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ORIGINAL ARTICLE Table of Contents   
Year : 2008  |  Volume : 5  |  Issue : 2  |  Page : 71-72
Multidisciplinary approach to expansion thoracoplasty for congenital spinal deformity: A preliminary report


Department of Paediatric Surgery, Children's Hospital Oxford, Headley Way, Headington, Oxford-OX39DU, United Kingdom

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   Abstract 

Background: In children with congenital chest wall deformities, the vertical expandable prosthetic titanium Rib (VEPTR) has recently been developed to move the emphasis away from corrective spinal fusion, to expanding the deformed hemithorax. The aim of this paper is to demonstrate the need for paediatric surgeons in what is primarily an orthopaedic procedure. Materials and Methods: All patients less than 5 years old who had primary congenital scoliosis with poor respiratory function and were treated by VEPTR at our institution in conjunction with the spinal orthopaedic surgeons were reviewed. Results: All 6 cases required rib exposure and thoracostomy by a paediatric surgeon. One required exposure of the ribs only, 3 required an extrapleural thoracotomy and 2 required intrapleural thoracotomy with a patch repair of the rib space. None of the patients required blood transfusion and there were no early complications. All patients showed radiological improvement of their spinal and thoracic deformity as well as improvement in their respiratory function. Conclusion: Paediatric surgeons play an important role in the thoracic exposure required for this orthopaedic procedure. The benefit of a multidisciplinary approach is highlighted in this paper. The VEPTR implant may replace major spinal fusion surgery in this challenging group of patients.

Keywords: Multidisciplinary approach, vertical expandable prosthetic titanium rib

How to cite this article:
Sherwood W, Lakhoo K. Multidisciplinary approach to expansion thoracoplasty for congenital spinal deformity: A preliminary report. Afr J Paediatr Surg 2008;5:71-2

How to cite this URL:
Sherwood W, Lakhoo K. Multidisciplinary approach to expansion thoracoplasty for congenital spinal deformity: A preliminary report. Afr J Paediatr Surg [serial online] 2008 [cited 2019 Jun 16];5:71-2. Available from: http://www.afrjpaedsurg.org/text.asp?2008/5/2/71/44179

   Introduction Top


In children with congenital chest wall deformities, the thorax is often unable to support normal respiration or lung growth leading to thoracic insufficiency syndrome.[1] The traditional approach to this problem has been to address the spinal deformity by early spinal fusion which often limits thoracic growth and development. [2] An alternative approach in use since 1989 is the vertical expandable prosthetic titanium rib (VEPTR). This device expands the deformed hemithorax, improving respiratory function and secondarily correcting the spinal deformity. [2],[3] Implantation of the VEPTR requires rib exposure and thoracostomy. [4] Our aim is to demonstrate the benefits of a multidisciplinary approach, involving general paediatric surgeons, to complex spinal deformity and to show that VEPTR is an effective alternative to spinal fusion.


   Materials and Methods Top


Six VEPTR devices have been implanted in 5 children less than 5 years old. All patients had primary congenital scoliosis with poor respiratory function. Pre and post-operative assessments of spinal deformity and respiratory status were made by the multidisciplinary team, which included the paediatric respiratory physicians, paediatric spinal surgeons and paediatric general surgeons.

With the patient in the lateral decubitus position, the device is placed vertically along the chest wall attaching each end to healthy ribs above and below the site of abnormality. The ends can then be distracted to achieve expansion of the deformed chest wall. The thoracotomy site defect may require a patch closure with Surgisis Gold (Cook Surgical Products, Ireland Ltd 2006)). Further lengthening of the device is carried out through a small incision as an outpatient procedure two or three times a year.


   Results Top


All primary implantations were carried out successfully with no requirement for blood transfusion and completed in one hour. One patient required exposure of the ribs only, 2 required extrapleural thoracotomy and 2 required intrapleural thoracotomy and patch repair. All thoracic exposure was performed by the paediatric general surgeon.

