Does sagittal alignment of the femoral component have an impact on radiological loosening and functional results in revision knee arthroplasty?

OBJECTIVES: In this study, we aimed to investigate the effect of sagittal alignment of the femoral component on both radiological loosening and functional results in revision total knee arthroplasty (rTKA), as well as the anterior condylar offset (ACO) and posterior condylar offset (PCO). PATIENTS AND METHODS: Between December 2005 and November 2020, a total of 47 patients (12 males, 35 females; mean age: of 67.1±8.4 years; range, 52 to 90 years) who underwent rTKA due to aseptic prosthesis failure were retrospectively analyzed. Demographic data including age, sex, body mass index (BMI), and clinical outcomes of the patients were recorded. Early postoperative sagittal alignment of the femoral component, ACO, and PCO were measured. Radiological loosening of patients was evaluated using the modified Knee Society Score, while the functional outcomes were assessed using the Knee Injury and Osteoarthritis Outcome Score (KOOS). RESULTS: The mean follow-up was 55.4±28.0 (range, 24 to 142) months. While there was a moderate and inverse correlation between the sagittal alignment of the femoral component and ACO (p=0.002), there was no significant correlation between the sagittal alignment of the femoral component and PCO (p=0.980). There was a weak and inverse correlation between BMI and KOOS (p=0.024). There was no significant relationship between the sagittal alignment of the femoral component, ACO, PCO, age, and sex with radiological loosening (p=0.241) or KOOS (p=0.894). CONCLUSION: In rTKA, sagittal alignment of the femoral component does not affect radiological loosening and functional results. The sagittal alignment of the femoral component exhibits a moderate and inverse correlation with ACO, while it has no significant correlation with PCO.

A comparison of exchange nailing and plate augmentation over a retained intramedullary nail in aseptic oligotrophic and atrophic femoral shaft pseudoarthrosis.

OBJECTIVES: This study aims to evaluate the success of plate augmentation over a retained intramedullary nail (IMN) against exchange nailing performed with autologous bone grafting in oligotrophic and atrophic pseudoarthrosis of the femoral shaft. PATIENTS AND METHODS: Between May 2005 and October 2020, a total of 42 of 56 patients (28 males, 14 females; mean age: 47.3±17.2 years; range, 19 to 84 years) with aseptic atrophic or oligotrophic femoral nonunion were retrospectively analyzed. The patients, 20 were operated with plate over a retained IMN, and the rest (n=22) by exchange nailing. Data including demographic and clinical characteristics of the patients, treatment success, duration of surgery, blood loss during surgery, infection rates, length of hospital stay, time to bridging of the nonunion site, and time to obliteration of the fracture line (solid union) were recorded. RESULTS: The mean follow-up was 23.8±20.4 (range, 12 to 96) months in the plate over an IMN group and 34.7±27.4 (range, 12 to 90) months in the exchange nailing group. At the final follow-up, solid union occurred in all of the patients in the plate augmentation over a retained IMN group, and 21 of 22 (95.45%) patients in the exchange nailing group. Blood loss during surgery was significantly less in the plate augmentation over IMN group (p=0.027). There was no statistically significant difference in the other variables between the two groups (p>0.05). CONCLUSION: Our study results demonstrate that plate over a retained IMN is effective as exchange nailing in the surgical treatment of oligotrophic and atrophic pseudoarthrosis of the femoral shaft. However, it can be speculated that plate application over IMN is more advantageous in terms of blood loss during surgery.

Pediatric infrafossal fracture of the humerus: A case series.

