Accuracy of Freehand Versus Modified Funnel Technique for Pedicle Screw Insertion in the Thoracic Spine.

AIM: To describe a new pedicle screw insertion technique, a modification of the funnel technique, and to compare this technique with conventional freehand screw insertion regarding their accuracy and complications in the thoracic spine. MATERIAL AND METHODS: Three hundred forty-three patients who underwent a posterior spinal fusion with different etiologies were retrospectively analyzed. In 84 patients, pedicle screws were placed using the freehand technique, and in 259 patients, the modified funnel technique was used. Screw malposition was evaluated in the immediate and final follow-up in anteroposterior and lateral spinal radiographs by two independent observers. The rates of incorrect pedicle screws and complications, surgical duration, and estimated blood loss were compared between the groups. RESULTS: A total of 6141 pedicle screws (1468 in the freehand group, 4673 in the modified funnel group) were evaluated. The rate of incorrect pedicle screws was higher in the freehand group (12.0% vs. 4.6%, p=0.001). The surgical time was shorter in the modified funnel group (190.9 ± 57.0 vs. 174.1 ± 47.6 min; p=0.017). The estimated blood loss was similar between the groups (1391.50 ± 570.01 vs. 1264.13 ± 602.29 mL; p=0.053). There were 82 intraoperative pedicle fractures but no neurologic complications in either group. CONCLUSION: The modified funnel technique provides more accurate pedicle screw insertion in the thoracic spine in the presence of dysplastic pedicles in conjunction with axial rotation compared with the freehand technique. Furthermore, surgical time may be reduced without increasing blood loss.

Management and results of early-onset scoliosis with dual magnetically controlled growing rods: Additional preliminary results of spinal fusion surgery.

OBJECTIVES: The aim of this study was to evaluate the clinical and radiographic outcomes and complications of dual magnetically controlled growing rods (MCGRs) in the treatment of early-onset scoliosis (EOS) and to investigate the results of patients with definitive spinal fusion following MCGR. PATIENTS AND METHODS: A total of 15 patients (7 males, 8 females; mean age: 8.7±1.7 years; range, 6 to 10 years) with EOS who underwent dual MCGR and were prospectively followed between February 2013 and March 2019 were included in this retrospective study. The Cobb angle, thoracic kyphosis, and the length of the spine between T1-T12 and T1-S1 were measured on preoperative, postoperative, and follow-up radiographs. The 24-Item Early-Onset Scoliosis Questionnaire (EOSQ-24) was used to assess the functional outcomes before and after the operation. All complications during the treatment were recorded. RESULTS: The mean follow-up was 27.8±10.4 (range, 12 to 60) months. The mean curve correction immediately after the index surgery and latest follow-up was 47.6% and 42.4%, respectively (p>0.05). At the last follow-up, there were no significant changes in mean Cobb and kyphosis angles. The mean T1-T12 length increase was 26.2±7.1 (range, 16 to 40) mm, while the mean T1-S1 length increase was 43.3±15.0 (range, 24 to 70) mm. Complications developed in four (26.6%) of 15 patients. Definitive spinal fusion surgery was performed in seven patients. Total mean Cobb angle difference between the final follow-up and fusion surgery was 9.3° (p=0.016) and kyphosis angle difference was -2.1° (p=0.349). After fusion surgery, total lengthening in T1-T12 and T1-S1 distance was 10.5 mm (p=0.036) and 15.0 mm (p=0.022), respectively. A significant increase in all subdomain scores of the EOSQ-24 (p<0.05), except for financial impact, was recorded in all patients. CONCLUSION: Dual MCGR technique is an effective, reliable, and robust treatment alternative for primary EOS. However, surgeons should be aware of the relatively high rate of complications. In addition, residual deformity can be corrected successfully with definitive surgery.

Comparison of Pedicle Screws Versus Hybrid Fixation With Sublaminar Polyester Bands in the Treatment of Neuromuscular Scoliosis.

