ORIGINAL ARTICLE
Lengthening Less Than 7 Months Leads to Greater Spinal
Height Gain With Rib-based Distraction
Catherine Qiu, MS, Carina Lott, MS, Perez Agaba, MD, Patrick J. Cahill, MD,
and Jason B. Anari, MD
Background: Severe early-onset scoliosis (EOS) has been asso-
ciated with a multitude of comorbidities, chief among them being
deficient thoracic spine growth and pulmonary complications.
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EOS management with rib-based instrumentation involves re-
peated lengthening. Despite expansion practice patterns, there is
limited literature and no evidence-based guidelines for optimal
expansion intervals. Our study evaluates clinical outcomes in
relation to lengthening intervals with the aim of optimizing the
timing of surgical expansion in EOS patients.
Methods: A single-institution retrospective review of 60 EOS patients
treated with rib-based growth instrumentation with a minimum of
3-year follow-up and 3 expansion/revision surgeries. Patients were
separated into 2 expansion cohorts: (1) more frequent lengthening
[MFL group ( ≤ 7 mo)] and (2) less frequent lengthening [LFL group
( > 7 mo)]. Demographic information and clinical factors were re-
corded. Univariate and bivariate analyses were performed.
Results: Both the MFL group (35 patients) and LFL group
(25 patients) were similar in sex distribution, diagnosis, preoperative
parameters of interest, and treatment duration. The mean follow-up
was 6.0 years. There was an increase in postoperative T1-S1 spine
height gained in the MFL group (P = 0.006) as well as a higher
percent expected spine growth based on normative values (P = 0.03)
when compared with the LFL group. The MFL group had more
expansion/revision surgeries (P = 0.003) but no increase in the number
of complications (P = 0.86).
Conclusions: More frequent lengthenings were associated with sta-
tistically significant overall spinal height gain and percent expected
growth without a significant increase in complication rates. It was
shown that change in major curve and space available for the lungs
was not associated with the lengthening intervals.
Level of Evidence: Level III—a comparative retrospective study.
Key Words: early-onset scoliosis, EOS, scoliosis, spine, neuro-
muscular, congenital, thoracic insufficiency syndrome, rib-based
growing instrumentation, distraction frequency
(J Pediatr Orthop 2020;40:e747–e752)
From the Division of Orthopaedic Surgery, The Children’s Hospital of
Philadelphia, Philadelphia, PA.
The authors did not receive funding for this work.
The authors declare no conflicts of interest.
Reprints: Jason B. Anari, MD, Division of Orthopaedic Surgery, The Child-
ren’s Hospital of Philadelphia, 3401 Civic Center Boulevard, 2nd Floor
Wood Building, Philadelphia, PA 19104. E-mail: anarij@email.chop.edu.
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/BPO.0000000000001625
J Pediatr Orthop  Volume 40, Number 8, September 2020
Copyright r 2020 Wolters Kluwer Health, Inc. All rights reserved.
E arly-onset scoliosis (EOS) has been associated with
various comorbidities among which are overall growth
restriction and suboptimal pulmonary function due to thora-
cic insufficiency syndrome, a complex condition that results
from restricted thoracic growth and lung expansion. As a
result, patients with progressive EOS have high morbidity and
a decreased quality of life.
The goal of treatment in the EOS patient cohort is to
optimize pulmonary function as well as the overall quality
of life by providing adequate control of the spine de-
formity and allowing for guided and less restricted spine
and thoracic growth.1 Among the most common surgical
procedures for the treatment of EOS deformity are growth-
sparing instrumentation.2,3 Periodic lengthening of the in-
strumentation is essential in keeping up with the growth of
the spine. Aside from slight variations, the current standard
practice for the rib-based growth instrumentation is to
lengthen every 6 months until a patient reaches an acceptable
maturity to undergo final fusion or to stop lengthening.3–5
Strikingly, Yang et al6 showed in their survey of 17 spine
surgeons that in actual practice, only 24% of lengthenings
occurred at a frequency of 6 months or less while the average
lengthening interval was reported to be 8.6 ± 5.1 months.
