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What not to do in VEPTR
or
4 of my worst VEPTR mistakes
John Emans
Children's Hospital
Harvard Medical School
Boston
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Conflicts of Interest
• Consultant:
– Medtronics
– J&J, Depuy/Synthes
– Biomet
• Royalties:
– Synthes spine (VEPTR II)
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Three things to not do with VEPTR
• Can you avoid my learning curve?
1. Upper thoracic kyphosis (esp NM pts.)
2. Reversed iliac hooks
3. Over-distraction
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Upper thoracic kyphosis
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Arthrogryposis, trach, vent at night
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• Halo gravity traction
to help correct upper
thoracic kyphosis
• Bilateral rib to pelvis
VEPTR
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• VEPTR lengthened x 5 years
• Vastly improved pulmonary status –
decannulated, no hospitalizations for respiratory
distress
• Gained weight, grew
• No cervical discomfort
• Worsening cervical lordosis, upper thoracic
kyphosis
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Age 8
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LC – arthrogryposis – age 3 to 8
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LL Arthrogryposis
• Cervico thoracic
junction collapsed
further into kyphosis,
rotating around
VEPTR attachments
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• Plan?
– Halo gravity traction
– Posterior VCR
– Add instrumented
posterior fusion from
approx C5 to T5
– Exchange of VEPTR
– Continue
lengthening VEPTR
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Early Onset Deformity. – etiology as a factor:
• Collapsing neuromuscular • Kyphosis (upper thoracic) problematic for both growing rods
and VEPTR
– Pre-op halo gravity traction may facilitate device insertion by
diminishing kyphosis
– Can get them in but will they hold?
• Growing rods can extend more cephalad
– Better for upper thoracic kyphosis
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Reversed iliac hooks
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4 y.o. with Ehlers Danlos variant
• Worsening deformity
• Recurrent breakdown
when attempting to
sit or with a brace
• Severe osteopenia,
recurrent fractures
• Increasing
respiratory distress
(secondary TIS)
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Ehlers Danlos with reversed iliac hooks
Hooks reversed –
loop on inner table of
pelvis to better resist
dorsal displacement
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Complications of VEPTR: Anchor Point Problems:
• Chronic, long-term: • Iliac S-hook drift
– Common over time, particularly in unilateral devices
• Drift is generally distal, not posterior or lateral
– Indications for revision: • Too close to hip joint
• Loss of fixation
– Revision straightforward but may require significant exposure
– If iliac hooks reversed, extraction much more difficult or even impossible
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Insufficient soft tissue management
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Acute Brachial Plexus palsy –5 yo with
thoracogenic scoliosis – resolution with device
shortening – 6 months
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Deep infection with primary procedure • 12 yo with TEF, multiple prior
thoracotomies, prior chest wall infections, rib fusions.
– Expansion thoracostomy x 2, rib to rib and rib to spine device
• No preparation of flaps, expanders
• Poor soft tissue coverage, no muscle coverage from prior procedures.
– POD 14 trauma to wound over prominent device while sitting against chair. On vacation
– Both devices removed – fusion 6 mo later
• Moral:
– Create healthy flaps
– No full thickness wounds over devices
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VEPTR Surgical Procedure:
• Incision planning
– Consider prior incisions
– Consider ‘delay’ of flap or tissue expanders
– Nutrition!
– Access for lengthening, exchange Later device access for expansion
– Periodic lengthening
– Distraction lock moves superiorly with expansions
– ?Tissue expanders
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VEPTR– create a healthy musculo-
cutaneous flap: • Preservation of
maximum soft tissue
envelope
• Goal: Healthy
musculo-cutaneous
flap
• Full thickness
elevation:
– Skin
– All muscles, scapula
– Trapezius more
distal than skin
• Medial elevation of
paraspinals
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Lengthenings:
• A 2x / year chance
for a
complication!
• Avoid full
thickness incision
over device
• Pull muscle back
together with
closure
– Attending level
closure
• Leave the
operative site
coverage better
than you found it.
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Avoiding full thickness incisions at the time of device
lengthening:
Deep
Superficial
Device Device
Prior skin
incision
Lengthening
incisions
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Over-distraction
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Rib fractures – acute loss of correction
• Patient #24
– VACTERL
– Rib fractures during initial insertion, distraction (‘just a little more’)
– Loss of correction, fixation
– Revision at 6 months
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Pre-op
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Rib fractures – acute loss of correction
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Rib fractures – revision after 6 months of healing,
drifted again to
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Rib fractures – eventual control with growing rods.
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3.5 years post op, after lengthenings:
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Thanks!