BACKGROUND: The choice of implants in neuromuscular scoliosis (NMS) surgery remains controversial. Sublaminar polyester bands (SPBs) seem to be a promising alternative implant. The purpose of current study was to compare clinical and radiologic results of posterior instrumentation and fusion using hybrid constructs versus only pedicle screws for NMS treatment. METHODS: In 24 patients, pedicle screws were used in all segments, and 18 patients underwent hybrid fixation. Cobb angle, thoracic kyphosis, lumbar lordosis angles, and pelvic obliquity were compared before and immediately after surgery, at the last follow-up radiographs. Demographic, clinical information, duration of surgery, estimated blood loss (EBL), blood transfusion, and complications were compared between groups. Additionally, patients were assessed for pain with visual analog scale (VAS) and quality of life with Short Form 36 (SF-36) and the Oswestry scale. RESULTS: Baseline characteristics of patients were similar except for EBL (P = 0.002) and follow-up duration (P = 0.004). The mean curve correction was 58.1% in the hybrid group, and 67.6% in the screw group (P = 0.07), and loss of correction was significantly lower in hybrid group (2.72° ± 1.48° vs. 3.66° ± 1.52°, P = 0.049). Functional scores at final follow-up were equal in both groups (VAS P = 0.865, Oswestry P = 0.097, SF-36 Physical P = 0.358, SF-36 Mental P = 0.145). CONCLUSIONS: SPBs might be a better fixation alternative at the apex of rigid spinal deformity in NMS. The deformity can be corrected with less blood loss and at a similar rate of correction, with similar rate complications compared with pedicle screws.

Efficiency of Balloon Kyphoplasty in the Treatment of Osteoporotic Vertebral Compression Fractures.

Eighty-seven osteoporotic vertebral fractures of 82 patients were treated with balloon kyphoplasty. Preoperative, postoperative and follow-up outcomes of functional impairment, pain scores and vertebral height restorations of the patients were recorded and evaluated statistically. Seventy-two of the patients were female (87.8%) and 10 (12.2%) were male. Mean age of all patients were 66.4 years. Preoperative mean Anterior Vertebral Body Height of 48.20±13.94 % and Middle Vertebral Body Height of 59.40±14.26 % were recorded as 79.91±9.50 % and 86.90±8.38 % respectively postoperatively and noted to be 73.26±8.59 % and 84.65±8.19 % at last controls respectively. The mean Oswestry Disability Index and Visual Analog Pain Scale also improved significantly. Local Kyphosis of all the patients were also evaluated and a significant improvement was noted postoperatively. The long term results of this study suggest that balloon kyphoplasty is an effective and safe treatment option in osteoporotic vertebral fractures and should be considered for functional improvement, pain relief and height restoration.

The prevalence of knee injuries ipsilateral to tibial shaft fractures and their impact on clinical outcome.

OBJECTIVE: The purpose of this prospective study was to examine the prevalence of occult knee injuries in patients with ipsilateral tibial shaft fractures and determine their impact on clinical outcome. MATERIALS AND METHODS: Preoperative knee MRI examination was performed in 41 patients (42 knees) with isolated tibial shaft fractures. Menisci, cruciate ligaments, collateral ligaments, extensor mechanism, osteochondral lesions, bone contusions and knee effusion were evaluated. All patients were treated with reamed and locked intra-medullary tibial nailing without an additional surgical procedure for knee injuries. All patients were followed to at least fracture union and were evaluated with knee examination and Lysholm knee score. RESULTS: Of the 42 knees, 41 (97.6 %) showed at least one defined injury around the knee. There was only one patient who had totally normal knee MRI findings. One or more ligamentous injuries of the knee were identified in 35 (83.3 %) of the knees. Five patents (11.9 %) had medial meniscal tear in posterior horn. Extensor mechanism injuries were seen in two patients. Mild to marked joint effusion was observed in 35 (81 %) knees. Twenty-two knees demonstrated bone bruise; femoral condyle (n = 7), tibial plateau (n = 12), patella (n = 2) and fibular head (n = 1). No patients had osteochondral lesion. Patients were followed with a mean of 13.2 ± 3.6 (range 8-22) months. Clinical knee examination revealed Grade II (+) anterior drawer test in two patients. The mean Lysholm knee score was 99.1 ± 2.14 (range 91-100) at the final follow-up. CONCLUSIONS: Ipsilateral intra-articular, extra-articular or combined knee injuries may occur at the time of injury with tibial shaft fractures. However, most of these injuries are not clinically relevant and heal without any sequel or remain asymptomatic late after fracture union. Routine use of preoperative knee MRI examination in patients with tibial shaft fractures is not necessary.

The prevalence of functional absence of flexor digitorum superficialis to the little finger: a study in a Turkish population.

