The Group
I patients
had an initial
mean
pre-operative
correction
until solid
bony
fusion
has occurred.
Until
spinal
curve
of 58 (range
35#{176}
to 80#{176}),
which
was correcently
bracing
has been considered
an essential
element
rected
at operation
to a mean
of 23#{176}
(range
10#{176}
to 36#{176}). ofthe
management
after such an operation.
The mean curve at two years was 30#{176}
(range
12#{176}
to 44#{176}).
The initial
techniques
described
by Hibbs,
Risser
The mean
correction
in the Group
I patients
was 26.4#{176} and Ferguson
(1931),
Cobb
(1952)
and Moe (1958)
did
(range
l61 to 36c). The overall
mean postoperative
loss of
not use internal
fixation
to stabilise
the spine during
concorrection
The
brace
in these curves
Group
II patients
had
a mean
was 7#{176}
(range
2#{176}
to I 2#{176}).
who were managed
without
pre-operative
curve
angle
of 54#{176}
(range
VOL.
curve
69-B.
No.
I 6#{176}
to 5 1 #{176}).
The
of 29. 1 #{176}(range
I. JANUARY
987
solidation
of the bone graft,
used to achieve
and maintain
but an external
support
was
correction.
The subsequent
use of Harrington
distraction
rods enabled
the correction
securely
obtained
and
supported.
More
was 22.8#{176} to be more
showed
a
recently
the supplementation
of this system
either
with a
transverse
Cotrel
bar on with sublaminal
wires has made
mean correc-
38c to 72) and the mean
postoperative
curve
(range
9#{176}
to 42#{176}).
The radiographs
at two years
mean
a
16
A. G. CHRISTODOULOU,
the fixation
postoperative
Leider
using
H. G. PRINCE,
more rigid. This suggests
the possibility
that
external
bracing
might
be unnecessary.
et al. (1973)
showed
a 4 loss of correction
a postoperative
localiser
cast.
Erwin
et al. (1976)
showed
a 5( loss in patients
who wore an underarm
cast
for
nine
months.
Robins,
Moe
and
Winter
(1975)
described
a T loss of correction
after operation
in their
series
of patients
who
wore
a thoracic
localiser
cast
pathic
conclude
that
thoracic
scoliosis
technique
of internal
and
grafting
bone
in patients
with
undergoing
fixation
obviates
with
the
adolescent
surgery,
facet
for
excision
Miss
lAnil 1958:40-A:51
Cobb
JR.
Outline
CourseLeci
Cobb
JR.
for the
H. Briggs
and to Mrs
Milwaukee
Joint
Surg
of scoliosis.
Am
Acad
Orthop
Surg
Instr
75.
Technique,
after-treatment.
An, Acad Orthop
Surg
scoliosis.
ET. The
J Bone
1-25.
study
la scoliose
idio-
WD,
Dickson
JH, Harrington
ment ofscoliosis
patients
treated
and fusion.
JBoneioint
Surg[Am]
PR. The postoperative
managewith Harrington
instrumentation
l976;58-A:479-82.
D, Breed A. Improved
postoperative
segmental
instrumentation
and
idiopathic
scoliosis.
J Pediat
Orthop
course
posterior
1984;4:
of scoliosis:
correction
and internal
fixation
J Bone
Joint
Surg
[Am]
l962;44-A:
Hibbs
RA. A report
of fifty-nine
cases of scoliosis
operation.
J Bone Joint Surg 1924;6:
3-37.
by the
fusion
Hibbs
RA, Risser JC, Ferguson
AB. Scoliosis
treated
by the
operation:
an end-result
study
of three
hundred
and sixty
JBonefointSurg
1931:13:91-104.
fusion
cases.
Leider
LL Jr, Moe JH, Winter
RB. Early ambulation
treatment
of idiopathic
scoliosis.
J Bone Joint
55-A: 1003-15.
ER.
Segmental
spinal
instrumentation
treated
after
Surg
for correction
the surgical
[Am]
1973;
of scoliosis.
Mir
SR, Cole JR, Lardone
J, Levine DB. Early
spinal
fusion
and Harrington
instrumentation
sis.CliiiOrthop 1975; 1 10: 54-62.
Moe
JH. A critical
analysis
of
evaluation
of two hundred
Surg l958:40A:
529-54.
methods
of
and sixty-six
ambulation
in idiopathic
following
scolio-
fusion
for scoliosis:
an
patients.
J Bone Joint
Robins PR, Moe JH, Winter
RB. Scoliosis
in Marfan’s
syndrome:
its
characteristics
and results
of treatment
in thirty-five
patients.
J Bone Joint Surg [Ani] 1975:57-A:
358-68.
Keever
ED,
Leonard
treatment
of scoliosis.
1948:5:261
de
Clin Ortliop 1982: 163: 192-8.
REFERENCES
WP,
Schmidt
AC,
brace
in the operative
dans
le traitement
1 :247-65.
PR. The evolution
of the Harrington
instruin scoliosis.
J Bone Joint
Surg
[Am]
1973;
Hamngton
PR. Treatment
by spine
instrumentation.
59 1-6 10.
Luque
bracing.
Blount
Erwin
postoperative
The authors
are grateful
to Mrs J. Sycamore,
SRN,
and
for help with collating
the patients
notes
and radiographs,
S. Blythe
for typing
the manuscript.
Y. Technique
nouvelles
pathique.
ml Orthop 1978:
Guadagni
J, Drummond
following
modified
spinal
fusion
for
8#{176}
405-8.
idio-
R. G. BURWELL
Dickson
JH, Harrington
mentation
technique
55-A:993-1002.
an efficient
correct
need
Cotrel
for
four months.
Tolo
and Gillespie
(1981)
reported
an
loss of correction
in patients
who were
braced
for six
months
after operation.
The incidence
of pseudarthrosis
in these series
ranged
from 4% to 5%. In our series no
patient
developed
pseudarthrosis
at the site of grafting.
Our results,
showing
a mean
loss of correction
in each
group
of approximately
6 , compare
well with
those
from other centres.
We
J. K. WEBB,
and results
of spine
fusion
Insir Course
Lect 1952;9:65-70.
for
Tambornino
JM, Armbrust
EN, Moe JH. Harrington
in correction
of scoliosis:
a comparison
with
JBoneJointSurg[Am]
1964:46-A:3I3-23.
Tolo
instrumentation
cast correction.
V, Gillespie
R. The use of shortened
periods
of rigid postoperative
immobilization
in the surgical
treatment
of idiopathic
scoliosis:
a
review
of sixty-four
cases. J Bone Joint
Surg [Am]
1981 ;63- A:
I 137-45.
THE
JOURNAl.
OF
BONE
AND
JOINT
SURGERY