Cotrel Traction, Exercises, Casting in the Treatment of Idiopathic Scoliosis: A Pilot Study and Prospective Randomized Controlled Clinical Trial

A pilot study of ten individuals with adolescent-onset idiopathic scoliosis demonstrated that a week of Cotrel traction and exercises did not improve curve correction obtained by the application of an elongation, derotation, flexion (EDF) cast. There was, however, a significant improvement in lateral bending correction during this period. A prospective, randomized, controlled clinical trial showed that the exercise programme and not the traction was responsible for rendering the spine less rigid.     

Results of Harrington instrumentation in the treatment for severe scoliosis.

Between July 1963 and December 1974, we surgically treated 207 patients who had severe scoliosis (curves greater than 90 degrees), 196 of whom were eligible for inclusion in this study. No patient was treated preoperatively with a cast or traction. Upon statistical analysis, age and preoperative curve magnitude proved to be significant variables relative to the amount of surgical correction obtained and the maintenance of that correction; sex and etiology of the scoliosis were not shown to affect either surgical outcome or maintenance of correction. A comparative analysis showed our results to be as good as those reported by others using various preoperative regimens of casting or traction or both. Therefore, we find that the preoperative application of traction to patients with severe scoliosis yields no better correction than the use of Harrington instrumentation and fusion alone.     

Preoperative skeletal traction in scoliosis.

To determine the role of preoperative traction in the treatment of spinal curves, ten patients with curves averaging 81 degrees by the Cobb measurement were studied. Each patient was treated in traction by means of a halo or skull tongs and femoral pins for two to three weeks prior to the surgical correction of the scoliosis with instrumentation. Weights were added to the traction apparatus, 1.8 kilograms a day, to a maximum of 18.1 kilograms. Pretraction supine roentgenograms were compared with supine roentgenograms made at three-day intervals throughout the traction period. Preoperative traction resulted in an average improvement of the curves of 34 degrees, or 41 per cent of the initial curve. Most of the correction was obtained within the first week of traction. Further correction during surgery with Harrington instrumentation yielded 13.5 degrees on the average (16 per cent) so that combined correction averaged 47 degrees, or 57 per cent.     

Preoperative Cotrel Traction in Idiopathic Scoliosis

Eighty consecutive patients with idiopathic scoliosis were treated preoperatively with Cotrel traction. Distraction X-rays were taken 2 or 3 days after start of traction and 8-10 days later. In 47 patients equal distraction force was applied in both instances. The force, averaging 28 klb, was measured on the head sling. Cotrel traction reduced the spinal curve 37.5 per cent in the first and 38.9 per cent in the second measurement. The difference is not significant. Preoperative Cotrel traction did not improve the surgical curve correction. Postoperative loss of correction and complication rate was insignificantly reduced compared with the results in a previous study. Cotrel traction does, however, give some indication of the surgical correction achievable.     

Preoperative Cotrel Traction in Idiopathic Scoliosis

Eighty consecutive patients with idiopathic scoliosis were treated preoperatively with Cotrel traction. Distraction X-rays were taken 2 or 3 days after start of traction and 8–10 days later. In 47 patients equal distraction force was applied in both instances. The force, averaging 28 klb, was measured on the head sling. Cotrel traction reduced the spinal curve 37.5 per cent in the first and 38.9 per cent in the second measurement. The difference is not significant. Preoperative Cotrel traction did not improve the surgical curve correction. Postoperative loss of correction and complication rate was insignificantly reduced compared with the results in a previous study. Cotrel traction does, however, give some indication of the surgical correction achievable.     

Halo-gravity traction in the treatment of severe spinal deformity: a systematic review and meta-analysis

Purpose

Halo-gravity traction has been reported to successfully assist in managing severe spinal deformity. This is a systematic review of all studies on halo-gravity traction in the treatment of spinal deformity to provide information for clinical practice.