OBJECTIVES: In this case series, we aimed to evaluate the clinical and radiographic outcomes of the patients with infrafossal fracture of the humerus and to evaluate the upper extremity and elbow function with the Mayo Elbow Performance Score (MEPS) and Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire. PATIENTS AND METHODS: Between January 2005 and July 2020, the clinical data and radiographs of 2,443 children who were treated due to distal humerus fracture were retrospectively analyzed. A total of six patients (5 males, 1 female; mean age: 6.7±2.6 years, range, 3 to 11 years) treated due to an infrafossal fracture of the humerus were included. Radiographic measurements, such as Baumann's angle, lateral capitellohumeral angle, and carrying angle of the elbow, were performed. At the final follow-up, elbow joint range of motion (ROM) was measured, functional scores of the elbow and upper extremity were assessed. Complications were also recorded. RESULTS: The mean follow-up was 62.8±47.4 (range, 20 to 140) months. Two patients underwent open and three underwent closed reduction and internal fixation by different surgeons. One of the patients was treated with a long-arm cast. There was no major elbow ROM limitation. There was no significant deterioration in the lateral capitellohumeral and elbow carrying angles of the patients. Baumann's angle was normal for all the patients; however, it could not be measured in two patients, as their epiphyses were closed. Four patients had an excellent MEPS and two patients a good MEPS. The QuickDASH scores were low in all patients. There were two patients with cubitus varus who were treated surgically using lateral closing-wedge corrective osteotomy. CONCLUSION: Infrafossal fracture of the humerus is a fracture type which is different from supracondylar and transcondylar fractures and has not been previously reported in the literature. Despite the cubitus varus developed in two of our patients, functionally satisfactory results were achieved in all patients at the end of the treatment. Due to the risk of developing cubitus varus, patients with infrafossal fracture of the humerus should be followed closely until the end of adolescence. Although the current study is very limited in terms of being a guide for the treatment, it may contribute to the literature in terms of defining a new fracture subtype.

Correlations of proximal junctional kyphosis with radiographic measurements, spinopelvic parameters, and health-related quality of life in Lenke type V adolescent idiopathic scoliosis.

OBJECTIVES: This study aims to investigate the effects of radiographic measurements, spinopelvic parameters, and Scoliosis Research Society-22r (SRS-22r) subscales on proximal junctional kyphosis (PJK) in patients with Lenke type V adolescent idiopathic scoliosis operated with only a posterior all-pedicle-screw instrumentation technique. PATIENTS AND METHODS: Between January 2011 and March 2019, data of 115 patients (17 males, 98 females; mean age: 14.6±2.9 years; range, 10 to 18 years) with Lenke type V AIS who were operated with posterior fusion were retrospectively analyzed. Proximal junctional angle (PJA) was measured as a Cobb angle (CA) between the inferior endplate of the upper instrumented vertebra and the superior endplate of the second suprajacent vertebra. A ≥10° PJA and being ≥10° greater than its preoperative value was defined as PJK. Radiographic measurements, SRS-22r scores, and correlations with the PJA were evaluated for PJK and non-PJK groups. RESULTS: The prevalence of PJK was 35.6%. There were statistically significant differences between the groups in terms of preoperative CA (p=0.002), preoperative thoracic kyphosis angle (TKA) (p<0.001), postoperative TKA (p=0.001), PJA (p<0.001), postoperative pelvic tilt (p=0.038), preoperative pain (p=0.005), preoperative self-image (SI) (p=0.045), preoperative subtotal score (p=0.006), preoperative total score (p=0.007), and sex distribution (p=0.002). No statistically significant differences were detected for other parameters (p>0.050). Positive correlations were found between PJA and preoperative TKA (p=0.042), postoperative TKA (p=0.002), preoperative sagittal balance (SB) (p=0.015), preoperative SI (p=0.012), postoperative SI (p=0.032), postoperative mental health (p=0.011), postoperative subtotal score (p=0.018), postoperative total score (p=0.014), and postoperative sacral slope (SS) (p=0.015). A negative correlation was found between PJA and preoperative satisfaction (p=0.044). CONCLUSION: The occurrence of PJK is multifactorial, including clinical, surgical, and radiographic factors. Male patients with higher pre and postoperative TKA, preoperative SB, and postoperative SS and patients with lower satisfaction have a higher risk of PJK development.

An evaluation of intra and inter observer reliability of the five used classification systems of tibial plateau fractures.