Currently, there are no evidence-based guidelines for
optimal intervals for rib-based growth instrumentation
lengthening. There have been limited studies that have
examined the impact of lengthening intervals on clinical
outcomes and complications.5,6 The purpose of our study
is to evaluate the clinical outcomes and complications in
relation to the lengthening intervals as we work towards
the development of empirical data for optimal timing of
surgical expansion in the treatment of EOS with rib-based
growth instrumentation.
METHODS
After obtaining Institutional Review Board approval, we
retrospectively reviewed EOS patients that were seen by the
Orthopaedic Surgery Department between 2007 and 2019 and
surgically treated at our institution with rib-based devices. Pa-
tients treated with other types of growing instrumentation such
as traditional growing rods, magnetic controlled growing rods
(MCGRs), or growth guidance systems and patients diagnosed
with skeletal dysplasia in which skeletal growth was abnormal
were excluded. Patients with inconsistent or short follow-up,
such as <3 lengthening surgeries or <3-year follow-up were also
excluded (Fig. 1). Patients were grouped by the average interval
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Qiu et al
FIGURE 1. Flow diagram of the patient population.
between expansion surgeries, which were defined as every
7 months or sooner (more frequent lengthening, MFL) or
greater than every 7 months (less frequent lengthening, LFL).
This average interval cutoff was chosen by looking at the mean/
median average interval between expansion surgeries for our
cohort as well as taking into account other studies that have
examined the timing of lengthenings. Any surgery where
distraction was applied, including exchanges and new implants,
were included as an expansion procedure.
Radiographic Measurements and Data
Collection
Sixty sets of coronal (anteroposterior/posteroanterior)
radiographs of EOS patients taken (1) within a month before
the initial device implantation surgery and (2) at the patient’s
most recent visit (before posterior spinal fusion, if performed)
were used to measure coronal T1-S1 spinal height, T1-T12
spinal height, major curve, and space available for lung (SAL)
using IntelliSpace PACS Enterprise software (Best, The Neth-
erlands). Clinical data recorded included sex, race/ethnicity,
age, C-EOS (Classification of Early-Onset Scoliosis) diagnosis,7
number of surgeries, and complications defined by Smith
Classifications scheme.8 Complications were classified as either
device-related or disease-related. Device-related complications
were directly related to the device itself or the surgical incisions
related to the procedure, such as migration, hardware failure,
or wound infection requiring irrigation and debridement. Dis-
ease-related complications were associated with the surgical
procedure but not specifically related to the device itself, such as
pneumonia, respiratory distress, or minor wound infection
treated with antibiotics. The complications got further divided
into the following grades based on the level of severity. For a
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J Pediatr Orthop  Volume 40, Number 8, September 2020
device-related complication, grade I was defined as a compli-
cation that did not require unplanned surgery and could be
managed at the next scheduled surgery. Grade II device-related
complications were divided into 2 groups. Grade IIA was a
complication that required 1 unplanned surgery and grade IIB
was a complication that required multiple unplanned surgeries.
Grade III was defined as a complication that ultimately re-
quired the abandonment of growth-friendly strategy and grade
IV was defined as death during treatment. For disease-related
complications, grade I was a complication that could be
managed without hospitalization, such as a minor wound in-
fection treated with antibiotics. Grade II was a complication
that required hospitalization such as pneumonia, grade III was
a complication that required the abandonment of growth-
friendly treatment, and grade IV was defined as death during
treatment.
Statistical Analysis
The percent expected growth was calculated based
on Dimeglio reference values1 to determine the expected
amount of height gained each year by age and how well
quantitatively each patient is meeting his/her goal. Descriptive
statistics were used to report on pooled patient data.
