Abstract
Purpose
The routine use of Ponte osteotomies in adolescent idiopathic scoliosis (AIS) surgery is controversial with conflicting data for coronal plane correction and little analysis in the sagittal plane. The objective of this study was to analyze the efficacy of Ponte osteotomies in large curve AIS.
Methods
A single institution, prospectively-collected series of consecutive AIS patients who had Ponte osteotomies (P cohort) was directly matched to patients with no Pontes (NP cohort) by age, gender, Lenke classification, surgeon, coronal, and sagittal Cobb angles. The radiographic review included adjusted values using a 3D-derived published formula for preoperative T5-T12 kyphosis. Patient-reported outcomes (PROs) were assessed with the SRS-30 and Spinal Appearance Questionnaire (SAQ).
Results
There were 68 patients (34/cohort) with minimum 2-year follow-up with no differences between P and NP cohorts in age, preoperative coronal Cobb (74.5° vs 70.8°), flexibility index, measured or 3D-adjusted T5-T12 kyphosis. Rod material/diameter, fusion levels, blood loss, and operative time did not differ, but implant density was higher in the P group (1.53 vs 1.31, p < 0.001). The P group had 7.9% greater coronal Cobb correction (66.6% vs 58.7%, p < 0.003) without difference in final Cobb angles (24.7° vs. 29.1°, p = 0.052). There were no differences in measured or adjusted T5-T12 kyphosis in the sagittal plane. The P group had a 15% rate of critical intraoperative neuromonitoring changes versus 0% in the NP group (p = 0.053). At follow-up, there were no differences in scoliometer measurements or any domain of SRS-30 or SAQ scores.
Conclusion
In this first reported matched series of AIS patients, Ponte osteotomies provide small radiographic gains in the coronal plane with no improvement in the sagittal plane and no change in truncal rotation. There was a higher risk of critical intraoperative neuromonitoring changes, and no benefits in patient-reported outcomes. This calls into question the routine use of Ponte osteotomies in AIS, even for curves averaging 70 degrees.
Level of evidence
II.
Similar content being viewed by others
References
Smith-Petersen MN, Larson CB, Aufranc OE (1969) Osteotomy of the spine for correction of flexion deformity in rheumatoid arthritis. Clin Orthop Relat Res 66:6–9
Ponte A (1985) Surgical treatment of Scheuermann’s hyperkyphosis. Orthop Trans 9:127
Ponte A (2003) Posterior column shortening for Scheuermann’s kyphosis. An innovative one-stage technique. J Spinal Disord Tech. 20:586–593
Ponte A, Orlando G, Siccardi GL (2018) The true ponte osteotomy: by the one who developed it. Spine Deformity 6(1):2–11. https://doi.org/10.1016/j.jspd.2017.06.006
Geck MJ, Macagno A, Ponte A, Shufflebarger HL (2007) The Ponte procedure: posterior only treatment of Scheuermann’s kyphosis using segmental posterior shortening and pedicle screw instrumentation. J Spinal Disord Tech 20(8):586–593. https://doi.org/10.1097/BSD.0b013e31803d3b16
McClendon J Jr, O’Shaughnessy BA, Sugrue PA, Neal CJ, Acosta FL Jr, Koski TR, Ondra SL (2012) Techniques for operative correction of proximal junctional kyphosis of the upper thoracic spine. Spine 37(4):292–303. https://doi.org/10.1097/BRS.0b013e318222dc8a
Grevitt M, Kamath V, Avadhani A, Rajasekaran S (2010) Correction of thoracic kyphosis with Ponte osteotomy. Eur Spine J 19(2):351–352. https://doi.org/10.1007/s00586-010-1311-3
La Maida GA, Misaggi B (2012) Posterior only treatment of adult thoracic kyphosis with multiple Ponte osteotomies and pedicle screw instrumentation. Eur Spine J 21(9):1891–1895. https://doi.org/10.1007/s00586-012-2472-z
Cho KJ, Bridwell KH, Lenke LG, Berra A, Baldus C (2005) Comparison of Smith-Petersen versus pedicle subtraction osteotomy for the correction of fixed sagittal imbalance. Spine 30(18):2030–2037. https://doi.org/10.1097/01.brs.0000179085.92998.ee (Discussion 2038)
Gill JB, Levin A, Burd T, Longley M (2008) Corrective osteotomies in spine surgery. J Bone Joint Surg Am 90(11):2509–2520. https://doi.org/10.2106/JBJS.H.00081