We aimed to evaluate the intraobserver and inter- observer variations of the five primary classification systems for assessing tibial plateau fractures via standard X-Ray, biplanar and reconstructed 3D CT images. Using anteroposterior (AP) - lateral X-Ray, and CT images, one hundred tibial plateau fractures were evaluated and classified by four surgeons according to the AO, Moore, Schatzker, modified Duparc, and 3-column classification systems. Each observer evaluated the radiographs and CT images separately - listed each time randomly - on a total of 3 occasions: with an initial evaluation, and then subsequently in weeks 4 and 8. Intra- and interobserver variabilities were assessed using the Kappa statistics. Intra- and interobserver variabilities were 0.55 ± 0.03 and 0.50 ± 0.05 for AO, 0.58 ± 0.08 and 0.56 ± 0.02 for Schatzker, 0.52 ± 0.06 and 0.49 ± 0.04 for Moore, 0.58 ± 0.06 and 0.51± 0.06 for the modified Duparc, and 0.66 ± 0.03 and 0.68 ± 0.02 for the 3-column classification. Evaluation of tibial plateau fractures using 3-column classification in conjunction with radiographic classifications has higher levels of consistency compared to radiographic classifications alone.

Quality of Life Among Patients with Early-Onset Scoliosis Treated with Magnetically Controlled Growing Rods-Early-Term Results.

BACKGROUND: The term "early-onset scoliosis" (EOS) refers to spinal deformities that develop before the age of 10 years. The aim of surgical treatment for EOS is stopping the progression of the curvature, maintaining the correction, ensuring the maximum growth of the vertebrae, and ensuring that the vertebrae remain mobile. Using magnetically controlled growing rods (MCGRs) in the treatment of EOS is intended to protect the patient from the negative effects of repetitive surgeries, increase patient compliance and satisfaction, and increase the speed of return to normal social life. Our aim was to report the early radiological evaluation findings and detect the changes in the quality of life of patients and their parents after the diagnosis of EOS and treatment with MCGRs. METHODS: We performed a retrospective clinical study (level 4 case series) of 20 patients with a surgical indication for the treatment of EOS. The 20 patients had undergone treatment with MCGRs and lengthening procedures at 3-month intervals from August 2014 to August 2016. The mean patient age at surgery was 7.9 years (range, 4-10 years), and the mean length of follow-up was 14.9 months (range, 6-30 months). The preoperative, early postoperative, and final follow-up radiographs of all patients were obtained. The Cobb angle, thoracic kyphosis, spinal height, thoracic height, sagittal balance, coronal balance, shoulder balance, and pelvic balance were measured from the radiographs. All the patients had undergone preoperative and final follow-up respiratory function tests, and all the patients completed the Early Onset Scoliosis 24-item questionnaire (EOSQ-24). The outcome measures were the Cobb angle, thoracic kyphosis, spinal height, thoracic height, sagittal balance, coronal balance, shoulder balance, and pelvic balance. All the patients had undergone preoperative and final follow-up respiratory function tests, and the parents of every patient completed the Turkish version of the EOSQ-24. RESULTS: The preoperative, early postoperative and final follow-up mean Cobb angles were 56.6° (range, 38°-93°), 30.5° (range, 13°-80°), and 33.5° (range, 14°-86°), respectively. These findings showed statistically significant improvement in the Cobb angle (P < 0.05). The thoracic height was also significantly increased. The preoperative, early postoperative, and final follow-up mean height was 181 mm (range, 123-224 mm), 200 mm (range, 164-245 mm), and 212 mm (range, 167-248 mm), respectively (P < 0.05). The measurements for spinal height had also increased significantly, with preoperative, early postoperative, and final follow-up values of 219 mm (range, 213-366 mm), 315 mm (range, 260-402 mm), and 338 mm (range, 261-406 mm), respectively (P < 0.05). The thoracic kyphosis measurement was 41° (range, 5°-65°) preoperatively, which had decreased significantly to 32.5° (range, 0°-53°) at the final follow-up (P < 0.05). Our measurements showed no statistically significant differences in the coronal and sagittal balance, pelvic balance, or shoulder balance. No significant differences were found between the preoperative and postoperative respiratory function test results. The assessment of the EOSQ-24 scores had demonstrated significant improvements in the mean scores at the final follow-up (P < 0.05). When different categories in the EOSQ-24 were evaluated separately, no statistically significant differences were found between the preoperative and final follow-up scores for general health, pain and discomfort, respiratory function, movement capability, physical function, or effects on daily life (P > 0.05). However, the exhaustion and energy levels, emotional state, effect of the disease on the parents and patient, and parent satisfaction scores had increased significantly from the preoperative assessment to the final follow-up (P < 0.05). The financial effect had decreased significantly at the final follow-up compared with the preoperative values (P < 0.05). Four patients had developed complications requiring further treatment, and none of the patients had developed infection that required surgical intervention. CONCLUSIONS: Our study showed that insertion of a MCGR is a safe procedure for treatment of EOS to correct the deformity and improve function in daily life. This method reduces the need for repetitive surgery and the likelihood of complications associated with other treatments. Thus, treatment with MCGRs increases patient satisfaction and facilitates patient compliance.