The 2 groups, defined by the frequency of expansion
surgeries, were univariately analyzed on clinical and radio-
graphic variables. The Kolmogorov-Smirnov test of normality
was used to determine whether data was normally distributed.
Comparisons were performed on continuous variables using
the independent t test following the Levene test for equality of
variances for normal distributions. Mann-Whitney U test was
used to analyze nonparametric data. Categorical variables were
compared using the Fisher exact test. The Pearson correlation
coefficient with a 2-tailed test for significance was calculated to
determine whether there was an association with growth and
other variables. The Spearman rank-order correlation was used
for nonlinear data. Subgroup analysis was also performed on
patients classified as congenital or neuromuscular scoliosis.
Statistically significant value was determined as
P-value <0.05. All statistical work was performed using
Stata, version 15.1 (College Station, TX), and Excel Data
Analysis Toolkit (Excel 2016, Microsoft).
RESULTS
A total of 60 patients (35 male and 25 female individuals)
underwent a rib-based device implantation surgery and were
regularly followed at the same institution for subsequent ex-
pansion surgeries. The average age at device implantation was
4.6 years (range: 0.5 to 12.9 y) with an average follow-up of
6.0 years (range: 3.0 to 12.3 y) and 10 total expansion surgeries
(range: 3 to 21 expansion surgeries). Patients were divided into
2 cohorts based on the frequency of device lengthenings: those
distracted on average every 7 months or less, or MFL (n = 35)
and those distracted greater than every 7 months, or LFL
(n = 25). Subjects in the MFL group on average were length-
ened every 174.3 days or ∼5.7 months. The LFL group had a
lengthening interval of 270 days or about 8.8 months. The
average age at device implantation was 4 years (range: 0.5 to
12.8 y) in the MFL group and was 5.6 years (range: 0.9 to
12.9 y) in the LFL group (P = 0.103). Demographics between
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J Pediatr Orthop  Volume 40, Number 8, September 2020 Timing of Rib-based Distraction Lengthening

TABLE 1. Demographics and Clinical Factors TABLE 3. Smith-classified Complications

MFL Group, LFL Group, MFL Group, LFL Group,
≤ 7 mo (N = 35) > 7 mo (N = 25) ≤ 7 mo (N = 35) > 7 mo (N = 25)
Variables [n (%)] [n (%)] P Device- Disease- Device- Disease-
Sex 0.965 related related related related P
Male 21 (60) 14 (56)
No. complications 59 25 28 12 0.855
Female 14 (40) 11 (44)
Migration 15 0 9 0 1
Race 0.021
Infection 38 14 15 2 0.322
White 26 (74) 10 (40)
Hardware failure 6 0 4 0 1
African American 4 (11) 5 (20)
Pneumonia 0 8 0 8 1
Asian 2 (6) 1 (4)
Sepsis 0 1 0 0 1
Multiracial 1 (3) 1 (4)
Pulmonary/ 0 2 0 2 1
Other 2 (6) 8 (32)
respiratory
Ethnicity 0.208
distress
Hispanic or Latino 5 (14) 9 (36)
Not Hispanic or 30 (86) 16 (64) LFL indicates less frequent lengthening; MFL, more frequent lengthening.
Latino
Age at surgery 4.0 ± 4.0 5.6 ± 3.6 0.103
(mean ± SD) (y)
Etiology 0.317 The major curve angle measured on preoperative and
Congenital 20 (57) 11 (44) postoperative films showed that both groups presented with
Neuromuscular 11 (31) 10 (40) similar severe curve deformities (P = 0.98) and comparably
Syndromic 2 (6) 4 (16)
Idiopathic 2 (6) 0 (0)
corrected at last follow-up (P = 0.98). SAL improved on
average for the patients but largely remained the same in both
Bold value indicate statistically significant. groups at baseline and last follow-up (P = 0.23). Measures of
LFL indicates less frequent lengthening; MFL, more frequent lengthening.