This prospective study was conducted to determine the prevalence of absence of flexor digitorum superficialis (FDS)-V tendon and to investigate the clinical usefulness of symmetry patterns, differences between sex, laterality, and dexterity in a Turkish population. Four hundred randomly-selected adult patients were examined for the absence of FDS-V function. The absence of FDS-V on both sides, results of the examination tests, age, sex, and dexterity were recorded and analysed statistically. The overall prevalence of absence of FDS-V was 18.5% in the Turkish population. The prevalence of functional absence of FDS-V was statistically similar between the body sides and sex (p = 0.258 and p = 0.333). The prevalence of symmetric occurrence of the variations in both hands was 87.2%. If a functional FDS is demonstrated in one hand, the probability of having a functional FDS-V in the contralateral hand is 91.8%. However, when the FDS-V is absent in one hand, the probability of having an absent FDS-V in the contralateral hand is 51.1%. The symmetric occurrence of variations was equally distributed in both sex and dexterity (p = 0.223 and p = 0.201). Prediction of FDS-V function in one hand through examining the opposite hand may cause false negative or false positive results. However, if the uninjured hand has independent FDS-V function, the inability to flex the PIP joint in the injured hand can be accepted as an injury to the FDS and surgical exploration should be performed. However, if the uninjured hand has an absent function, assumption of symmetric distribution should not be used.

Prevalence and distribution of sesamoid bones of the hand: a radiographic study in Turkish subjects / Prevalencia y distribución de los huesos sesamoideos de la mano; un estudio radiográfico en sujetos turcos

The purpose of this study was to examine the plain anteroposterior radiographs of the hands in Turkish subjects in order to determine the prevalence of sesamoid bones and their distribution. A total of 923 hand radiographs from 459 men and 464 women with a mean age of 43.76±14.8 years (range, 18-85 years) were examined. Two sesamoid bones (ulnar and radial) were always present at the metacarpophalangeal (MCP) joint of the thumb (100 percent). One sesamoid bone in the thumb interphalangeal (IP) joint was observed in 21.3 percent of the cases. The prevalence of sesamoid bone of the index and little MCP joint were 36.6 percent and 53.2 percent respectively. Sesamoid bones palmar to the MCP joints of the middle finger and ring finger were rare; the incidence for these locations being 1.3 percent (12 hands) and 0.9 percent (8 hands), respectively. There were no significant differences between left and right hand digits. The distribution of sesamoid bones in different locations between male and female subjects were statistically similar in 1st IP joint (p=0.530), 4th MCP (p=0.631), 5th MCP (p=0.067) joints. However, the sesamoid bones in 2nd MCP and 3rd MCP joints were statistically more frequent in female subjects (p=0.024 and p=0.018 respectively). The present study represents the first report on the prevalence and distribution of sesamoid bones in the hand in Turkish subjects. The prevalence of sesamoid bones in Turkish population is considerably different from the Africans and Europeans, but rather resembles Mediterranean and Arab populations...

El objetivo de este estudio fue examinar radiografías anteroposteriores de manos en sujetos turcos para determinar la prevalencia y distribución de los huesos sesamoideos. Fueron examinadas 923 radiografías de mano, 459 hombres y 464 mujeres, con edad media de 43,76 ± 14,8 años (rango, 18-85 años). Dos huesos sesamoideos (ulnar y radial) estuvieron siempre presentes en la articulación metacarpofalángica (MCF) del primer dedo de la mano (100 por ciento). Un solo hueso sesamoideo en la articulación interfalángica (IP) del primer dedo de la mano se observó en el 21,3 por ciento de los casos. La prevalencia del hueso sesamoideo, índice y articulación MCP fueron fue de 36,6 por ciento y 53,2 por ciento respectivamente. Los huesos sesamoideos palmares a las articulaciones metacarpofalángica del dedo medio y dedo anular eran poco frecuentes, su incidencia fue 1,3 por ciento (12 manos) y 0,9 por ciento (8 manos), respectivamente. No hubo diferencias significativas entre los dígitos izquierdos o derechos. La distribución de los huesos sesamoideos en diferentes lugares entre los sujetos de ambos sexos fueron estadísticamente similares entre las articulaciones primera interfalángica (p = 0,530), cuarta MCP (p = 0,631) y quinta MCP (p = 0,067). Sin embargo, los huesos sesamoideos en las articulaciones segunda MCP y tercera MCP fueron estadísticamente más frecuentes en el sexo femenino (p = 0,024 y p = 0,018, respectivamente). El presente estudio representa el primer informe sobre la prevalencia y distribución de los huesos sesamoideos en la mano en sujetos turcos. La prevalencia de los huesos sesamoideos en la población turca es considerablemente diferente de los africanos y los europeos, pero se asemeja a las poblaciones mediterráneas y árabes...