Shufflebarger HL, Clark CE (1998) Effect of wide posterior release on correction in adolescent idiopathic scoliosis. J Pediatr Orthop B 7(2):117–123. https://doi.org/10.1097/01202412-199804000-00005
Shufflebarger HL, Geck MJ, Clark CE (2004) The posterior approach for lumbar and thoracolumbar adolescent idiopathic scoliosis: posterior shortening and pedicle screws. Spine 29(3):269–276. https://doi.org/10.1097/01.brs.0000109881.63411.48 (Discussion 276)
Pizones J, Izquierdo E, Sanchez-Mariscal F, Alvarez P, Zuniga L, Gomez A (2010) Does wide posterior multiple level release improve the correction of adolescent idiopathic scoliosis curves? J Spinal Disord Tech 23(7):e24-30. https://doi.org/10.1097/BSD.0b013e3181c29d16
Shah SA, Dhawale AA, Oda JE, Yorgova P, Neiss GI, Holmes L Jr, Gabos PG (2013) Ponte osteotomies with pedicle screw instrumentation in the treatment of adolescent idiopathic scoliosis. Spine deformity 1(3):196–204. https://doi.org/10.1016/j.jspd.2013.03.002
Samdani AF, Bennett JT, Singla AR, Marks MC, Pahys JM, Lonner BS, Miyanji F, Shah SA, Shufflebarger HL, Newton PO, Asghar J, Betz RR, Cahill PJ (2015) Do Ponte osteotomies enhance correction in adolescent idiopathic scoliosis? An analysis of 191 Lenke 1A and 1B Curves. Spine Deform 3(5):483–488. https://doi.org/10.1016/j.jspd.2015.03.002
Halanski MA, Cassidy JA (2013) Do multilevel Ponte osteotomies in thoracic idiopathic scoliosis surgery improve curve correction and restore thoracic kyphosis? J Spinal Disord Tech 26(5):252–255. https://doi.org/10.1097/BSD.0b013e318241e3cf
Holewijn RM, Schlosser TP, Bisschop A, van der Veen AJ, Stadhouder A, van Royen BJ, Castelein RM, de Kleuver M (2015) How does spinal release and Ponte osteotomy improve spinal flexibility? The law of diminishing returns. Spine Deform 3(5):489–495. https://doi.org/10.1016/j.jspd.2015.03.006
Parvaresh KC, Osborn EJ, Reighard FG, Doan J, Bastrom TP, Newton PO (2017) Predicting 3D thoracic kyphosis using traditional 2D radiographic measurements in adolescent idiopathic scoliosis. Spine Deform 5(3):159–165. https://doi.org/10.1016/j.jspd.2016.12.002
Wiemann J, Durrani S, Bosch P (2011) The effect of posterior spinal releases on axial correction torque: a cadaver study. J Child Orthop 5(2):109–113. https://doi.org/10.1007/s11832-011-0327-5
Sangiorgio SN, Borkowski SL, Bowen RE, Scaduto AA, Frost NL, Ebramzadeh E (2013) Quantification of increase in three-dimensional spine flexibility following sequential ponte osteotomies in a cadaveric model. Spine Deform 1(3):171–178. https://doi.org/10.1016/j.jspd.2013.01.006
Wang C, Bell K, McClincy M, Jacobs L, Dede O, Roach J, Bosch P (2015) Biomechanical comparison of Ponte osteotomy and discectomy. Spine 40(3):E141-145. https://doi.org/10.1097/BRS.0000000000000697
Reames DL, Smith JS, Fu KM, Polly DW Jr, Ames CP, Berven SH, Perra JH, Glassman SD, McCarthy RE, Knapp RD Jr, Heary R, Shaffrey CI, Scoliosis Research Society M, Mortality C (2011) Complications in the surgical treatment of 19,360 cases of pediatric scoliosis: a review of the Scoliosis Research Society Morbidity and Mortality database. Spine 36(18):1484–1491. https://doi.org/10.1097/BRS.0b013e3181f3a326
Jankowski PP, Yaszay B, Cidambi KR, Bartley CE, Bastrom TP, Newton PO (2018) The relationship between apical vertebral rotation and truncal rotation in adolescent idiopathic scoliosis using 3D reconstructions. Spine Deform 6(3):213–219. https://doi.org/10.1016/j.jspd.2017.10.003
Funding
This was an IRB-approved study. Funded by Texas Scottish Rite Hospital for Children Research Department.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
LF (none), KP (none), DG (none), DS (Globus, Royalties, outside of submitted work).
Rights and permissions
About this article
Cite this article
Floccari, L.V., Poppino, K., Greenhill, D.A. et al. Ponte osteotomies in a matched series of large AIS curves increase surgical risk without improving outcomes. Spine Deform 9, 1411–1418 (2021). https://doi.org/10.1007/s43390-021-00339-x
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s43390-021-00339-x