Pedicle screw versus hybrid instrumentation in adolescent idiopathic scoliosis

Abstract

Background:Incidence of complications and reoperations between pedicle screw (PS) and hybrid instrumentations (HI) are still controversial in adolescent idiopathic scoliosis (AIS) patients. A systematic review and meta-analysis were performed to compare overall complications, reoperations, and radiographic outcomes between the 2 constructs.Methods:Strictly followed the PRISMA 2009 guidelines, the MEDLINE, EMBASE, and the Cochrane Library databases were used to search for literatures up to April 2016, addressing PS versus HI in AIS patients. The Newcastle–Ottawa scale was adopted to assess the quality of the studies. Data on complications, reoperations, Cobb angle of major curve, thoracic kyphosis, and proximal junctional measurement were extracted from the included studies. RevMan 5.3 and SPSS 21.0 were used for statistical analysis.Results:Twenty-four case-control studies with a total of 3042 AIS patients (1582 PS, 1460 HI) were included, consisting of 1 randomized controlled trial, 1 prospective study, and 22 retrospective studies. Decreased overall complications (95% CI 0.42–0.87, P = .007; I2 = 38%) and reoperations (95% CI 0.22–0.62, P = .0001; I2 = 0%) were found in PS group compared with HI group. As regard to reasons for reoperations, increased incidence of pseudarthrosis (P = .005), dislodged instrumentation (P = .005), and deep infection (P = .016) occurred in HI group. PS group achieved a better coronal correction (95% CI −7.06 to −4.54, P < .00001; I2 = 34%), but HI group was more powerful in restoring thoracic kyphosis (95% CI −7.88 to −3.70, P < .00001; I2 = 60%), and no significant differences were found in proximal junctional measurement (95% CI −0.88 to 1.54, P = .59; I2 = 0%) between the 2 constructs.Conclusion:Compared with hybrid instrumentation, pedicle screw construct provides better coronal correction but less thoracic kyphosis restoring, with decreased incidence of overall complications and reoperations in AIS patients. As regard to the pedicle screw construct, the most common reasons for reoperation are malposition, deep infection, pseudarthrosis, and prominent implant.

Postoperative Spinal Implant Infections (PSII)—A Systematic Review: What Do We Know So Far and What is Critical About It?

“…Like with RCT, only 4 meta-analyzes were able to demonstrate statistically significant results (Table 5): Vancomycin powder reduces the rate of spinal implant infection, sacral 2 alar iliac screw fixation showed a lower risk of infection compared to iliac screw fixation, and pedicle screws demonstrated a significantly higher rate of reoperations for reinfection than hybrid instrumentation. 57,58,76,77 In contrast significantly reduced risk for infection was not identified with extended postoperative and preoperative antimicrobial prophylaxis, or different screw fixation techniques. 74,78,79,80-84…”

“…72,73,75 Like with RCT, only 4 meta-analyzes were able to demonstrate statistically significant results (Table 5): Vancomycin powder reduces the rate of spinal implant infection, sacral 2 alar iliac screw fixation showed a lower risk of infection compared to iliac screw fixation, and pedicle screws demonstrated a significantly higher rate of reoperations for reinfection than hybrid instrumentation. 57,58,76,77 In contrast significantly reduced risk for infection was not identified with extended postoperative and preoperative antimicrobial prophylaxis, or different screw fixation techniques. 74,78,79,[80][81][82][83][84] After analyzing the context of the study, the term "deep spinal infection" 71,77 and the unspecified term "infection (rate)" 57,58,72,76,78 were considered equivalent to the term PSII in the included RCT and meta-analyzes, as opposed to solely wound healing delay and superficial infection.…”

“…Stepanov et al (2020) 57 Vancomycin powder reduces the incidence of infection in cases of stabilizing implant surgeries (P ¼ .004); 28 studies; 17.469 patients Keorochana et al (2019) 76 Iliac screw fixation with statistically significant higher chance of infection by relative risk of 3.03 (95% CI, 1. 62-5.66) compared to sacral 2 alar iliac screw fixation; 7 studies; 377 patients Luo et al (2017) 77 Pedicle screw (PS) compared to hybrid instrumentation (HI) for adolescent idiopathic scoliosis demonstrated no statistically significant difference (P > .05) concerning infection (PS 1.068 patients; HI 963 patients). However, a significantly higher rate of reoperations due to "deep infections" (in this context considered implant infection) (P ¼ .016) in the PS group (969) was identified compared with the HI group (663) Khan et al (2014) 58 Patients with implants had a reduced risk of infection with vancomycin powder (P ¼ .023), compared with those without spinal implants (P ¼ .226); 10 studies; 2.574 cases in the control, 2.518 in the treatment group Phillips et al (2020) 74 No statistically significant difference concerning PSII development between extended postoperative and preoperative antimicrobial prophylaxis in instrumented surgery (P ¼ .93); 888 patients Wang et al (2019) 78 No statistically significant difference concerning infection between (P ¼ .24) cortical bone trajectory and pedicle screw in posterior lumbar fusion surgery; 14 studies; 954 patients Zhang et al (2018) 79 No significant difference concerning postoperative infections between combined pedicle screw fixation at the fracture vertebrae compared to conventional method cross the fracture vertebrae (P ¼ .39); 7 studies; 388 patients Tong et al (2018) 80 No statistically significant difference concerning infection rate between intersegmental pedicle screws (4-screw fixation) and addition of intermediate fixation screws (6-screw fixation) for thoracolumbar fractures; 6 studies; 310 patients Liu et al (2017) 81 No statistically significant difference concerning infection rate between unilateral and bilateral pedicle screw fixation with PLIF; 6 studies; 500 patients (P ¼.32) Vertuani et al (2015) 82 Minimal invasive TLIF with lower infection rate (0.09) than an open based TLIF (0.12); no P value calculated Ye et al (2013) 83 No significant difference between PLF and PLIF group with transpedicular screw fixation for isthmic spondylolithesis concerning infection rate (P ¼ .191); 4 studies; 226 cases Lykissas et al (2013) 84 Infection rates following instrumented posterior spinal fusion for adolescent idiopathic scoliosis: Harrington rods (5.5%), cotrel-dubousset (4.3%), pedicle screws (1.1%); 14 studies; 721 patients 10 Global Spine Journal infection in patients with and without a sterile film-forming cyanoacrylate liquid, and between single and multiple dose AB prophylaxis.…”

Prediction of Accuracy and Screw Size by Pedicle Anatomic Parameters and Screws in Idiopathic Scoliosis With Freehand Screw Placement Based on Machine Learning

“…The pedicle screw system has advantages of strong pull-out strength resistance, multi-plane stability, less fusion joints, less postoperative support 3 . When applied to correction surgery, it has strong correction strength, lower incidence of complication and lower reoperation rate 4,5 . Nowadays, freehand technique is the most common technique of pedicle screw placement.…”

Characteristics of Cobb angle distribution in the main thoracolumbar/lumbar curve in adolescent idiopathic scoliosis

“…For the severe scoliosis, correction surgery is essential to reconstruct the alignment. [ 3 ] It is commonly accepted that Cobb angle is frequently used to quantify the severity of this deformity. [ 4 ] In addition, the Cobb angle based on anteroposterior radiograph is the necessary prerequisite to plan the surgery, and correction surgery is always required when a Cobb angle > 50°.…”