Methods

A comprehensive search was conducted for articles on halo-gravity traction in the treatment of spinal deformity according to the PRISMA guidelines. Appropriate studies would be included and analyzed. Preoperative correction rate of spinal deformity, change of pulmonary function and prevalence of complications were the main measurements.

Results

Sixteen studies, a total of 351 patients, were included in this review. Generally, the initial Cobb angle was 101.1° in the coronal plane and 80.5° in the sagittal plane, and it was corrected to 49.4° and 56.0° after final spinal fusion. The preoperative correction due to traction alone was 24.1 and 19.3%, respectively. With traction, the flexibility improved 6.1% but postoperatively the patients did not have better correction. Less aggressive procedures and improved pulmonary function were observed in patients with traction. The prevalence of traction-related complications was 22% and three cases of neurologic complication related to traction were noted. The prevalence of total complications related to surgery was 32% and that of neurologic complications was 1%.

Conclusion

Partial correction could be achieved preoperatively with halo-gravity traction, and it may help decrease aggressive procedures, improve preoperative pulmonary function, and reduce neurologic complications. However, traction could not increase preoperative flexibility or final correction. Traction-related complications, although usually not severe, were not rare.

     

Combined staged anterior and posterior correction and fusion of the spine in scoliosis following poliomyelitis.

The problems with severe forms of scoliosis following poliomyelitis include the associated muscle imbalance, soft tissue contractures and pelvic obliquity. Such deformities militate against optimal correction and maintenance of that correction and their treatment is often marred by pseudarthroses. Seventeen patients with an average curve of 93 degrees have been treated and followed for up to 38 months. Preliminary traction was used in 8 patients, then a staged anterior and posterior correction and fusion was done, using Dwyer's instrumentation of the major curve in all and a Harrington rod to supplement the posterior fusion in eleven patients. With this technique the major curve was corrected by 80 per cent with an average 2 per cent loss over 18 months. No pseudarthroses were seen when the Harrington rod was used. Great care must be taken if halo-pelvic traction is to be used for patients with pelvic obliquity, for preliminary correction halo-femoral traction will often be adequate. In the more severe forms of paralytic scoliosis a combined staged anterior and posterior correction and fusion should be considered if the aim is maximal correction of the scoliosis and avoidance of pseudarthroses.     

Effectiveness of spinal release and halo-femoral traction in the management of severe spinal deformity

The purpose of this retrospective review was to assess the effectiveness of spinal release and halo-femoral traction in the management of severe spinal deformity. Twenty-four patients had halo-femoral traction and a spinal release. Analysis focused on pre-traction curve, preoperative curve in bending or hyperextension films, final traction curve, traction weight as a percent of body weight, and complications associated with traction. The average pre-traction curve was 95 degrees and the average pre-traction curve in bending was 73 degrees; the final traction average curve was 44 degrees. The difference between the magnitude of curve correction in bending and traction films was statistically significant. Traction weight was increased to an average of 54% of body weight. The only complication was a bilateral lower extremity sensory deficit that resolved after traction weight reduction. The average final correction was 71%. Spinal release and halo-femoral traction offer a safe approach to the correction of severe spinal deformities before fusion.     

Swan-neck deformity secondary to osteomyelitis of the posterior elements of the cervical spine. Case report.

A case of osteomyelitis is described, involving the posterior elements of the cervical vertebrae in a 7-year-old girl and resulting in swan-neck deformity. Treatment was initiated with antibiotics, and the patient was placed in halo traction. Eventually posterior cervical fusion was performed, which provided excellent stability and correction of the deformity.     

Epiphyseal traction to correct acquired growth deformities. An animal and clinical investigation

In a canine model with a transepiphyseal distal femoral fracture, varus deformity was corrected and the arrested limb was lengthened using transphyseal traction (turnbuckle). Correction was possible without removing the transphyseal bone bridge operatively. Subsequent growth was not adversely affected in most animals. Based on this study, two patients with significant growth deformities secondary to an enchondroma were treated by epiphyseal traction. Although correction was achieved initially, both lost the length previously gained because of premature removal of the external fixator and/or subsequent early growth plate closure.     