There have been no complications to date. All patients have now completed 1 expansion at 6 months and have shown radiological improvement of their spinal and thoracic deformity [Figure 1] as well as improvement in their respiratory function as assessed by the respiratory team.


   Discussion Top


Congenital scoliosis and chest wall deformities present a challenging surgical problem. The conventional approach has been early corrective spinal fusion, which may have major long-term implications for spinal and thoracic growth. [2],[5] VEPTR is a new technique which focuses on expansion of the deformed hemithorax and secondarily corrects spinal deformity. The technique has been in use since 1989 in the USA and from the beginning, a multidisciplinary approach has been advocated involving paediatric spinal and general surgeons along with paediatricians and paediatric intensivists. [5] This approach achieved VEPTR with no intra-operative complications and minimal blood loss in this present series.

Operative times were much shorter than comparative spinal fusion procedures. All of the patients in this series had impressive cosmetic appearance and a subjective improvement in respiratory function. Other published series reported objective improvement of spinal deformity, spinal growth and lung function and volume.[4],[6],[7],[8] There have been no post-operative complications in this series, although larger series reported some problems with bony and soft tissue erosion due to the device. [8]

VEPTR is an effective device for the correction of spinal and thoracic deformity. A team approach minimises morbidity associated with the procedure in this challenging group of patients. Further studies are required to quantify more precisely the benefits of the procedure in terms of spinal and thoracic growth and improvements in pulmonary function.

 
   References Top

1.Campbell RM Jr, Smith MD, Mayes TC, Mangos JA, Willey-Courand DB, Kose N, et al . The characteristics of thoracic insufficiency syndrome associate with fused ribs and congenital scoliosis. J Bone Joint Surg Am 2003;85:399-408.   Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Campbell RM Jr, Hell-Vocke AK. Growth of the thoracic spine in congential scoliosis after expansion thoracoplasty. J Bone Joint Surg Am 2003;85:409-20.   Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Campbell RM Jr, Smith MD, Hell-Vocke AK. Expansion thoracoplasty: The surgical technique of opening wedge thoracostomy. J Bone Joint Surg Am 2004;86:51-64.   Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Emans JB, Caubet JF, Ordonez CL, Lee EY, Ciarlo M. The treatment of spine and chest wall deformities with fused ribs by expansion thoracostomy and insertion of vertical expandable prosthetic titanium rib. Spine 2005;30:S58-68.   Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Hell AK, Campbell RM, Hefti F. The vertical expandable prosthetic titanium rib implant for the treatment of thoracic insufficiency syndrome associated with congenital and neuromuscular scoliosis in young children. J Pediatr Orthop B 2005;14:287-93.   Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Latalski M, Fatyga M, Gregosiewicz A. The Vertical expandable prosthetic titanium rib (VEPTR) in the treatment of scoliosis and thoracic deformities: Preliminary report. Ortop Traumatol Rehabil 2007;9:459-66.   Back to cited text no. 6  [PUBMED]  [FULLTEXT]
7.Motoyama EK, Deeney VF, Fine GF, Yang CI, Mutich RL, Walczak SA, et al . Effects on lung function of multiple expansion thoracoplasty in children with thoracic insufficiency syndrome: A longitudinal study. Spine 2006;31:284-90.   Back to cited text no. 7  [PUBMED]  [FULLTEXT]
8.Waldhausen JH, Redding GJ, Song KM. Vertical expandable prosthetic titanium rib for thoracic insufficiency syndrome: A new method to treat an old problem. J Pediatr Surg 2007;42:76-80.   Back to cited text no. 8  [PUBMED]  [FULLTEXT]

Top
Correspondence Address:
K Lakhoo
Department of Paediatric Surgery, Children's Hospital Oxford, Headley Way, Headington, Oxford-OX39DU
United Kingdom
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0189-6725.44179

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    Abstract
    Introduction
    Materials and Me...
    Results
    Discussion
    References
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