Inter- and intraobserver reliability of the Crowe and Hartofilakidis classifications in the assessment of developmental dysplasia of the hip in adult patients.

BACKGROUND: The purpose of this study is to investigate the inter- and intraobserver reliability of Crowe and Hartofilakidis classifications in the assessment of developmental dysplasia of the hip in adult patients. MATERIALS AND METHODS: Two consultant orthopedic surgeons classified 141 dysplastic hips on 103 standard anterior-posterior pelvis radiographs according to the Crowe and Hartofilakidis classifications. Assessments were performed in random order by each observer on two separate occasions, at least 4 weeks apart. Kappa statistics were used to establish a relative level of agreement between observers for the two readings and between separate readings by the same observer. RESULTS: At the first readings, interobserver reliability analysis revealed kappa coefficient of 0.71 for the Crowe classification and 0.54 for the Hartofilakidis classification. At the second reading, the kappa coefficient was 0.72 for the Crowe classification and 0.75 for the Hartofilakidis classification. Intraobserver reliability analysis revealed kappa coefficients of 0.71 for the Crowe and 0.80 for the Hartofilakidis classification for observer A, and 0.76 and 0.70 for observer B. CONCLUSIONS: In conclusion, we have found substantial inter- and intraobserver agreement for Crowe classification and substantial to moderate agreement for Hartofilakidis classification in this study. Both classification systems assess the different aspects of developmental dysplasia of hip in adults. Each system has advantages and disadvantages. We suggest using both of these classifications together to increase the accuracy.

Treatment of high hip dislocation with a cementless stem combined with a shortening osteotomy.

INTRODUCTION: The purpose of this study was to review the clinical and radiographic outcomes and report the major complications in a group of hips with Crowe type IV developmental dysplasia that underwent reconstruction with a cementless total hip arthroplasty and a transverse subtrochanteric shortening osteotomy fixed with locking compression plate and screws. METHOD: Fifteen consecutive patients (21 hips) who had coxarthrosis secondary to Crowe Group IV developmental dysplasia of the hip were treated with a cementless prosthesis and a transverse subtrochanteric osteotomy fixed with locking compression plates at a mean age of 41. The mean follow-up period was 5 years. The acetabular cup was placed in the position of the anatomical hip center in every patient. Subtrochanteric femoral shortening osteotomy was fixed with plates and screws in all patients. RESULTS: The mean Harris hip score improved from 36.2 ± 9.8 points to 90.8 ± 2.5 points. Trendelenburg sign was positive in seven hips and two patients complained about continuing anterior thigh pain at the final follow-up. There was no infection. No cases of nonunion were encountered. Two patients had dislocation on early postoperative period (15th and 20th postoperative day). Of these patients, femoral head was changed to 28 mm with stem revision in one patient, and one had acetabular component revision with use of constrained acetabular liner. There was one permanent sciatic nerve palsy. One patient had implant related pain during lying laterally. Plate and screws were removed at postoperative 16th month. CONCLUSION: Cementless total hip arthroplasty combined with subtrochanteric osteotomy for the treatment of patients with Crowe Group IV developmental dysplasia of the hip is an effective technique to reduce the hip to its original acetabular location and restore the rotational deformities. Plate and screw fixation is a viable option for a secure and stable fixation of femoral stem after subtrochanteric osteotomy.

Cosmetic results of wedge resection of nail matrix (Winograd technique) in the treatment of ingrown toenail.

OBJECTIVE: The purpose of this retrospective study is to evaluate the cosmetic results of wedge resection of the nail matrix (Winograd technique) in the treatment of ingrown toenail. MATERIALS AND METHODS: This study retrospectively reviewed medical charts of 68 patients with 75 ingrown toenails who underwent surgical correction with the Winograd technique between January, 2008, and December, 2009, at the Orthopaedics and Traumatology Department, Antalya Education and Research Hospital. For the final follow-up, patients were contacted by telephone and completed a telephone questionnaire. Recurrence, cosmetic results, and satisfaction of the patients were the major outcome measures. RESULTS: There was recurrence in 9 patients (13.2%). The mean recurrence time was 6.7 months (range = 2-12 months). All recurrences involved the lateral border of the toenail. Cosmetic ratings were statistically lower in female patients (P = .005). The reasons for poor and acceptable cosmetic results were proximal-incision scar and narrowing of the nail plate. CONCLUSION: Wedge resection of nail matrix has a considerably high recurrence rate. Furthermore, narrowing of the nail plate is a disadvantage of this procedure. All patients should be informed about the possibility of recurrence and disfigurement in their toenails (narrow nail plate). Particularly, female patients who care about the cosmesis may be dissatisfied with this surgical technique.

