title: Deep Surgical Site Infection Following 2344 Growing-Rod Procedures for Early-Onset Scoliosis: Risk Factors and Clinical Consequences.
abstract: BACKGROUND
  Deep surgical site infection may change the course of growing-rod treatment of early-onset scoliosis. Our goal was to assess the effect of this complication on subsequent treatment.
  
  
  METHODS
  A multicenter international database was retrospectively reviewed; 379 patients treated with growing-rod surgery and followed for a minimum of two years were identified. Deep surgical site infection was defined as any infection requiring surgical intervention.
  
  
  RESULTS
  Forty-two patients (11.1%; twenty-five males and seventeen females) developed at least one deep surgical site infection. The mean age at the initial growing-rod surgery was 6.3 years (range, 0.6 to 13.2 years) and the mean duration of follow-up was 5.3 years (range, 2.2 to 14.3 years). The mean interval between the initial surgery and the first deep surgical site infection was 2.8 years (range, 0.02 to 7.9 years). Ten (2.6%) of the 379 patients developed deep surgical site infection before the first lengthening. Twenty-nine patients (7.7%) developed the infection during the course of the lengthening procedures, and three patients (0.8%) developed it after final fusion surgery. Thirty (13.6%) of 221 patients with stainless-steel implants had at least one deep surgical site infection compared with twelve (8%) of 150 patients with titanium implants (p < 0.05). (The remaining patients were treated with chromium-cobalt implants.) Twenty-two (52.4%) of the forty-two patients with deep surgical site infection underwent implant removal, which was complete in thirteen and partial in nine. Growing-rod treatment was terminated in two patients with partial removal and six patients with complete removal. An increased risk of deep surgical site infection was associated with stainless-steel implants (odds ratio [OR] = 5.7), non-ambulatory status (OR = 2.9), and the number of revisions before the development of deep surgical site infection (OR = 3.3). Neuromuscular etiology and non-ambulatory status increased the possibility of implant removal to treat infection (p < 0.05).
  
  
  CONCLUSIONS
  The prevalence of deep surgical site infection associated with growing-rod surgery is higher than that associated with standard pediatric spinal fusion (historical data). Non-ambulatory status, more revisions, and stainless-steel implants increased the risk of deep surgical site infection. After eight surgical procedures, the risk of deep surgical site infection increased to approximately 50%. When patients have implant removal, efforts should be made to retain one longitudinal implant to continue treatment.
  
  
  METHODS
  Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
authors.affiliation: San Diego Center for Spinal Disorders, 4130 La Jolla Village Drive, Suite 300, San Diego, CA 92037. E-mail address for B.A. Akbarnia: akbarnia@ucsd.edu.
authors.forename: Nima
authors.initials: N
authors.lastname: Kabirian
authors.affiliation: San Diego Center for Spinal Disorders, 4130 La Jolla Village Drive, Suite 300, San Diego, CA 92037. E-mail address for B.A. Akbarnia: akbarnia@ucsd.edu.
authors.forename: Behrooz A
authors.initials: BA
authors.lastname: Akbarnia
authors.affiliation: San Diego Center for Spinal Disorders, 4130 La Jolla Village Drive, Suite 300, San Diego, CA 92037. E-mail address for B.A. Akbarnia: akbarnia@ucsd.edu.
authors.forename: Jeff B
authors.initials: JB
authors.lastname: Pawelek
authors.affiliation: San Diego Center for Spinal Disorders, 4130 La Jolla Village Drive, Suite 300, San Diego, CA 92037. E-mail address for B.A. Akbarnia: akbarnia@ucsd.edu.
authors.forename: Milad
authors.initials: M
authors.lastname: Alam
authors.affiliation: San Diego Center for Spinal Disorders, 4130 La Jolla Village Drive, Suite 300, San Diego, CA 92037. E-mail address for B.A. Akbarnia: akbarnia@ucsd.edu.
authors.forename: Gregory M
authors.initials: GM
authors.lastname: Mundis
authors.affiliation: San Diego Center for Spinal Disorders, 4130 La Jolla Village Drive, Suite 300, San Diego, CA 92037. E-mail address for B.A. Akbarnia: akbarnia@ucsd.edu.
authors.forename: Ricardo
authors.initials: R
authors.lastname: Acacio
authors.affiliation: Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106. E-mail address: George.Thompson@UHhospitals.org.
authors.forename: George H
authors.initials: GH
authors.lastname: Thompson
authors.affiliation: The Royal Orthopaedic Hospital, Bristol Road, Northfield, Birmingham B31 2AP, United Kingdom. E-mail address for D.S. Marks: david.s.marks@talk21.com. E-mail address for A. Gardner: adriangardnerd@googlemail.com.
authors.forename: David S
authors.initials: DS
authors.lastname: Marks
authors.affiliation: The Royal Orthopaedic Hospital, Bristol Road, Northfield, Birmingham B31 2AP, United Kingdom. E-mail address for D.S. Marks: david.s.marks@talk21.com. E-mail address for A. Gardner: adriangardnerd@googlemail.com.
authors.forename: Adrian
authors.initials: A
authors.lastname: Gardner
authors.affiliation: Johns Hopkins Bloomberg Children's Center, 1800 Orleans Street, Room 7359, Baltimore, MD 21287. E-mail address: psponse@jhmi.edu.
authors.forename: Paul D
authors.initials: PD
authors.lastname: Sponseller
authors.affiliation: Department of Orthopaedic Surgery, Children's Hospital Los Angeles, 4650 Sunset Boulevard, M/S 69, Los Angeles, CA 90027. E-mail address: DSkaggs@chla.usc.edu.
authors.forename: David L
authors.initials: DL
authors.lastname: Skaggs
mesh_terms: D000293:Adolescent; D017668:Age of Onset; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D016268:Internal Fixators; D008297:Male; D019857:Osteogenesis, Distraction / Q000295:instrumentation*; D012189:Retrospective Studies; D012307:Risk Factors; D012600:Scoliosis / Q000601:surgery*; D013530:Surgical Wound Infection / Q000453:epidemiology* / Q000473:pathology