T1-T12 spinal height were similar at preoperative assessment
(P = 0.24) and over the course of the treatment in both cohorts
the groups were similar, in regards to sex (P = 0.965) and eth- (P = 0.23). However, measures of T1-S1 spine growth revealed
nicity (P = 0.208). There was a slight difference, however, in the differences. At the preoperative assessment, coronal T1-S1
distribution of patient races between the 2 groups (P = 0.021). spine height were similar (P = 0.20). Yet, over the course of
Both groups presented with similar C-EOS etiology distribution treatment, the MFL group saw greater total gains in height
(P = 0.317). There was no statistically significant difference in (P = 0.006). For growth gained per year, patients’ total height
the length of follow-up (P = 0.099). At the latest follow-up, was divided by their number of years of follow-up; again, there
those distracted more often underwent more expansion sur- was a significant difference in groups (P = 0.006). To control
geries (P = 0.003). Results are included in Tables 1 and 2. for differences in growth because of age, we calculated percent
expected growth using age-matched normative spine growth
values.1 This, too, maintained that shorter distraction interval
was associated with more closely reaching normative growth
TABLE 2. Radiographic and Surgical Outcomes (P = 0.031).
MFL Group, LFL Group, There were 124 total Smith-classified complications in 50
Variables ≤ 7 mo (N = 35) > 7 mo (N = 25) P patients, for an average of 2.5 complications per patient. Eight
Total expansion 11.5 ± 3.9 8.4 ± 3.7 0.003 patients in the LFL group and 2 patients in the MFL group
surgeries (n) had no complications. Types of complications are summarized
Follow-up (y) 5.6 ± 1.5 6.6 ± 2.7 0.099 in Table 3 and grades of severity are summarized in Table 4.
Major curve angle (deg.)
Preoperative 69.2 ± 28.5 69.0 ± 27.2 0.983 Importantly, it did not seem that more frequent operations
Correction 9.7 ± 23.7 9.56 ± 22.9 0.987 significantly increased risk for Smith-classified complications.
SAL (%)
Preoperative 79 ± 14 79 ± 20 0.976
Change 10 ± 13 5 ± 20 0.228 TABLE 4. Smith-classified Severity Grades
T1-T12 (mm) MFL Group, LFL Group,
Preoperative 123.5 ± 35.1 134.4 ± 35.4 0.243
≤ 7 mo (N = 35) > 7 mo (N = 25)
Growth 37.4 ± 22.4 35.4 ± 19.3 0.391
Growth per year 7.4 ± 6.1 5.8 ± 3.9 0.231 Severity Device- Disease- Device- Disease-
Spinal height (mm) Grade (SV) related related related related P
Preoperative 209.4 ± 51.4 226.4 ± 49.3 0.203
Growth 63.6 ± 29.7 43.7 ± 24.6 0.006 Grade I 18 13 10 2 0.163
Growth per year 12.6 ± 8.5 7.4 ± 5.4 0.006 Grade II 0 12 0 10 1
Percent of expected 78 ± 56 51 ± 39 0.031 Grade IIA 17 0 10 0 1
growth Grade IIB 22 0 8 0 1
Grade III 0 0 0 0 1
Bold values indicate statistically significant. Grade IV 0 0 0 0 1
Data are represented as mean ± SD.
LFL indicates less frequent lengthening; MFL, more frequent lengthening; LFL indicates less frequent lengthening; MFL, more frequent lengthening; SV,
SAL, space available for lung. level of severity for complication.