Management of a wild boar wound: a case report.

Injuries caused by wild boar attacks are rare. A 34-year-old male shepherd sustained injuries caused by a wild boar attack, and was brought to our emergency department. The patient had 2 skin and deep tissue lacerations on the posterior aspect of his thigh. Herein, we discuss the clinical management of a wild boar bite wound with a review of the literature.

Isolated medial cuneiform fractures: report of two cases and review of the literature.

Although fractures of the midfoot are common, cuneiform fractures are rarely seen. These fractures are frequently associated with other fractures of the midfoot such as Lisfranc fracture-dislocations. However, isolated cuneiform fractures are extremely rare, with few cases reported in the relevant literature. Herein, the authors report 2 cases of isolated medial cuneiform fractures. One of the patients was treated with headless screw fixation due to displacement in fracture configuration, and the other was treated conservatively. Fractures were united without any complication in both patients. In this report, the authors discuss the mechanism of injury, diagnostic challenges, and treatment options of isolated medial cuneiform fractures.

Proximal realignment surgery for unilateral chronic patella dislocation in Morquio syndrome: a case report.

Mucopolysaccharidosis IVA (MPS IVA: Morquio A syndrome) is a lysosomal storage disorder caused by a deficiency of N-acetylgalactosamine-6-sulfate sulfatase. Patients with MPS IVA appear healthy at birth. Morquio-specific radiographic changes can be observed prior to clinical signs and symptoms. Patients are usually affected by a severe joint degeneration from the 2nd or 3rd decade. Hyperlaxity of the joints is prominent due to the excess of intermediate metabolites. We report a patient with inherited dwarfism, in which a proximal soft tissue realignment procedure was performed to treat chronic patellar dislocation.

Minimum 5-year follow-up surgical results of post-traumatic thoracic and lumbar kyphosis treated with anterior instrumentation: comparison of anterior plate and dual rod systems.

STUDY DESIGN: A retrospective follow-up study of post-traumatic thoracic and lumbar kyphosis after anterior instrumentation with anterior plate and dual rod systems. OBJECTIVE: To investigate the outcome of anterior vertebrectomy, anterior strut grafting, and anterior instrumentation in patients with > 30 degrees sagittal contour deformity. SUMMARY OF BACKGROUND DATA: Post-traumatic kyphosis may lead to mechanical pain due to the impairment of physiologic sagittal contours as well as cosmetic complaints. METHODS: Forty patients with post-traumatic kyphosis were followed for a minimum of 5 years. Mean age was 44.7 +/- 12.4 years (range, 18-65 years); 18 were female and 22 were male. All patients underwent anterior vertebrectomy and decompression; anterior fusion was carried out with costal or iliac ala grafts. Patients were randomly assigned into 2 treatment groups: correction and internal fixation was performed by using either plate-screw (n = 20) or double rod-screw (n = 20). Patients were also evaluated clinically by using Pain and Functional Assessment Scale (PFA) and SRS-22 questionnaire. RESULTS: Before surgery, the mean value for local sagittal contours was 51.4 degrees +/- 13.8 degrees; after surgery, it was reduced to 7.0 degrees +/- 7.6 degrees, resulting in an 88.7% +/- 11.3% correction (P = 0.00). At the last follow-up visit, a mean correction loss of 1.4 degrees +/- 1.8 degrees was found. A statistically significant improvement in local kyphosis angles and PFA scores was found after surgery and at the last visit. In 92.5% of the patients (n = 36), pain completely resolved; and in the remaining 3 patients, it is markedly reduced. Neurologic improvement was achieved in all of the 24 patients with neural claudication and other neurologic findings. Solid fusion mass was obtained in all patients. The type of instrumentation system did not differ significantly in terms of kyphotic deformity correction rates, correction losses, PFA scores, and SRS-22 scores. Final PFA scores showed a statistically significant correlation with SRS-22 scores (r = -0.918, P < 0.01). Final pain, function, mental status, self image and satisfaction domain scores and total SRS-22 score were > or = 4. The time from trauma to operation and the severity of kyphotic deformity were inversely correlated with postoperative correction rates. On the other hand, these 2 parameters were positively correlated with both final PFA and final SRS-22 scores (P < 0.01). CONCLUSIONS: In light of the present study's findings, we suggest that the technique of anterior decompression, strut grafting, and anterior instrumentation is an effective method for the treatment of post-traumatic kyphotic deformity and that the success of the technique depends on the time from trauma to operation and the severity of baseline deformity, regardless of the type of instrumentation.

