THE USE OF CRANIAL HALO TRACTION VERSUS TEMPORARY INTERNAL DISTRACTION IN STAGED SURGERY FOR SEVERE SCOLIOSIS: A COMPARATIVE STUDY

ABSTRACT Objective: To determine which method is more effective – cranial halo traction or temporary internal distraction – in staged surgeries for patients with severe (≥ 100°) and stiff (<25% flexibility) scoliosis. Methods: A sample of 12 patients with traction and 7 patients without traction, operated on between January 2013 and December 2017. The patients’ demographic data, the type of surgery performed, complications, and coronal and sagittal alignment parameters were recorded before surgery and in the final follow-up. The data were processed in SPSS 20.0. Comparisons were made between the means (Student's t-test) and the clinical and procedure-related characteristics (likelihood ratio and Fisher's Exact tests), at a confidence level of 0.05. Results: There were no significant intergroup differences for clinical characteristics, complications or degree of correction. However, more patients in the group submitted to temporary internal distraction required vertebral resection osteotomies during definitive surgery (p<0.05). Conclusions: Based on the results, it was not possible to establish which is the most effective method, but it is suggested that staged traction may be more effective, and safer, particularly when the surgeon is less experienced, during surgery on patients with severe and stiff scoliosis. Level of evidence IV; Vase series.

Unanticipated Fractures of the Zygomatic-Maxillary Suture in LeFort III Internal Distraction: Salvage of Midfacial Advancement via Rigid External Distraction of an Orphaned LeFort II Segment

Currently, the most common approach for treating midface hypoplasia in syndromic craniosynostoses patients is the LeFort III with distraction osteogenesis. Distraction osteogenesis can be performed through either internal or external distraction systems. Each modality offers unique advantages and disadvantages. A rare complication associated with internal distraction is fracture of the zygomatic-maxillary suture caused by distraction forces on this area. This complication has been reported in patients with Pfeiffer and Apert syndromes, related to convexity of temporal bones increasing force on the zygomatic-maxillary suture. In the current report, we present the first case in the literature of an internal distraction associated zygomatic-maxillary fracture in a patient with Crouzon syndrome. We also present a subunit osteotomy salvage approach. Through mobilization of a LeFort II segment and rigid external distraction to advance orphaned segments of the midface, a favorable aesthetic result was salvaged from this complication.

Morphological improvement after multi-directional cranial distraction osteogenesis procedure for syndromic craniosynostosis

The multidirectional cranial distraction osteogenesis (MCDO) procedure, which uses an external distraction device, enables tailor-made distraction in an arbitrary direction, eliminating the disadvantage of unidirectional distraction with an internal distraction device. Multiple-suture synostosis cases for syndromic craniosynostosis patients are better indicated for this procedure. Here the authors describe seven cases in which the MCDO procedure was used to treat syndromic craniosynostosis. In each case, the MCDO procedure and postoperative distraction, with reference to midsagittal vector analysis of normal morphology in Japanese children, resulted in morphological improvement. The video can be found here: https://vimeo.com/519006555

A novel posterior multiple screws distraction reducer system versus anterior release, posterior internal distraction, and subsequent spinal fusion for severe scoliosis

Purpose We previously reported anterior release, posterior internal distraction, and subsequent spinal fusion (ARPIDF) for the correction of severe scoliosis with a satisfactory correction rate. However, surgical procedures were completed in 2–3 stages. Here we compare Cobb angle of ≥90° in scoliosis correction between a novel posterior multiple screws distraction reducer (MSDR) system and ARPIDF. Methods Thirty-six patients with severe scoliosis treated by MSDR or ARPIDF (n = 18 in both groups). We retrospectively analyzed and compared outcome measures between the two groups over a minimum follow-up duration of 2 years. The following variables were compared between the two groups: age at surgery, sex, etiology, flexibility of the main thoracic curve, number of fused segments and screws, operation time, estimated blood loss, hospitalization time, follow-up duration, various radiological parameters, complication rate, and Scoliosis Research Society-30 score. Results There were no significant between-group differences with respect to age, sex, etiology, flexibility of the main thoracic curve, number of fused segments and screws, and follow-up duration. Further, there was no significant difference in terms of preoperative, postoperative, and final follow-up findings of the radiographic data. However, the ARPIDF group had longer operation and hospitalization times and greater blood loss. In the ARPIDF group, 4 patient developed complications (infection, intraoperative neuromonitoring changes, transient dyspnea); none of these events occurred in the MSDR group. Conclusion The use of MSDR helped achieve greater scoliosis correction with a shorter operation time, lower blood loss, and lower complication rate than the use of ARPIDF. MSDR facilitates safer and easier correction of severe scoliosis without increasing surgical risk.

Le Fort III Distraction Osteogenesis: Early Experience With an Internal Bilevel Midface Distraction System

Internal distraction devices for severe midface hypoplasia are often criticized for their distraction at a single pivot point, resulting in “mid-face tipping,” a phenomenon which is in part related to the differential resistance of the soft tissues at orbital and maxillary levels. To address this deficiency, we present our early experience with an internal bi-level midface distraction system. Four patients underwent midface advancement with an internal bi-level distraction system. The specifics of design, application, distraction, and removal are detailed. Hospital records were reviewed to capture patient demographics, length of stay, OR times, and complications. Relevant cephalometry was performed pre- and post-operatively, and compared. In 2015, 4 patients with severe mid-face hypoplasia were treated with an internal bi-level mid-face distraction system. The mean age was 13.5 ± 1.7 years. The mean operative time was 269.7 ± 67.4 min. The mean LOS was 10 ± 7.4 days. The on-table distraction was 5 mm. Distraction subsequently proceeded at a variable rate of 0.5 to 1.0 mm daily with a maximal distraction of 20 and 30 mm at orbital and maxillary levels, respectively. Mean time to distractor removal was 11.2 ± 1.1 weeks. Device design allowed facile removal through minimally invasive incisions. Cephalometry was seen to progress towards age-matched norms. There were no major complications. Minor complications included breakage of the vertical component of the maxillary arm at the time of device removal in 1 patient. By allowing real-time adjustment at the orbital and maxillary levels to combat differential resistance, early experience with our device maximizes occlusal advancement without overcompensating orbital translation.

A Grounded-Theory Study of Meta-Attention in Golfers

This study sought to construct a theoretical understanding of meta-attention in golfers. Eight male golfers (7 competitive-elite and 1 successful-elite) were interviewed about their experiences of attentional processes in competitive golf. A Straussian grounded-theory approach was used throughout the research process, and interview transcripts were analyzed using open, axial, and selective coding. Results indicated that meta-attention is resource based, with metacognitive reflections of logistic and shot resources that facilitate attentional control. Attentional control required successful target selection, consistent preshot routines, and consistent postshot routines. Failures in wider or immediate resources or failure to initiate control routines can lead to internal distraction. The emergent theory provides an understanding of the function of meta-attention in golf performance that can be used by golfers, coaches, or psychologists to improve attentional strategies.