Preoperative traction in patients with hip fractures.

A series of 80 patients with cervical, trochanteric or subtrochanteric hip fractures were randomized to either treatment without traction, skin traction, or skeletal traction during the 1883 h between admission and operation. The institution of skin or skeletal traction was not particularly painful for the patient, but we found no indication that either was of discernible benefit. The number of analgesic medications needed was no higher in patients without traction. We conclude that traction should not be administered routinely to patients awaiting operation for hip fracture.     

牵引结合后路手术治疗重度脊柱侧凸的疗效分析

[目的]探讨Halo-股骨髁上牵引结合后路矫形对柔韧性30%～40%的重度脊柱侧凸患者的疗效.[方法]对2000年1月～2006年6月治疗的41例柔韧性30%～40%重度脊柱侧凸患者,按照是否行牵引治疗分为两组.牵引组A组 22例,主侧凸平均Cobb' s角91.2°;对照组B组 19例,主侧凸平均Cobb' s角87.5°.[结果]两组无严重神经系统并发症.A组平均牵引18 d(14～22 d)后主侧凸平均矫正46%,14例肺功能减退患者均改善.两组均行一期后路松解三维矫形术,术后C7～S1偏移值、顶椎偏移矫正A组优于B组.A组主侧凸平均矫正55.2°,B组45.7°,A组优于B组 (P<0.05). A组平均随访40个月, B组平均随访42个月,末次随访两组平均冠状面矫正丢失分别为3°、2.4°,矢状面无丢失,两组均获骨性融合.[结论]对于柔韧性30%～40%的重度脊柱侧凸,术前Halo-股骨髁上牵引可改善肺功能,结合牵引下后路松解矫形术可以获得更好的畸形矫正和躯干平衡,减少术中术后并发症. )后主侧凸平均矫正46%,14例肺功能减退患者均改善.两组均行一期后路松解三维矫形术,术后C_7～S_1偏移值、顶椎偏 矫正A组优于B组.A组主侧凸平均矫正55.2°,B组45.7°,A组优于B组 (P<0.05). A组平均随访40个月, B组平均随访42个月,末次随访两组平均冠状面矫正丢失分别为3°、2.4°,矢状面无丢失,两组均获骨性融合.[结论]对于柔韧性30%～40%的重度脊柱侧凸,术前Halo-股骨髁上牵引可改善肺功能,结合牵引下后路松解矫形术可以获得更好的畸形矫正和躯干平衡,减少术中术后并发症. )后主侧凸平均矫正46%,14例肺功能减退患者均改善.两组均行一期后路松解三     

术前大质量Halo-股骨髁上牵引在治疗僵硬型特发性脊柱侧凸中的应用

目的 探讨术前快速大质量Halo-股骨髁上牵引在治疗僵硬型特发性脊柱侧凸中的应用价值.方法 对2003年7月至2006年5月行术前快速大质量Halo-股骨髁上牵引治疗且临床资料完整的16例僵硬型特发性脊柱侧凸患者进行回顾性分析.其中男性4例,女性12例;年龄12～20岁,平均16岁,术前冠状面Cobb角平均111°,胸椎后凸(T_(5～12))平均64°.术前行Halo-双侧股骨髁上牵引,最大质量(可达体质量的1/2)牵引2～3周后,行后路矫形内固定融合术.对术前Bending像、牵引后和术后侧凸纠正率进行比较.结果 随访12～60个月(平均36个月).最大牵引质量平均19 kg,为体质量的35%～56%.1例患者在牵引12 d后出现右侧臂丛神经麻痹,减轻牵引质量后逐渐恢复.矫形术后无瘫痪、死亡等并发症,无呼吸衰竭的发生.术前平卧位Bending像X线片的侧凸纠正率平均18.7%,Halo-股骨髁上牵引后侧凸纠正率平均达31.9%.与Bending像相比,牵引后侧凸纠正率提高了13.2%,差异具有统计学意义(P<0.05).后路矫形术后侧凸矫正率平均为48.6%,胸椎后凸矫正率平均为51.9%.末次随访时冠状面矫正丢失率平均为2.0%,矢状面矫正丢失率平均为5.8%.结论 术前短时间大质量Halo-股骨髁上牵引结合后路广泛松解可改善僵硬型特发性脊柱侧凸畸形矫形率,但应注意与牵引相关的并发症.     

