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Scientific Articles   |    
Harrington and Cotrel-Dubousset Instrumentation in Adolescent Idiopathic ScoliosisLong-Term Functional and Radiographic Outcomes
Ilkka Helenius, MD, PhD1; Ville Remes, MD, PhD2; Timo Yrjönen, MD, PhD2; Mauno Ylikoski, MD, PhD2; Dietrich Schlenzka, MD, PhD2; Miia Helenius, DDS, BM2; Mikko Poussa, MD, PhD2
1 Hospital for Children and Adolescents, Helsinki University Central Hospital, P.O. Box 281, Helsinki FIN-00029 HUS, Finland. E-mail address: ilkka.helenius@helsinki.fi
2 ORTON Orthopaedic Hospital, Invalid Foundation, Tenholantie 10, Helsinki FIN-00280, Finland
View Disclosures and Other Information
In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from the Instrumentarium Scientific Foundation, Finnish Orthopaedic and Traumatology Foundation, Päivikki and Sakari Sohlberg Foundation, Emil Aaltonen Foundation, Juselius Foundation, The Foundation for Pediatric Research, and Sivia Kosti Foundation. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at ORTON Orthopaedic Hospital, Invalid Foundation, Helsinki, Finland

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2003 Dec 01;85(12):2303-2309
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Abstract

Background: Previous studies have shown that the long-term clinical outcome does not correlate with the radiographic outcome in patients treated with Harrington instrumentation for adolescent idiopathic scoliosis. Cotrel-Dubousset instrumentation has been reported to provide better correction radiographically, but it is unclear whether it provides better long-term clinical or functional outcomes. We are not aware of any long-term studies comparing Harrington and Cotrel-Dubousset instrumentation.

Methods: Seventy-eight patients in whom adolescent idiopathic scoliosis was treated with Harrington instrumentation and fifty-seven in whom it was treated with Cotrel-Dubousset instrumentation participated in this study. The mean duration of follow-up was 20.8 years for the Harrington instrumentation group and 13.0 years for the Cotrel-Dubousset instrumentation group. The mean age at the time of follow-up was thirty-six years and twenty-eight years, respectively. Radiographs were made preoperatively and at the two-year and final follow-up examinations. The Scoliosis Research Society questionnaire was completed, a physical examination was performed, and spinal mobility and non-dynamometric trunk strength were measured at the final follow-up visit.

Results: The mean preoperative Cobb angle of the thoracic curves was 53° in the Harrington instrumentation group and 55° in the Cotrel-Dubousset instrumentation group. The mean numbers of vertebrae included in the instrumentation were 10.7 and 9.9, respectively. At the two-year follow-up evaluation, the mean postoperative Cobb angles were 38° and 25°, respectively (p < 0.0001). At the final follow-up evaluation, the mean angles were 45° and 32° (p < 0.0001). No significant difference in thoracic kyphosis or lumbar lordosis was observed between the study groups at the final follow-up evaluation. The average score on the Scoliosis Research Society questionnaire was 97 points in both groups. Measurements of non-dynamometric trunk strength corresponded with age and sex-adjusted reference values, on the average, but patients with Cotrel-Dubousset instrumentation performed significantly better in the squatting test (p = 0.010). Abnormal lumbar extension and trunk side-bending were significantly more common in the Harrington instrumentation group (p = 0.050 and p = 0.0061, respectively). Complications were recorded for nine (12%) of the patients treated with Harrington instrumentation and fifteen (26%) of those treated with Cotrel-Dubousset instrumentation (p = 0.027).

Conclusions: Cotrel-Dubousset instrumentation yielded better long-term functional and radiographic outcomes in patients with adolescent idiopathic scoliosis than did Harrington instrumentation. However, complications were more common in the Cotrel-Dubousset instrumentation group.

Level of Evidence: Therapeutic study, Level III-2 (retrospective cohort study). See Instructions to Authors for a complete description of levels of evidence.