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Qiu et al J Pediatr Orthop  Volume 40, Number 8, September 2020

TABLE 5. Comparison of Outcomes Based on Scoliosis Diagnosis and Distraction Interval

Congenital (N = 31) Neuromuscular (N = 21)
MFL Group, LFL Group, MFL Group, LFL Group,
≤ 7 mo (n = 20) > 7 mo (n = 11) P ≤ 7 mo (n = 11) > 7 mo (n = 10) P
Age at surgery (y) 2.8 ± 3.3 5.08 ± 3.4 0.098 6.6 ± 4.6 6.9 ± 3.6 0.874
Total expansion surgeries (n) 11.6 ± 3.6 9.4 ± 4.5 0.175 10 ± 3.7 7.7 ± 3.4 0.152
Follow-up (y) 5.8 ± 1.5 7.5 ± 3.3 0.133 5.1 ± 1.7 5.8 ± 2.3 0.396
Preoperative major curve (deg.) 59.4 ± 26.5 65.3 ± 29.8 0.653 86.0 ± 29.1 77.2 ± 23.9 0.461
Major curve correction (deg.) 3.4 ± 19.2 10.5 ± 21.5 0.372 16.7 ± 26.0 10.1 ± 27.9 0.580
Preoperative SAL (%) 79 ± 16 78 ± 13 0.920 81 ± 12 72 ± 23 0.281
SAL change (%) 8 ± 13.0 6 ± 23.1 0.774 8 ± 11.5 6 ± 18.7 0.728
Preoperative T1-T12 (mm) 107.5 ± 23 128.7 ± 37 0.105 154 ± 38.8 143.9 ± 31.2 0.519
T1-T12 growth (mm) 33.9 ± 20.6 41.1 ± 16 0.286 44.1 ± 27.3 36.4 ± 16.6 0.440
Preoperative spinal height (mm) 185.0 ± 29.4 219.3 ± 46.2 0.041 254.3 ± 60.8 240.0 ± 48.9 0.563
Spinal height growth (mm) 57.4 ± 27.7 49.1 ± 25.1 0.410 74.0 ± 34.6 44.0 ± 21.9 0.028
Percent of expected growth 62 ± 33 56 ± 48 0.714 109 ± 84 55 ± 31 0.069
Bold values indicate statistically significant.
Data are represented as mean ± SD.
LFL indicates less frequent lengthening; MFL, more frequent lengthening; SAL, space available for lung.

The number of device-related and disease-related complications
were similar between the 2 groups (P = 0.855). The most
common complication in both groups was a device-related
infection. No patient had a grade III or IV complication.
The relationship between percent of expected growth
achieved for all 60 patients and the average interval of
their distraction surgeries was plotted and analyzed by
Spearman correlation showing a moderate negative cor-
relation (ρ61 = − 0.4461, P = 0.0002). Similarly, performing
the Pearson analysis on expected growth versus length of
follow-up for all patients revealed a moderate negative
relationship (r61 = −0.40, P = 0.0015).
Subgroup comparative analyses were also performed
on the 2 scoliosis types with sufficient subject numbers—
congenital (n = 31) and neuromuscular patients (n = 21)
(Table 5). Sex and ethnicity were similar in distraction
frequency groups for both congenital and neuromuscular
(P > 0.05). The race of neuromuscular patients was more
dispersed in the LFL group (P = 0.03). There were no
significant differences found in age at surgery, total expansion
surgeries, length of follow-up, preoperative major curve, or
SAL. Congenital patients who were lengthened less often had
started treatment with greater T1-T12 and T1-S1 spinal height
(P = 0.105 and 0.04, respectively). However, the 2 groups had

FIGURE 2. Boxplot showing the distribution of percent expected growth achieved by distraction interval group for all patients and
stratified by congenital and neuromuscular scoliosis etiologies. Statistical significance was found between total patients in less
frequent lengthening (LFL) and more frequent lengthening (MFL) (P = 0.031); no statistical significance found in congenital
(P = 0.714) or neuromuscular (P = 0.069) subgroups.

