Cotrel-dubousset instrumentation for the correction of adolescent idiopathic scoliosis. Long-term results with an unexpected high revision rate

Abstract

BackgroundFor many years, the CD instrumentation has been regarded as the standard device for the surgical correction of adolescent idiopathic scoliosis (AIS). Nevertheless, scientific long-term results on this procedure are rare. Therefore, we conducted a retrospective follow-up study of patients treated for AIS with CD instrumentation and spondylodesis.MethodsA total of 40 patients with AIS underwent CD instrumentation in our department within 3 years and between 1990 and 1992. For the retrospective analysis, first all the patient documents were reviewed, and pre-/postoperative X-ray images as well as those at the latest follow-up were analysed. Furthermore, it was attempted to conduct a clinical survey using the SRS-24 questionnaire, which was sent to the patients after a preceding announcement on the phone.ResultsRadiologically, the frontal main curvature was improved from a preoperative angle of 69.2° to a postoperative angle of 35.4°, and the secondary curvature was improved from a preoperative angle of 42.6° to a postoperative angle of 20.5°. The latest radiological follow-up at average 57.4 months post surgery showed an average loss of correction of 9.6° (main curvature) and 4.6° (secondary curvature), respectively.Within the first 30 days post surgery, 3 out of 40 patients (7.5%) received early operative revision for the dislocation of hooks or rods.At an average of 45.7 months (range 11 to 142 months), 19 out of 40 patients (47.5%; including 2 patients with early revision) received late operative revisions: The reasons were late infection (10 out of 40 patients; 25%) with the development of fistulae (7 cases) or putrid secretion (3 cases), which was resolved with the complete removal of instrumentation after all. The average time until revision was 35.5 months (range 14 to 56 months) after CD instrumentation. Furthermore, complete implant removal was necessary in 8 out of 40 patients (20%) for late operate site pain (LOSP). The average time until removal of instrumentation was 62.7 months (range 18 to 146 months) post surgery; and one patient received partial device removal for prominent instrumentation 11 months post surgery. Altogether, only 22 out of 40 CD instrumentations (55%) were still in situ.After an average period of 14.3 years post surgery, it was possible to follow-up 14 out of 40 patients (35%) using the SRS-24 questionnaire. The average score was 93 points, without showing significant differences between patients with or without their instrumentation in situ.ConclusionsRetrospectively, we documented for the first time a very high revisions rate in patients with AIS and treated by CD instrumentation. Nearly half of the instrumentation had to be removed due to late infection and LOSP. The reasons for the high rate of late infections with or without fistulae and for LOSP were analysed and discussed in detail.

Serial Case Reporting Yoga for Idiopathic and Degenerative Scoliosis

“…Surgery brings a 44% to 59% reduction of the curves on which it is performed. [29][30][31][32][33][34][35][36] However, there is substantial comorbidity, including restriction of spinal mobility, hardware malfunctioning, extra strain on the vertebrae above and below the fusion, and pseudoarthroses. A recent study documented a rate of 50% of revision surgery following Cotrel-Dubousset surgical intervention.…”

Remodelling of trunk and backshape deformities in patients with scoliosis using standardized asymmetric computer-aided design/computer-aided manufacturing braces

“…In the skeletally immature patient with Cobb angles in excess of 40° and in more mature patients where Cobb angle measures in excess of 45° or 50°, spinal fusion surgery is the most common intervention. However, long-term studies have revealed outcomes concluding that the risks of surgery are many [21][22][23][24][25][26][27] . In contrast, bracing of the highest standards now offers an alternative for the patient, leading to improved outcomes, without surgery.…”

“…In contrast, bracing of the highest standards now offers an alternative for the patient, leading to improved outcomes, without surgery. Brace advancements must be fostered to provide patients with curvatures greater than 50° withbeneficialclinicalandradiological outcomes, without the associated risks [21][22][23][24][25][26][27][28][29] .…”

“…In the literature, it has been stated that a curve exceeding 40° cannot be halted using the Boston brace, and surgical management with spinal fusion has been proposed for larger curves 15,16 . Today, it is known that surgical treatment has a high rate of long-term complications estimated to exceed 50% with no proven beneficial effects on patients' health in terms of improving vital capacity, and under discussion recently, the uncertainty of the long-term effects of metallosis [21][22][23][24][25][26][27][28][29] . Currently, brace treatment has advanced (Figure 1), with success rates exceeding 95% when the SRS criteria for inclusion are applied 30 .…”

“…Currently, brace treatment has advanced (Figure 1), with success rates exceeding 95% when the SRS criteria for inclusion are applied 30 . Therefore, clinicians should strive to improve in-brace correction and patient compliance 14 through comfort, since bracing today offers the best documented mode of treatment with an acceptable 'cost/effect relation' for the patient during growth [21][22][23][24][25][26][27][28][29] and is non-invasive. In the literature, there are papers showing improvement of curvatures under brace treatment, but this mainly relates to results revealed on an X-ray, not clinically 30 .…”