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    Ilkka Helenius, MD, PhD
    Posted on December 30, 2003
    Dr. Helenius and colleague respond
    ORTON, Orthopaedic Hospital, Helsinki, Finland

    We thank Dr Price for his interest in our retrospective comparative study between Harrington and Cotrel-Dubousset instrumentation in adolescent idiopathic scoliosis (JBJS Am 2003;85-A:2303-2309). Due to the historical nature of the study design, the studied groups were somewhat different, as the number of patients with King type I curves was three times (9/78 vs 2/57) more common in Harrington than in Cotrel-Dubousset instrumentation group. It is true that anterior instrumentation (Zielke) alone or along with Cotrel-Dubousset instrumentation was used for thoracolumbar or lumbar curves during the study period (between 1987 and 1990). However, those patients treated with anterior instrumentation were not included in the present study, which may have produced a small selection bias to this study. In the original manuscript we stated: "If patients with King type I curves were excluded from both groups, the number of patients with abnormal lumbar extension (30% vs. 15%) and trunk side bending (56% vs. 36%) was significantly higher in the Harrington rod instrumentation group (p = 0.039 and p = 0.026, respectively) (than in Cotrel-Dubousset instrumentation group). No correlations were observed between the magnitudes of the thoracic or lumbar curves and the spinal mobility measurements."

    The large and significant difference in the radiographic correction does not disappear, if patients with King type I curves are excluded from both groups (Table 1), but instead becomes even more stronger.

    Thus, based on our article and additional data represented here, we do not believe that improvements seen in this study would be due to patient selection or improvements in anteriorsurgery. Instead, we can conclude that Cotrel-Dubousset instrumentation yielded better long-term functional and radiographic outcomes in patients with adolescent idiopathic scoliosis than did Harrington instrumentation, even if patients with lumbar curves were excluded.

    Ilkka Helenius, MD, PhD, Research Fellow
    Mikko Poussa, MD, PhD, Chief Orthopedic Surgeon
    ORTON, Orthopaedic Hospital, Helsinki, Finland

    Table 1. Radiographic correction in coronal plane deformities if patients with King type I curve are excluded.

      Harrington Instrumentation (n=69) Cotrel-Dubousset Instrumentation (n=55) P value
    Thoracic curve      
       Preoperative 54±10° 55±10° N. S.
       Two-year follow-up 39±101° 25±12° <0.0001
       Correction 27±178% 55±15% <0.0001
       Final follow-up 45±12° 33±11° <0.0001
       Final correction 15±26% 40±19% <0.0001
    Lumbar curve      
       Preoperative 35±11° 33±11° N. S.
       Two-year follow-up 26±11° 19±15° 0.0001
       Correction 29±26% 50±39% <0.0001
       Final follow-up 29±13° 23±13° 0.001
       Final correction 15±32% 35±32% 0.0001

    Charles T. Price, M.D.
    Posted on December 15, 2003
    A Comparison of Harrington and Cotrel-Dubousset Instrumentation
    Nemours Children's Clinic, 83 W. Columbia Ave., Orlando, FL 32806.

    To the Editor:

    The article by Helenius, et.al., "Harrington and Cotrel-Dubousset Instrumentation in Adolescent Idiopathic Scoliosis" (JBJS 85A:2303-9) is an excellent attempt to compare an older method to a newer method. Changes in techniques are often made for theoretical reasons without proven benefit. Then it becomes difficult to perform randomized contemporaneous studies of efficacy. The authors have indicated some of the limitations of this historical method of comparison.

    However, it should be noted that there are more than four times the number of lumbar curves (King I) in the Harrington group than in the Cotrel-Dubousset group. Did this represent a change in selection of lumbar curves for anterior instrumentation during the time when Cotrel-Dubousset instrumentation was available? If so, the Harrington group may contain a disproportionate number of lumbar curves that underwent two-stage distraction with posterior instrumentation rather than anterior instrumentation. This small selection bias could affect the comparison due to elimination of patients from the Cotrel-Dubousset group who would no longer be candidates for posterior surgery. Thus the improvements seen in this study may reflect changes in patient selection and improvements in anterior surgery rather than a change in posterior instrumentation.

    Charles T. Price, M. D. Chief of Pediatric Orthopedics Surgeon in Chief Nemours Children's Clinic 83 W. Columbia Ave. Orlando, FL 32806

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