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TABLE 6. Comparison of Smith-classified Complications Based on Scoliosis Diagnosis and Distraction Interval
Congenital N = 31) Neuromuscular (N = 21)
MFL Group, ≤ 7 mo LFL Group, > 7 mo MFL Group, ≤ 7 mo LFL Group, > 7 mo
(n = 20) (n = 11) (n = 11) (n = 10)
Device- Disease- Device- Disease- Device- Disease- Device- Disease-
related related related related P related related related related P
No. complications 27 14 8 1 0.247 24 9 15 6 1
Migration 6 0 2 0 1 5 0 4 0 1
Infection 19 7 4 0 0.548 15 5 9 1 0.633
Hardware failure 2 0 2 0 1 4 0 2 0 1
Pneumonia 0 4 0 1 1 0 4 0 4 1
Sepsis 0 1 0 0 1 0 0 0 0 1
Pulmonary/respiratory 0 2 0 0 1 0 0 0 1 1
distress
LFL indicates less frequent lengthening; MFL, more frequent lengthening.

similar absolute growth gains and percent predicted growth
(Fig. 2). Neuromuscular patients presented preoperatively with
comparable height in both T1-T12 and T1-S1 spinal height;
however, patients more frequently expanded achieved
greater T1-S1 spinal length (P = 0.028) and a trend toward
better percent of expected growth (P = 0.069). The number of
device-related and disease-related complications and grade of
severity did not differ within the groups of the scoliosis subtypes
(Tables 6, 7).
DISCUSSION
Management of EOS continues to be a challenge in
pediatric spine surgery. Rib-based devices are among the
various constructs utilized in the surgical care of EOS
patients that meet operative criteria. Current rib-based
device lengthening intervals are based on best-practice
guidelines in the absence of evidence-based protocols. Our
study sheds more light on clinical outcomes and compli-
cation rates in regard to lengthening intervals when using
rib-based devices in the treatment of EOS patients, data
that is essential as we further investigate the need to op-
timize outcomes.
There were a multitude of reasons why patients were
lengthened at intervals longer than 7 months, either
purposefully or inadvertently. These included both patient
and surgeon-dependent factors such as social constraints,
age, maturity, occurrence of illness, weight, skin coverage
issues, and surgeon’s standard of practice. Similarly, there
were patient-dependent and surgeon-dependent factors
that came into play when deciding the age at initial im-
plantation. The treating surgeons considered factors such
as growth remaining, comorbidities, skin coverage issues,
weight/nutritional status, and social factors. Patient dem-
ographics were largely similar between the cohorts with
the exception of the distribution of race. For example,
there was a greater proportion of more frequently dis-
tracted patients identified as “other.” This population
consists of some international patients who may have had
greater difficulty with frequent follow-up. The majority of
patients were white, non-Hispanic with a scoliosis etiology
of congenital or neuromuscular.
Expectedly, over the same treatment period, a shorter
distraction interval meant a greater number of surgeries for the
patient. Akbarnia et al9 showed that MFLs of dual growing
rods ( ≤ 6 mo) improved major curve correction as well as
overall growth rate. Interestingly, our study shows that the
frequency of distractions did not have a statistically significant
effect on the improvement of major curve or SAL. However,
there was a statistically significant impact on spinal height

TABLE 7. Comparison of Smith-classified Severity Grades Based on Scoliosis Diagnosis and Distraction Interval
Congenital (N = 31) Neuromuscular (N = 21)
MFL Group, ≤ 7 mo LFL Group, > 7 mo MFL Group, ≤ 7 mo LFL Group, > 7 mo
(n = 20) (n = 11) (n = 11) (n = 10)
Severity Grade Device- Disease- Device- Disease- Device- Disease- Device- Disease-
(SV) related related related related P related related related related P
Grade I 7 6 3 0 0.25 9 5 5 1 0.613
Grade II 0 8 1 0 1 0 4 0 5 1
Grade IIA 12 0 4 0 1 3 0 4 0 1
Grade IIB 8 0 1 0 1 12 0 6 0 1
Grade III 0 0 0 0 1 0 0 0 0 1
Grade IV 0 0 0 0 1 0 0 0 0 1
LFL indicates less frequent lengthening; MFL, more frequent lengthening; SV, level of severity for complication.