Modified Woodward Technique for Sprengel Deformity and a Modification of the Cavendish Classification.

INTRODUCTION: Sprengel deformity (SD) is the most common congenital anomaly of the shoulder. Surgery is required for moderate and severe forms. The modified Woodward procedure is the most widely used procedure for the surgical treatment. METHODS: SD patients who applied to our institution between 2005 and 2018 were retrospectively reviewed. A modification of the Cavendish classification was used for preoperative and postoperative evaluations. RESULTS: Eighteen shoulders of 17 (mean age: 8.5 y, range: 2 to 18 y, 5 males and 12 females) patients were included. The right, left, and bilateral shoulders were affected in 9, 7, and 1 cases, respectively. The mean follow-up time was 62.9 months (12 to 161 mo). Preoperatively, 3 shoulders were type 2, 12 shoulders were type 3, and 3 shoulders were type 4 according to the Cavendish classification and 2 shoulders were type 0, 6 shoulders were type 1, and 10 shoulders were type 2 postoperatively. CONCLUSIONS: Periscapular congenital malformations play a significant role in range of motion limitation. The modified Woodward procedure is a viable alternative in the surgical treatment of SD and the proposed modification of Cavendish classification (grade 0) is functional.

Change of Sagittal Spinopelvic Parameters after Selective and Non-Selective Fusion in Lenke Type 1 Adolescent Idiopathic Scoliosis Patients.

AIM: To compare the postoperative changes of both sagittal spinal and spinopelvic parameters in patients with Lenke Type 1 adolescent idiopathic scoliosis (AIS) who underwent selective and non-selective fusion surgery. MATERIAL AND METHODS: We conducted a retrospective study among 53 Lenke Type 1 AIS patients who underwent corrective surgery at our centre between 2006 and 2012. Patients were classified as group 1 if they underwent selective surgery and as group 2 if they underwent non-selective surgery. Surgical results of preoperative and postoperative sagittal and spinopelvic measurements, pelvic tilt (PT), pelvic incidence (PI), sacral slope (SS), lumbar lordosis (LL) and thoracic kyphosis (TK) values were analysed using the SURGIMAP© Software (Nemaris Inc. USA) measurement system. RESULTS: In both groups, a comparison of pre- and postoperative sagittal spinal parameters did not show a statistically significant difference. In both groups, pre- and postoperative measurements of LL and TK did not show a statistically significant difference. CONCLUSION: After selective and non-selective surgery, sagittal spinal and spinopelvic parameters are not affected in the middle term. We think that the long-term studies to be done in this regard will increasingly require the necessity of keeping the pelvis in mind while evaluating the sagittal plan in AIS surgery.

The proprioception of the knee joint following tibia plateau fractures.