Pelvic obliquity. Its causes and its treatment

Pelvic obliquity can be caused by leg length inequality, contractures about the hips, as part of a structural scoliosis, or as a combination of two or more of these causes. Careful physical and radiologic evaluations are necessary to establish the correct diagnosis. Treatment is then directed toward the specific cause, ie, leg length balancing, release of hip contractures, or scoliosis correction. Structural scolioses with pelvic obliquity may be either congenital or paralytic. If a traction roentgenogram reveals the curve to be flexible enough that the pelvis can be fully leveled, then a posterior fusion only is necessary. If the pelvis will not level with traction, then anterior convex wedge excisions (discectomies for the paralytic, hemivertebra excision for the congenital) are necessary for achieving adequate correction. Posterior instrumentation and fusion must follow the anterior procedure. Various forms of internal correction and fixation devices are now available, and there is no single best procedure. Anterior internal fixation devices are being used less and less, while posterior segmental fixation with Luque rods are wires is being used more and more.     

Irradiation induced kyphosis.

Eighty-one patients with Wilms tumor treated by irradiation and chemotherapy were studied. Despite the fact that multiple portals for irradiation were used, each crossing the midline, the amount of irradiation delivered to different parts of the vertebral body varied and it was this variation in delivered dose which produced axial skeletal deformities in 70% of the patients. Of the 57 patients with these deformities 32 had scoliosis, 22 kyphoscoliosis and 3 patients pure kyphosis; 12 patients had a kyphotic deformity of over 25 degrees, 7 patients requiring surgical correction. A high incidence of pseudarthrosis following posterior fusion has led to the preference of a 2-stage procedure, anterior interbody fusion followed by a posterior fusion with Harrington rods after 2 weeks of correction in halo femoral traction.     

Early ambulation following spinal fusion and Harrington instrumentation in idiopathic scoliosis.

Eighty-six patients with idiopathic scoliosis managed by Harrington instrumentation and spinal arthrodesis were ambulated 10 days following surgery. Preoperative reduction of the curves was obtained by Cotrel traction and modified Cotrel localizer cast. Patients were kept immobilized in plaster cast for 7 months following operation. No significant loss of correction was found in these patients ambulated early as compared to a previous group kept recumbent for 3 to 6 months and reported by the authors (DBL). The only exception to this was a patient with double structural curve patterns. A successful surgical program for most cases of idiopathic scoliosis included: (1) Preoperative reduction and balancing of curves by non-skeletal traction and/or correction body cast; (2) Meticulous spinal arthrodesis and employment of Harrington distraction internal fixation; (3) Autogenous iliac bone graft; (4) Ambulation at two weeks following surgery in a well fitting body cast and removal of this cast after 7 months. Deep infection rate was 1 per cent without the use of routine prophylatic antibiotics. One neurological complication resulted from the use of a single distraction rod bridging two curves where the rod was not prebent to allow for kyphosis. There were no pseudarthroses. The average follow-up was 28 months with a range of 18-39 months.     