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Qiu et al
(growth) per annum and over the treatment period. Relatedly,
regular surgeries allowed these patients to better meet the
amount of growth expected when comparing to normative
values. This was confirmed by observing a negative relationship
between the average interval between surgeries and growth. In
addition, this was not done at the expense of higher risk for
complications and the need for reoperation because of infection
or device revision/removal. It should be noted that a negative
correlation was also found between the length of treatment and
growth, or less height gained over time, congruous with the
“Law of Diminishing Returns” previously described.10
To report on a more homogeneous patient cohort, sub-
group analysis was performed on patients classified with con-
genital scoliosis and those with neuromuscular scoliosis to
examine whether distraction intervals had an impact on out-
comes. It was interesting to see that there was no detectable
difference for congenital patients except that those who had less
frequent expansions presented with an initial greater spinal
height. Moreover, the amount of height gained per year was
calculated to be about 8 mm/y in both cohorts. This can be
compared with Campbell and Hell-Vocke’s11 study of con-
genital patients who achieved ∼8 mm/y of thoracic spine
height, measured 3-dimensionally. A more noticeable effect was
presented in the neuromuscular group with greater absolute
height achieved by MFLs although the percent of expected
growth did not quite reach statistical significance. These results
may suggest some influence from the syndromic or idiopathic
patients’ outcomes but are likely underpowered due to the
small number of patients in each group.
In comparison, the small study by Akbarnia et al,9
growing rod patients in both distraction interval groups
(less than or greater than every 6 mo) experienced complica-
tions although the limited sample size impeded further
statistical analysis. Hosseini et al12 noted that there was no
association between lengthening intervals and risk for rod
fractures. Studies on outcomes for MCGRs when considering
distraction interval are more limited. A 2016 abstract by
Akbarnia et al13 presented early results on MCGR patients
that showed more frequent distractions were associated with an
increased incidence of distraction failure and proximal junc-
tional kyphosis but fewer implant-related complications. Last,
Agarwal et al14 simulated a juvenile spine with a finite element
model, finding that shorter intervals of distraction led to a
reduction of stresses on the rod while maintaining spinal height.
These previous reports in addition to our study exhibit the
importance of considering distraction interval, especially
for devices such as MCGR with nonsurgical expansions, to
optimize outcomes without compromising patient safety.
Limitations of this study include the sample size
because this was a single-center study on a relatively small
population to begin with and the lack of patients with tradi-
tional growing rods. Because of the retrospective nature of the
study, missing clinical data precluded us from performing ad-
equate analyses on variables such as pulmonary function test-
ing data. Not all patients graduated from treatment (expansion
surgeries) leading to varied follow-up and time points in pa-
tients’ surgical management. Intrasubject SD was also more
variable in the less frequently distracted group of patients,
meaning subjects may not necessarily have consistently been
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J Pediatr Orthop  Volume 40, Number 8, September 2020
lengthened at long intervals between every surgery. Last, while
predetermined normative values were used as a benchmark
to compare how well patients achieved expected growth, we
recognize that the underlying diagnoses and comorbidities for
these patients may obstruct regular growth. We exclude pa-
tients that have diagnoses related to abnormal skeletal growth
but do not, for example, dismiss patients who may have
hemivertebrae or unsegmented bars.
Our single-institution study shows that lengthening
intervals <7 months are associated with increased overall
T1-S1 spine height gain, percent expected growth without
significant change in a major curve, SALs, or complications as
defined by Smith and colleagues. The results of this study
may be useful in discussions about lengthening intervals for
other forms of distraction-based EOS implants, particularly
MCGRs where the limitations of frequent lengthenings are less
concerning than open lengthening surgery. However, higher-
powered multicenter studies are needed to help optimize
distraction intervals as well as further investigate associated
device-related complications as we work towards the es-
tablishment of evidence-based clinical guidelines that can
be applied across implant constructs and institutions.
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