Proprioception is a conscious and/or unconscious perception of position change in an extremity or joint in space. In our study our purpose was to evaluate whether the lower extremity proprioception in long term, is altered following tibia plateau fractures and to assess its relation with age and type of fracture. This retrospective study includes the evaluation of proprioception in 38 tibia plateau fracture patients (29 male, 9 female) of various types who were operated with open reduction and internal fixation (ORIF) technique in our clinic, by comparison of both operated knee and unaffected knee. The mean age of the patients were 38,8 (range, 20-60) and mean follow-up time was 56 months (range, 13-120 months). Proprioception measurements were assessed at 30° and 60° of knee flexion degrees both passively and actively. There were no significant difference between the operated knee and unaffected knee by mean absolute angular deviation values at passive (p = 0,22) or active 60° (p = 0,22). Accordingly passive (p = 0,47) and active 30° (p = 0,62) mean absolute angular deviation values showed no significant difference. Our study has indicated that proprioception at the operated extremity is not significantly different from the unaffected knee in tibia plateau fractures at long term follow-up.

The Treatment of Cleidocranial Dysostosis (Scheuthauer-Marie-Sainton Syndrome), a Rare Form of Skeletal Dysplasia, Accompanied by Spinal Deformities: A Review of the Literature and Two Case Reports.

Cleidocranial dysostosis is a skeletal dysplasia inherited in an autosomal dominant manner and may lead to complications such as scoliosis and kyphosis, concurrent with various orthopedic involvements. Since concurrent spinal deformities are of progressive nature, surgical treatment may be necessary. In addition to other orthopedic problems, possible accompanying complications such as atlanto-axial subluxation, myelopathy, syringomyelia, congenital spine deformities, spondylosis, and spondylolisthesis should be kept in mind while planning for the treatment of scoliosis and kyphosis. Lengthening the use of growth-friendly systems (growing rod) in patients, like ours, with an early onset of symptoms, and performing posterior instrumentation and fusion once the spinal growth is complete will yield successful results with no complications in the middle and the long term. Further multicenter studies with more comprehensive assessments are required to find solutions to spinal problems related to this rare skeletal dysplasia.

Tibial tubercle-trochlear groove distance and angle are higher in children with patellar instability.

PURPOSE: The purpose of this study was to assess the variations in tibial tubercle-trochlear groove distance and angle as a function of age and gender in a population of children without patellar instability (PI) compared with those with PI. METHODS: A retrospective review of 869 children's knee MRIs, ages 5 to 15 years, were evaluated using a control group (792 children) without evidence of PI and a group with PI (77 children). Tibial tubercle-trochlear groove distance (TT-TGd) and angle (TT-TGa) were measured twice by two readers to assess intra- and inter-observer reliability and compared between PI and control groups. In both groups, functions of age and gender on TT-TGd and TT-TGa values were evaluated. RESULTS: Both TT-TGd and TT-TGa measurements showed excellent intra- and inter-observer reliability. The mean TT-TGd for the PI group was 17.2 mm (SD 6.6) and significantly higher than the mean TT-TGd for the control group (10.4 SD 3.8 mm, P = 0.001). The mean TT-TGa for the PI was 20.8° (SD 8.3°), which was also significantly higher than the mean TT-TGa for the control group (12.5° SD 4.6°, P < 0.001). Control group revealed a positive correlation between age and TT-TGd measurements (r = 0.243, P < 0.001). The mean TT-TGa for girls (13.3° SD 4.7°) was higher than the mean TT-TGa for boys (11.9° SD 4.4°) in the control group (P < 0.001). CONCLUSION: TT-TGa and TT-TGd are reliable and can be used for the evaluation of the extansor mechanism alignment in children with and without PI. However, it must be considered that TT-TGd is increasing in growing patients. Soft-tissue procedures may be prone to failure, since bony procedures for patellar alignment cannot be done until skeletal maturity. LEVEL OF EVIDENCE: III.

The Effect of Previous Hip Surgery on the Outcome of Hip Arthroplasty in Young Patients.

