Vertical Expandable Prosthetic Titanium Rib

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Vertical Expandable Prosthetic Titanium Rib
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VEPTR

• History
• Indications
• Complications
• Benefits
• Surgical Procedure
• Literature
• Case Example

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Indications

• Thoracic Insufficiency Syndrome (TIS) in
  skeletally immature patients
• Flail Chest Syndrome
• Rib fusion and scoliosis
• Hypoplastic thorax syndrome, (Jeunes syndrome,
  Achondroplasia, Jarcho-Levin syndrome, Ellis van
  Creveld syndrome)

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Contraindications

• Poor bone quality
• Incompetent diaphragm
• Lack of soft tissue coverage
• lt 6mo of age or skeletally mature
• Titanium allergy
• Active infection at operative site

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Surgical Technique- Expansion Thoracoplasty

• Lateral decubitus position with concave hemi
  thorax exposed
• Upper and lower extremity SSEP monitoring
• Modified thoracotomy skin incision L shape
  caudal to scapula tip
• Trapezius, rhomboid, and latissimus divided
• Superior retraction of scapula

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Surgical Technique- Expansion Thoracoplasty

• Scalene muscles identified with anterior
  neurovascular bundles
• Lateral to medial dissection of paraspinous
  muscles w/o damage to the periosteum
• Opening wedge thoracostomy at apex of fused ribs

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Surgical Technique- Expansion Thoracoplasty

• Application of superior and inferior rib cradles

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Surgical Technique- Expansion Thoracoplasty

• Hybrid Rib Prosthesis for Thoracolumbar Scoliosis
• Proximal rib clamp and second incision for lamina
  hook
• Sub muscular passage of contoured rod to distal
  lamina fixation

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Surgical Technique- Expansion Thoracoplasty

• Bone graft is used for a 1 level fusion at the
  site of the lamina hook
• Closure in layers with a chest tube if needed
• ICU monitoring
• No post operative bracing

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Device Expansion Procedures

• 4-6 month intervals
• Separate incisions with thick muscle flaps

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1-2/yr lengthening
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Benefits of VEPTR

• More normal growth patterns without spine growth
  limitations
• More room for alveolar development
• Decreased spinal deformity
• Quality of life

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Complications

• Infection
• Brachial Plexus Palsy
• Horners syndrome
• Rib fracture
• Device migration requiring intervention
• Chest wall scarring / stiffness

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The Literature

• Campbell et all (1)
• 27pts opening wedge thoracostomy/VEPTR
• Avg age 3.2yrs with avg 5.7yr f/u
• Cobb correction 74deg 49deg
• Thoracic spine height increase 0.71cm/yr
• At last f/u, highest of predicted normal vital
  capacity for patients lt 2yr at time of operation

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Campbell et all (1)

• 52 complications
• Asymptomatic superior migration of device (7)
• Skin slough (4)
• Infection (4)
• ARDS, brachioplexopathy, dural tear

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Campbell et all (2)

• CT measurements of spinal growth in 21 pts. With
  congenital scoliosis and fused ribs
• Significant and equal growth of both the convex
  and concave sides of the curves
• 11 pts with an unsegmented bar demonstrated avg
  7.3 increase in the length of the bar
• Avg 4.2 yr f/u

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The European Experience

• Hell et all (3)- 15 children, 9- congenital
  scoliosis, 6- neuromuscular scoliosis
• Cobb improvement from 76deg to 55 deg
• Parents reported improved sitting posture and
  increased activity
• 3 complications- skin breakdown, lumbar hook
  displacement, rib fracture

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The Boston Experience

• Emans et all (4)- 31pts mean age 4 with avg f/u
  of 2.6yrs
• 30/31 patients had spinal deformity controlled
  normal thoracic spine growth rates
• Significant increase in volume of the constricted
  hemithorax and total lung volume (CT measurements)

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The Boston Experience

• Complications
• Migration of device (8)
• Brachial plexus palsy (2)
• Recurrence of rib fusions, infection, rib
  fracture

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Case Example

• 5 yo male with congenital left thoracic scoliosis
  and 5 level bar
• Expansion thoracostomy 3rd 11th rib, 3rd rib
  to L2, rib bar apex osteotomy
• 6 weeks cobb correction from 65- 40 deg
• 7 months time for a lengthening

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Case Example

• 5yo female with congenital scoliosis T10 fully
  segmented , non incarcerated, hemivertebra with r
  rib fusions T9-11, T1-4
• Osteotomy of fused ribs T9-10 with VEPTR 4th-11th
  ribs, T3- lumbar 2 lamina
• Thoracic curve correction from 40- 35 deg
• Lengthening 7 mo from index procedure
• Lamina hook detachment

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Conclusions

• Expansion thoracostomy with the VEPTR device
  addresses TIS by improving congenital scoliosis
  curves, increasing lung volume of the constricted
  hemithorax, and allowing normal rates of thoracic
  spine growth

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Bibliography

• 1. Campbell RM Jr, Smith MD, Mayes TC, Mangos JA,
  Willey-Courand DB, Knose N, Pinero RF. The effect
  of opening wedge thoracostomy on thoracic
  insufficiency syndrome associated with fused ribs
  and congenital scoliosis. J Bone Joint Surgery Am
  2004861659-74
• 2. Campbell RM Jr, Hell-Vocke, AK. Growth of the
  thoracic spine in congenital scoliosis after
  expansion thoracoplasty. J Bone Joint Surgery Am
  2003 85409-20
• 3. Campbell RM Jr, Hell-Vocke, AK et all. The
  vertical expandable prosthetic titanium rib
  implant for the treatment of thoracic
  insufficiency syndrome associated with congenital
  and neuromuscular scoliosis in young children.
  Journal of Pediatric Ortho 2005 14287-293
• 4. Emans, JB,et all. The treatment of spine and
  chest wall deformities with fused ribs by
  expansion thoracostomy and insertion of Vertical
  Expandable Prosthetic Titanium Rib. Spine 2005
  vol 30 558-268