Minimum 10 years follow-up surgical results of adolescent idiopathic scoliosis patients treated with TSRH instrumentation.

Last two decades witnessed great advances in the surgical treatment of idiopathic scoliosis. However, the number of studies evaluating the long-term results of these treatment methods is relatively low. During recent years, besides radiological and clinical studies, questionnaires like SRS-22 assessing subjective functional and mental status and life-quality of patients have gained importance for the evaluation of these results. In this study, surgical outcome and Turkish SRS-22 questionnaire results of 109 late-onset adolescent idiopathic scoliosis patients surgically treated with third-generation instrumentation [Texas Scottish Rite Hospital (TSRH) System] and followed for a minimum of 10 years were evaluated. The balance was analyzed clinically and radiologically by the measurement of the lateral trunk shift (LT), shift of head (SH), and shift of stable vertebra (SS). Mean age of the patients was 14.4+/-1.9 and mean follow-up period was 136.9+/-12.7 months. When all the patients were included, the preoperative mean Cobb angle of major curves in the frontal plane was 60.8 degrees +/-17.5 degrees . Major curves that were corrected by 38.7+/-22.1% in the bending radiograms, postoperatively achieved a correction of 64.0+/-15.8%. At the last follow-up visit, 10.3 degrees +/-10.8 degrees of correction loss was recorded in major curves in the frontal plane with 50.5+/-23.1% final correction rate. Also, the mean postoperative and final kyphosis angles and lumbar lordosis angles were 37.7 degrees +/-7.4 degrees , 37.0 degrees +/-8.4 degrees , 37.5 degrees +/-8.7 degrees , and 36.3 degrees +/-8.5 degrees , respectively. A statistically significant correction was obtained at the sagittal plane; mean postoperative changes compared to preoperative values were 7.9 degrees and 12.9 degrees for thoracic and lumbar regions, respectively. On the other hand, normal physiological thoracic and lumbar sagittal contours were achieved in 83.5% and 67.9% of the patients, respectively. Postoperatively, a statistically significant correction was obtained in LT, SH, and SS values (P<0.05). Although, none of the patients had completely balanced curves preoperatively, in 95.4% of the patients the curves were found to be completely balanced or clinically well balanced postoperatively. This rate was maintained at the last follow-up visit. Overall, four patients (3.7%) had implant failure. Early superficial infection was observed in three (2.8%) patients. Radiologically presence of significant consolidation, absence of implant failure, and correction loss, and clinical relief of pain were considered as the proof of a posterior solid fusion mass. About ten (9.2%) patients were considered to have pseudoarthrosis: four patients with implant failure and six patients with correction loss over 15 degrees at the frontal plane. About four (3.7%) patients among the first 20 patients had neurological deficit only wake-up test was used for neurological monitoring of these patients. No neurological deficit was observed in the 89 patients for whom intraoperative neurological monitoring with SSEP and TkMMEP was performed. Overall, average scores of SRS-22 questionnaire for general self-image, function, mental status, pain, and satisfaction from treatment were 3.8+/-0.7, 3.6+/-0.7, 4.0+/-0.8, 3.6+/-0.8, and 4.6+/-0.3, respectively at the last follow-up visit. Results of about 10 years of follow-up these patients treated with TSRH instrumentation suggest that the method is efficient for the correction of frontal and sagittal plane deformities and trunk balance. In addition, it results in a better life-quality.

Augmentation of third generation instrumentation with sublaminar titanium wiring in late onset idiopathic scoliosis: the surgical results and analysis of trunk balance.