BACKGROUND: The incidence of total hip arthroplasty (THA) is increasing in all age groups, especially in young patients. The outcome of THA is believed to be affected by morphological deformities created by previous pelvic or femoral procedures performed in childhood. The aim of the present study was to assess whether previous hip surgery impaired the functional outcome in young patients who underwent THA. METHODS: Data were collected from the records of patients aged less than 30 years who had undergone THA between 2002 and 2011. Thirty-five patients (44 hips) were included. The Western Ontario and McMaster Universities Osteoarthritis Index and Harris Hip Scores were collected as primary functional outcome measures. The secondary outcome measures were the major and minor complications. Patients were divided into 2 groups: those who had not undergone hip surgery before THA (group I, 17 patients, 24 hips) and those with a history of prior hip surgery (group II, 18 patients, 20 hips). RESULTS: The mean age at the time of surgery was 25 ± 4 years in group I and 23 ± 4 years in group II. The mean Harris Hip Score was slightly higher in group I (90 ± 7) than in group II (87 ± 7) (P = .2). The mean Western Ontario and McMaster Universities Osteoarthritis Index scores were similar in both groups (in group I 14 ± 7 and in group II 14 ± 6, P = .9). Complication rates were also similar in both groups (P = .7). CONCLUSIONS: It is often difficult to decide whether to perform THA in young patients. One potential risk factor for complications is hip surgery before THA. Our study revealed that young patients with or without a history of previous hip surgery achieved satisfactory functional outcomes with similar complication rates after THA.

Analysis of complications following posterior vertebral column resection for the treatment of severe angular kyphosis greater than 100°.

OBJECTIVE: The aim of this study was to evaluate the complications, efficacy and safety of posterior vertebral column resection (PVCR) in severe angular kyphosis (SAK) greater than 100°. METHODS: The medical records of 17 patients (mean age 17.9 (range, 9-27) years) with SAK who underwent PVCR, were reviewed. Mean follow-up period was 32.2 (range, 24-64) months. Diagnosis of the patients included congenital kyphosis in 11 patients, post-tuberculosis kyphosis in 3 patients and neurofibromatosis in 3 patients. The sagittal plane parameters (local kyphosis angle, lumbar lordosis, sagittal vertical axis, pelvic tilt, sacral slope and pelvic incidence) were measured in the preoperative and the early postoperative periods and during the last follow-up on the lateral radiographs. RESULTS: The mean preoperative localized kyphosis angle was 121.8° (range, 101°-149°). The mean local kyphosis angle (LKA) was 71.5° at postoperatively evaluation (p < 0.05). Complications were detected in 12 patients (70.6%) with spinal shock in 4 patients, hemothorax in 3 patients, postoperative infection in 2 patients, dural laceration in 2 patients, neurological deficit in 2 patients (1 paraplegia and 1 root injury), the shifted cage in 2 patients and rod fracture in 2 patients. Neurological events occurred in six patients (35%) with temporary neurological deficit in 5 patients and permanent neurological deficit in 1 patient. CONCLUSION: PVCR is an efficient and a successful technique for the correction of SAK. However, it can lead to a large number of major complications in SAK greater than 100°. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Vitamin-D measurement in patients with adolescent idiopathic scoliosis.

Our retrospective study compared vitamin-D levels in 229 patients with adolescent idiopathic scoliosis (AIS) and 389 age-matched controls, and evaluated the correlation between vitamin-D levels and sex, Cobb's angle, and serum levels of calcium (Ca), phosphorus, and alkaline phosphatase in the AIS group. Vitamin-D levels were lower in the AIS group, with no sex-specific effects, indicative of a possible vitamin-D resistance in AIS. Vitamin-D levels correlated positively with Ca levels and negatively with Cobb's angle, indicative of a possible role of vitamin D in the etiopathogenesis of AIS. Patients with AIS should be monitored for vitamin-D deficiency/insufficiency.

A New Radiological Sign for Severe Angular Kyphosis: "The Baltalimani Sign".

