The vertical expandable prosthetic titanium rib implant for the treatment of thoracic insufficiency syndrome associated with congenital and neuromuscular scoliosis in young children

Abstract

Expansion thoracoplasty and vertical expandable prosthetic titanium rib (VEPTR; Synthes Spine Co., West Chester, Pennsylvania, USA) implantation is a new method for the treatment of thoracic insufficiency syndrome and congenital spinal deformity in children. The longitudinal rib implant expands the thorax and indirectly corrects spinal deformity, thus allowing spinal, thoracic and probably lung growth. VEPTR has been used since 1989 in San Antonio, USA, and was introduced to Europe in 2002. This paper describes the preliminary experience with the European patients. Fifteen children with progressive scoliosis had a VEPTR implantation at a mean age of 6 years (11 months to 12 years). Nine children had thoracic insufficiency syndrome due to unilateral unsegmented bars (n = 4), absent ribs (n = 1), hemivertebrae (n = 2) or bilateral fused ribs (n = 2). Six children had severe thoracolumbar scoliosis and pelvic obliquity due to neuromuscular scoliosis. After VEPTR implantation, families and patients reported improvement of the thoracic insufficiency syndrome and better sitting abilities in the neuromuscular patients, as well as radical cosmetic improvement. There were three complications (skin breakage, lumbar hook displacement, rib fracture) after performing fifteen primary VEPTR implantations and 13 expansion surgeries in eight patients. Our experience suggests that expansion thoracoplasty and VEPTR implantation is a safe and efficient method for the treatment of thoracic insufficiency syndrome in young children with severe scoliosis.

Variability of Expert Opinion in Treatment of Early-onset Scoliosis

“…The literature supports the use of both techniques but also documents complications in this population including proximal migration of devices with rib fractures, and skin problems secondary to recurrent surgery and hardware [3,8,10,13]. The complication rates ranged from 8% to 50% [2,3,8,10,13]. The literature also suggests the growing rod systems are associated with a high complication rate (ie, 8% to 50%) with the majority being minor; these systems appear to halt curve progression but not reduce curve magnitude [10,13].…”

“…Growing rods [7] and the Vertical Expandable Prosthetic Titanium Rib (VEPTR TM ; Synthes Spine Co, West Chester, PA) [8] are commonly used to treat EOS. The literature supports the use of both techniques but also documents complications in this population including proximal migration of devices with rib fractures, and skin problems secondary to recurrent surgery and hardware [3,8,10,13]. The complication rates ranged from 8% to 50% [2,3,8,10,13].…”

“…The VEPTR TM has been studied under an Investigational Device Exemption (IDE) that resulted in the US Food and Drug Administration (FDA) granting a Humanitarian Device Exemption (HDE) as FDA requirements for safety and efficacy were satisfied. The complications reported were frequent (ie, 9% to 21%) but not life threatening and deformities were corrected or controlled [3,8]. Full approval of the VEPTR TM was not granted because the FDA believed there was insufficient control data.…”

“…An opening wedge thoracostomy sometimes is performed as part of distraction thoracoplasty [10], but some surgeons prefer not opening the thoracic cavity as they are concerned by the potential for scarring and subsequent restriction this could cause [8].…”

The effect of a vertical expandable prosthetic titanium rib on shoulder balance in patients with congenital scoliosis

“…Hell et al [12] reported three complications encompassing 15 primary VEPTR implantations. These included rib fracture, lumbar hook displacement, and skin breakdown.…”