In recent years, third generation instrumentation systems which achieve correction by maneuvers like derotation and translation, have been widely used in the treatment of idiopathic scoliosis. To increase correction, additional procedures that increase stability, such as screw application for every segment, have been used. In this study, as a new technique, the effects of combined translation and derotation maneuver with augmentation by using titanium double crimp Songer cable applied on apical region, on trunk balance, sagittal and frontal planes have been examined. 45 idiopathic scoliosis patients operated between 1996 and 2002 have been included in the study. Mean age was 14.5+/-1.7 years and female/male ratio was 30/15. Mean follow up time was 51.9+/-22.7 months. According to King Classification, 15 patients had Type II, 18 patients Type III and 12 patients had Type IV curves. One of the apical cables has been tensioned and translation has been performed. At the second step, derotation has been applied to the vertebra, which is firmly attached to the rod. Sagittal and frontal Cobb angles have been measured in preoperative, postoperative and recent radiographic examinations. Trunk balance has been examined both clinically and radiographically. Also, secondary curves have been measured in every examination for decompensation findings. In overall frontal plane measurements, postoperative correction was 79.9+/-13.5 %, loss of correction 2.9 degrees +/-3.2 degrees and final correction 74.3 % +/-14.3 %. In postoperative measurements, normal physiological contours have been achieved in 97.8 % of the patients for the thoracic region (30 degrees -50 degrees ) and 80.7 % of the patients for the lumbar region (40 degrees -60 degrees ). In secondary curves, 75.2+/-34.4 % postoperative correction has been observed. No decompensation findings have been observed in the last examination. In postoperative and last follow up examinations, balanced and totally balanced vertebral column has been achieved in every patient of the study group. Solid fusion mass has been observed in every patient. No early or late, local or systemic postoperative complications have been observed. Given these findings, we conclude that derotation-translation combined maneuver performed with 3rd generation instrumentation reinforced sublaminar wires is a good choice in the treatment of the late-onset idiopathic scoliosis.

Comparison of anterior instrumentation systems and the results of minimum 5 years follow-up in the treatment of tuberculosis spondylitis.

Anterior debridement, strut grafting and instrumentation have an increasing popularity in the treatment of tuberculosis of spine. Anterior fixation can be done either by a plate or a rod system. This study reports on the surgical results of 59 patients with Pott's disease that had anterior radical debridement and anterior fusion and anterior instrumentation with 5 years follow-up. Average age at the time of operation was 46.3+/-13.5 years. Average follow-up was 84.6+/-11.3 months. Local kyphosis was measured as the angle between the upper and lower end plates of the collapsed vertebrae preoperatively, postoperatively and at the last follow-up visit. Vertebral collapse, destruction, cold abscess, and canal compromise were assessed in MR images. The indication for surgery was either one of the deformity, instability or neurological compromise. Surgical treatment included anterior radical debridement followed by grafting with tricortical auto graft and anterior instrumentation at levels just above and below the diseased segment(s) with either plate (Sofamor-Danek, Z plate, Group A) or rod (Sofamor-Danek, CDH, Group B) systems. There were 23 patients in group A and 36 patients in group B. All patients had similar anti tuberculosis chemotherapy. Patients had similar rehabilitation program after the surgery. The deformity in the sagittal and the coronal plane was measured and presence of significant consolidation, along with the absence of implant failure or correction loss was considered as signs of fusion. The two groups were similar according to age (46.9+/-14.2 vs. 45.8+/-13.1), gender, average number of involved levels (1.8+/-0.5 vs. 1.6+/-0.5), location of involved levels, severity of deformity (21.5 degrees+/-9.9 masculine vs. 24.8 degrees+/-11.9 masculine) and type of autografts (p>0.05 for all parameters). 39.1 % of patients in group A and 41.6 % of patients in group B had neurological compromise with improvement in majority at the end of follow-up. Deformities were corrected to 5.2 degrees+/-5.7 masculine in group A and 6.1 degrees+/-6.8 masculine in group B with no significant difference. At the time of latest follow-up there were 1.7 degrees+/-2.0 masculine correction loss in group A and 1.4 degrees+/-1.9 masculine in group B with no significant difference in between two groups (p>0.05). Overall, it was observed that, the addition of anterior instrumentation increased the rate of correction of the kyphotic deformity (78.5+/-20.5%), and was effective in maintaining it with an average loss of 1.5 degrees+/-1.9 degrees. Of the 24 (44.1%) patients with neurological symptoms, 20 (83.3%) had full and 4 (16.7%) partial recoveries. There was no apparent pseudoarthrosis and implant failure in both groups and all patients demonstrated clinical improvement in tuberculosis infection without recurrences and reactivation. Four major complications occurred in the group A (major vessel complication: 3.4%, secondary non-specific infection: 3.4%). Disease reactivation was not seen with the employment of an aggressive chemotherapy regimen. It was concluded that anterior instrumentation is a safe and effective method in the treatment of tuberculosis spondylitis. There were no significant differences between the two instrumentation systems in terms of sagittal alignment reconstruction and fusion rate. In rod-screw systems, the disadvantages of scoliotic deformity correction through frontal plan in plate performing did not occur and it is though to have the advantage of long instrumentation in multiple level deformities.

