Can infection associated with rib distraction techniques be managed without implant removal?

Retrospective clinical cohort study of infections in patients treated using rib distraction techniques.

To determine if patients with early onset spinal deformity, who develop infection around their rib distraction implant, can be successfully managed without implant removal.

Vertical Expandable Prosthetic Titanium Rib (VEPTR) has gained wide acceptance for the management of progressive complex spinal deformity in children. Many children in this population have significant comorbidities and low body mass index putting them at high risk for infection. Typically, the protocol for treating all but early infection recommends implant removal. The purpose of this study is to determine if a VEPTR infection can be managed effectively without implant removal.

This is an institutional review board-approved retrospective review of medical records of all patients who had VEPTR procedures and developed infections at PCMC from 2002 to 2008.

Ninety-seven patients underwent 678 VEPTR procedures. Nineteen infections developed in 16 patients, with a 2% overall rate of infection per procedure. The average body mass index (16.2) and absolute neutrophil count (8.2) were predictably low for this population. The diagnosis was varied. Infection was associated with initial implantation (31%), expansion (47%), exchange (5%), and revision (21%). Seventeen of 19 infections followed a wound dehiscence. Thirteen infections were classified as superficial and six deep. All patients were treated with initial irrigation and debridement (I&D) and intravenous antibiotics. The average duration of intravenous therapy was 58 days, followed by oral suppressive therapy for 34 days (2-126). Three patients required more than one debridement to control the infection (range, 2-4 I&D). No patient has required VEPTR removal to resolve the infection.

These data suggest that infections involving VEPTR instrumentation without fusion procedures can be effectively managed without implant removal. Nutrition and improved soft tissue management may be significant in reducing the incidence of infection in this patient population.