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Growth-Friendly Spine Surgery in Arthrogryposis Multiplex Congenita
Bram P Verhofste1, John B Emans1, Patricia E Miller1
1Department of Orthopaedic Surgery, Boston Children's Hospital (Harvard Teaching Hospital), Boston, Massachusetts.
Insights
Growth-friendly instrumentation (GFI) in children with arthrogryposis multiplex congenita (AMC) and early-onset scoliosis (EOS) showed less initial correction but comparable final outcomes to idiopathic EOS. However, AMC patients experienced more complications, especially nonambulatory ones.
Area of Science:
- Pediatric Orthopedics
- Spinal Surgery
- Congenital Disorders
Background:
- Arthrogryposis multiplex congenita (AMC) involves congenital contractures, with spinal deformity occurring in 3-69% of cases.
- Limited data exist on growth-friendly instrumentation (GFI) for spinal deformities in AMC patients.
- Understanding GFI outcomes in AMC is crucial for managing early-onset scoliosis (EOS) in this population.
Purpose of the Study:
- To describe current GFI trends in children with AMC and EOS.
- To compare long-term spinal outcomes of GFI in AMC versus idiopathic EOS (IEOS).
- To determine if spinal rigidity or extremity contractures impact GFI outcomes in AMC.
Main Methods:
- Retrospective review of a multicenter EOS database (1993-2017) for AMC patients treated with GFI for ≥24 months.
- Propensity score matching to compare 35 AMC patients with 112 IEOS patients.
- Analysis of spinal deformity changes, functional outcomes (EOSQ-24), complications, and reoperations using statistical modeling.
Main Results:
- AMC patients had reduced initial coronal correction and larger residual curves post-GFI compared to IEOS.
- Final spinal curve magnitudes and T1-S1 growth were comparable between AMC and IEOS groups after definitive surgery.
- AMC patients experienced significantly more complications (51% higher incidence) and poorer EOSQ-24 scores.
Conclusions:
- While GFI provides comparable final spinal alignment and growth in AMC and IEOS, initial correction is less effective in AMC.
- Nonambulatory AMC patients with longer GFI treatment durations face higher complication rates.
- Multidisciplinary perioperative management is essential for optimizing GFI outcomes and quality of life in AMC patients with EOS.
Background:
Arthrogryposis multiplex congenita (AMC) is a condition that describes neonates born with ≥2 distinct congenital contractures. Despite spinal deformity in 3% to 69% of patients, inadequate data exist on growth-friendly instrumentation (GFI) in AMC. Our study objectives were to describe current GFI trends in children with AMC and early-onset scoliosis (EOS) and to compare long-term outcomes with a matched idiopathic EOS (IEOS) cohort to determine whether spinal rigidity or extremity contractures influenced outcomes.
Methods:
Children with AMC and spinal deformity of ≥30° who were treated with GFI for ≥24 months were identified from a multicenter EOS database (1993 to 2017). Propensity scoring matched 35 patients with AMC to 112 patients with IEOS with regard to age, sex, construct, and curve. Multivariable linear mixed modeling compared changes in spinal deformity and the 24-item Early Onset Scoliosis Questionnaire (EOSQ-24) across cohorts. Cohort complications and reoperations were analyzed using multivariable Poisson regression.
Results:
Preoperatively, groups did not differ with regard to age (p = 0.87), sex (p = 0.96), construct (p = 0.62), rate of nonoperative treatment (p = 0.54), and major coronal curve magnitude (p = 0.96). After the index GFI, patients with AMC had reduced percentage of coronal correction (35% compared with 44%; p = 0.01), larger residual coronal curves (49° compared with 42°; p = 0.03), and comparable percentage of kyphosis correction (17% compared with 21%; p = 0.52). In GFI graduates (n = 81), final coronal curve magnitude (55° compared with 43°; p = 0.22) and final sagittal curve magnitude (47° compared with 47°; p = 0.45) were not significantly different at the latest follow-up after definitive surgery. The patients with AMC had reduced T1-S1 length (p < 0.001), comparable T1-S1 growth velocity (0.66 compared with 0.85 mm/month; p = 0.05), and poorer EOSQ-24 scores at the time of the latest follow-up (64 compared with 83 points; p < 0.001). After adjusting for ambulatory status and GFI duration, patients with AMC developed 51% more complications (incidence rate ratio, 1.51 [95% confidence interval (CI), 1.11 to 2.04]; p = 0.009) and 0.2 more complications/year (95% CI, 0.02 to 0.33 more; p = 0.03) compared with patients with IEOS.
Conclusions:
Patients with AMC and EOS experienced less initial deformity correction after the index surgical procedure, but final GFI curve magnitudes and total T1-S1 growth during active treatment were statistically and clinically comparable with IEOS. Nonambulatory patients with AMC with longer GFI treatment durations developed the most complications. Multidisciplinary perioperative management is necessary to optimize GFI and to improve quality of life in this complex population.
Level Of Evidence:
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