[An evaluation of the types and the results of surgical treatment for congenital scoliosis]. / Dogustan skolyozda cerrahi tedavi seçeneklerinin degerlendirilmesi.

OBJECTIVES: We evaluated the types and the results of surgical treatment performed for congenital scoliosis. METHODS: Forty-one patients (26 females, 15 males; mean age 12.8 years) with congenital scoliosis were included. The patients were classified according to the Winter's system. Transpedicular hemiepiphysiodesis, "egg shell" procedure, and anterior hemiarthrodesis and posterior convex fusion were performed in infantile (n=1) and juvenile (n=8) patients. In the adolescent (n=32) group, posterior in situ fusion was performed for rigid curves (n=15), posterior fusion after correction with posterior instrumentation for moderate curves (n=8), and posterior fusion and correction with posterior instrumentation after an anterior osteotomy for segmentation failures (n=6). Five patients with unincarcerated fully segmented hemivertebrae had anterior or posterior instrumentation following anterior-posterior hemivertebrectomy. The mean follow-up was 51.8 months (range 26 to 132 months). RESULTS: Fourteen patients (34.2%) had formation failures, 19 patients (46.2%) had segmentation failures, and eight patients (19.6%) had mixed types of deformities. Klippel-Feil syndrome was detected in two patients, and heart valve abnormality was found in two patients. Although the infantile patient who underwent transpedicular hemiepiphysiodesis showed no improvement after surgery, a spontaneous correction rate of 60% was found during her final controls. Patients who underwent anterior hemiarthrodesis obtained a final correction rate of 54.3% following a 42% of correction at surgery. The correction rates for posterior instrumentation were 26.2% with translation and 49.3% after an anterior osteotomy. Patients who had anterior or posterior instrumentation after anterior-posterior hemivertebrectomy had final correction rates of 73.3% and 59.2%, respectively. Final evaluations showed that nine patients (21.9%) had no change in their curves, while 10 patients (24.4%) had spontaneous correction. Four patients developed superficial (n=2) and deep (n=2) infections following posterior instrumentation. Of these, three patients were successfully treated with debridement and antibiotic therapy, whereas one patient required implant removal in the eighth month. No neurologic deficits or systemic complications occurred during or after surgery. CONCLUSION: Surgical treatment may yield successful results in progressive congenital scoliosis when an appropriate surgical technique is selected based on the patient's age and the type of deformity.

Anterior radical debridement and anterior instrumentation in tuberculosis spondylitis.

The conventional procedure in the treatment of vertebral tuberculosis is drainage of the abscess, curettage of the devitalized vertebra and application of an antituberculous chemotherapy regimen. Posterior instrumentation results are encouraging in the prevention or treatment of late kyphosis; however, a second-stage operation is needed. Recently, posterolateral or transpedicular drainage without anterior drainage or posterior instrumentation following anterior drainage in the same session has become the preferred treatment, in order that kyphotic deformity can be avoided. Information on the use of anterior instrumentation along with radical debridement and fusion is scarce. This study reports on the surgical results of 63 patients with Pott's disease who underwent anterior radical debridement with anterior fusion and anterior instrumentation (23 patients with Z-plate and 40 patients with CDH system). Average age at the time of operation was 46.8+/-13.4 years. Average duration of follow-up was 50.9+/-12.9 months. Local kyphosis was measured preoperatively, postoperatively and at the last follow-up visit as the angle between the upper and lower end plates of the collapsed vertebrae. Vertebral collapse, destruction, cold abscess, and canal compromise were assessed on magnetic resonance (MR) images. It was observed that the addition of anterior instrumentation increased the rate of correction of the kyphotic deformity (79.7+/-20.1%), and was effective in maintaining it, with an average loss of 1.1 degrees +/-1.7 degrees. Of the 25 patients (39.7%) with neurological symptoms, 20 (80%) had full and 4 (16%) partial recoveries. There were very few intraoperative and postoperative complications (major vessel complication: 3.2%; secondary non-specific infection: 3.2%). Disease reactivation was not seen with the employment of an aggressive chemotherapy regimen. It was concluded that anterior instrumentation is a safe and effective method in the treatment of tuberculosis spondylitis.