A 7-year-old female with Marfan’s syndrome diagnosed with scoliosis at 3 years old, who had undergone bracing and growing rods and then had loss of proximal implant fixation and crankshaft phenomenon after definitive fusion. Revision operative management was slightly delayed due to her emaciated state and need for nutritional optimization by gastroenterology consultation, along with placement of a gastrostomy tube and enteral supplementation. (a) An anteroposterior radiograph taken prior to the revision surgery showing loss of proximal fixation, main thoracic apex left curve from T5 to T12 measuring 128° and a 35° curve from T12 to L5. After application of preoperative traction, the T5–T12 curve was reduced to 108°. She had global kyphosis of 60°, was Risser 0, and had 3-dimensional imaging demonstrative of dural ectasia. She was indicated for revision anteroposterior fusion with posterior instrumentation and underwent anterior osteotomies from T5 to T12 and a staged posterior procedure. During the second-stage posterior procedure, multiple Smith-Petersen osteotomies were performed, and an ISOLA four-rod construct was used to instrument from T2 to L4 with claw and wire fixation. (b) A postoperative anteroposterior radiograph showing the revision instrumentation and correction of deformity with residual thoracic scoliosis of 40°. At most recent follow-up seven years after the revision surgery, she had gained 8 in. in height and 24 lb in weight and was pain-free and neurologically intact

A 13-year-old female with progressive kyphosis after “growing rods.” She was diagnosed with neurofibromatosis type 1 at age 2 years and began growing rod management at age 3.5 years. She had 11 surgeries prior to presenting to our institution, the last of which involving infected implants, requiring implant removal and deformity management with a TLSO appliance. (a) A standing lateral radiograph taken prior to the placement of halo traction showing T3–L1 kyphosis of 125° with apex at T8/T9. She underwent a staged procedure where a halo fixator was applied; she had 3 months of axial traction (50 % of body weight), where the T3–L1 kyphosis decreased to 100°; and she underwent T2–L3 posterior spine fusion with instrumentation, including a T8–T10 posterior vertebral column resection. (b) A standing lateral radiograph taken at 1 year postoperatively following PSFI with PVCR demonstrating revision posterior instrumentation, anterior titanium mesh cage, posterior titanium mesh connected to the rods preventing soft tissue encroachment on the neuroelements, and overall kyphosis measurement of 55°. She had physiological coronal and sagittal balance, was neurologically intact, had no pain symptoms, and had returned to participation in her school play