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I am a third-year medical student considering pediatric orthopedics as a speciality. Right now I have a case of a child with a diagnosis of neurofibromatosus. She's 12 years-old and had a stainless steel rod placed along her spine for severe scoliosis. She was recently admitted to the hospital with a fracture in the rod. For an assignment, I am supposed to find out how this kind of problem can be avoided. Do you have any studies you can recommend or information that might be helpful?
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As you know, children with severe scoliosis (curvature of the spine) may have surgery to insert a rod along the spine. The rod helps keep the spine straight. It's actually a growing rod, which means it operates like a telescope and can lengthen as the child grows. The vertebrae are not fused so the rod spans long sections of the spine.
One of the main problems with growing rods is that they fracture (break). To understand more about growing rod fractures and ways to prevent problems, a group of 10 pediatric orthopedic centers from around the United States put together a growing rod database. They combined all the information they had from 327 children treated with growing rods throughout all 10 centers.
By putting information about each case into a computer database, they could study and analyze the data. In this study, they looked for risk factors for rod breakage. The hope was to find ways to prevent this complication. Some of the more common risks included using single rods, stainless steel (rather than titanium) rods, and smaller diameter rods.
Fractures didn't usually occur right away. Some children did have a rod fracture as early as four months after rod insertion. But the more times the rod was lengthened, the greater the risk for breakage.
Most of the fractures occurred at places along the spine where the rod was connected to the bone. When they took a closer look, they saw that the type of connector made a difference. Rod fractures occurred more often with hooks (as opposed to screws or hooks and screws combined).
Age, weight, and severity of scoliosis did not appear to be risk factors. Wearing a brace at any time before or after surgery did not appear to provide protection from rod fractures.
What can be done to prevent this common complication? The authors didn't know yet without further study but they offered some thoughts. It's possible that replacing rods sooner in the process might help. The downside of that suggestion is the added surgery and increased risk of other complications like infections and blood clots.
Finding a better way to attach the rods might help. Using thicker, dual titanium rather than single stainless steel rods may be advised. Since metal fatigue may be part of the reason rods break, studies to find a better rod design might be helpful.
Surgeons were advised to consider making gradual bends in the rod rather than single angles when adjusting the rods to the curves. It might be better if broken rods were replaced rather than repaired.
The authors pointed out that the child's compliance with bracing might be an important factor. It's possible that bracing does provide some protection but we won't know that unless actual wearing is confirmed and compared with rod fracture rates.
This is actually the first study to examine growing rod breakage. The percentage of children who experienced growing rod fractures was 15 per cent. A higher number (26 per cent) of those with rod fractures had repeat fractures. It's a common complication of these growing rods without spinal fusion. Further study is needed to unravel all the possible risk factors and find evidence-based (proven) ways to prevent this problem.
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