The use of traction methods to correct severe cervical deformity in rheumatoid arthritis patients: a report of five cases

STUDY DESIGN: A case series is presented. OBJECTIVES: To describe the methods of correction used in this study for flexible severe cervical deformity, and to report the results in patients with rheumatoid arthritis. SUMMARY OF BACKGROUND DATA: Long-standing rheumatoid arthritis can lead to severe cervical deformity, causing significant functional deficits and poor cosmesis. Information on the use of traction combined with surgical stabilization to achieve correction of flexible deformity in rheumatoid patients is sparse in the English literature. METHODS: A review of five cases, including pertinent history, physical examination, radiographic evaluation, traction techniques, surgical stabilization, and outcomes, was conducted. RESULTS: Excellent correction of deformity and radiographic union were achieved in all the patients. One patient had minimal loss of correction after surgery and thereafter remained stable. Pin tract infections were the only significant complication. CONCLUSIONS: Severe cervical flexible deformity in rheumatoid patients can cause significant disability and can be treated successfully with a combination of traction techniques and surgical stabilization.     

拉长式弹性牵引矫治烧伤后爪形手畸形

目的 探讨修复烧伤后爪形手畸形的新途径.方法 2006年5月至2010年7月,对12例瘢痕切除松解植皮或皮瓣移植术后畸形矫正不满意的烧伤爪形手,应用个性化手功能支具结合橡皮筋、指端克氏针(或粘胶带)对手指进行拉长式弹性牵引.结果 术后随访0.5～2年,弹性牵引对烧伤爪形手中存在的掌指关节过伸畸形、近侧指间关节屈曲畸形、虎口挛缩均有效果,可将屈曲短缩的手指拉长,也有利于掌弓复位.少部分(8/28)拉长复位的近侧指间关节屈曲畸形复发或关节不稳,需关节融合.结论 拉长式弹性牵引是矫治烧伤后爪形手畸形的有效方法,损伤小,效果较稳定.     

拉长式弹性牵引矫治烧伤后爪形手畸形

目的 探讨修复烧伤后爪形手畸形的新途径.方法 2006年5月至2010年7月,对12例瘢痕切除松解植皮或皮瓣移植术后畸形矫正不满意的烧伤爪形手,应用个性化手功能支具结合橡皮筋、指端克氏针(或粘胶带)对手指进行拉长式弹性牵引.结果 术后随访0.5～2年,弹性牵引对烧伤爪形手中存在的掌指关节过伸畸形、近侧指间关节屈曲畸形、虎口挛缩均有效果,可将屈曲短缩的手指拉长,也有利于掌弓复位.少部分(8/28)拉长复位的近侧指间关节屈曲畸形复发或关节不稳,需关节融合.结论 拉长式弹性牵引是矫治烧伤后爪形手畸形的有效方法,损伤小,效果较稳定.     

拉长式弹性牵引矫治烧伤后爪形手畸形

目的 探讨修复烧伤后爪形手畸形的新途径.方法 2006年5月至2010年7月,对12例瘢痕切除松解植皮或皮瓣移植术后畸形矫正不满意的烧伤爪形手,应用个性化手功能支具结合橡皮筋、指端克氏针(或粘胶带)对手指进行拉长式弹性牵引.结果 术后随访0.5～2年,弹性牵引对烧伤爪形手中存在的掌指关节过伸畸形、近侧指间关节屈曲畸形、虎口挛缩均有效果,可将屈曲短缩的手指拉长,也有利于掌弓复位.少部分(8/28)拉长复位的近侧指间关节屈曲畸形复发或关节不稳,需关节融合.结论 拉长式弹性牵引是矫治烧伤后爪形手畸形的有效方法,损伤小,效果较稳定.

Abstract：

Objective To investigate a new method for correction of claw hand deformity after burns. Methods From May 2006 to Jul. 2010, 12 patients with claw hands deformities after burns were treated with skin grafts (11 hands) and skin flap(1 hand) with unsatisfactory results. Then elastic traction (skin traction or skeletal traction) were performed with individual functional brace. Results All patients were followed up for 0. 5 to 2 years. Elastic traction was effective in the correction of metacarpophalangeal joint deformity, buttonhole deformity, thumb-in-palm deformity, scar contracture, and palmar arch deformity. Conclusions Elastic traction is a simple and effective way for the correction of claw hand deformity after burns with less morbidity and stable results.