STUDY DESIGN: Retrospective diagnostic study. PURPOSE: To define a new radiological sign, "Baltalimani sign," in severe angular kyphosis (SAK) and to report its relationship with the risk of neurological deficits and deformity severity. OVERVIEW OF LITERATURE: Baltalimani sign was previously undefined in the literature. METHODS: We propose Baltalimani sign as the axial orientation of the vertebrae that are located above or below the apex of angular kyphosis on anteroposterior radiographs. Patients with SAK of various etiologies with kyphotic angles ≥90° were selected and evaluated for the presence of Baltalimani sign. Demographic data of the patients including age, gender, etiology, neurological status, local kyphosis angles, and the location of the kyphosis apex were recorded. Sensitivity, specificity, positive predictive value (PPV), and negative predictive values (NPV) of Baltalimani sign for the risk of the neurological deficits were evaluated by the IBM SPSS ver. 20.0. A p-values of <0.05 were considered statistically significant. Cohen's kappa was used for analysis of interrater agreement. RESULTS: The mean local kyphosis angle in all patients was 124.2° (range, 90°-169°), and 15 of 40 (37.5%) patients had neurological deficits. Baltalimani sign was seen in 13 of 15 patients with neurological deficits (p=0.001). Baltalimani sign showed a sensitivity and specificity PPV and NPV of 61.9%, 86.7%, 89.5%, and 68.8% for the risk of the neurological deficits in SAK patients, respectively. Cohen's kappa value was moderate (κ=0.506). CONCLUSIONS: The detection of Baltalimani sign in SAK may indicate severity of deformity and the risk of neurological deficits.

Preoperative and Postoperative Photographs and Surgical Outcomes of Patients With Kyphosis.

STUDY DESIGN: A retrospective clinical study was performed. OBJECTIVE: The aim of the study was to show patients their pre- and postoperative body photographs, and determine the effect on postoperative patient satisfaction for thoracic and thoracolumbar sharp and round angular kyphosis. SUMMARY OF BACKGROUND DATA: Previous studies have reported the normative values of pelvic sagittal parameters and the classification of normal patterns of sagittal curvature, but no study has investigated and compared the clinical photographs of sharp and round kyphosis. METHODS: In patients who underwent surgery for thoracic and thoracolumbar sharp and round angular kyphosis, whole spine anteroposterior and lateral radiographs, and clinical photographs were obtained preoperatively and at the final follow-up. Pelvic and spinal parameters were measured, and the pre- and postoperative photographs were shown to patients. The Scoliosis Research Society 22r (SRS22r) and Short Form 36 surveys were administered to all patients, and the scores were analyzed. RESULTS: Thirty-eight patients diagnosed with kyphosis (mean age 19.6 yr, mean follow-up duration 26.4 mo) were divided into two groups: sharp (18 patients, mean age 20.1 yr) and round (20 patients, mean age 19.6 yr) kyphosis. There was no difference between values in the sharp and round groups in terms of age, follow-up duration, and Risser score (P > 0.05). In both groups, the subscores for pain, self-image, mental health, and satisfaction, except for the function/activity score, and the total score of the SRS22r survey were, however, significantly different between pre- and postoperative photographs. In addition, there was no significant difference between the two groups in any SRS22r domain and Short Form 36 scores. CONCLUSION: The surgical treatment of kyphosis was uniformly associated with improved quality of life, regardless of the kyphosis type. Thus, showing patients their pre- and postoperative photographs may enhance patient satisfaction, as measured by SRS22r scores. LEVEL OF EVIDENCE: 4.

Sacral agenesis: evaluation of accompanying pathologies in 38 cases, with analysis of long-term outcomes.

PURPOSE: Sacral agenesis (SA), or caudal regression syndrome, is a congenital malformation of the spine of varying degree of severity. The aim of our study was to identify associated impairments in structure and function of the orthopedic, neurological, cardiopulmonary, genitourinary, and gastrointestinal systems, and to evaluate their impact on function. METHODS: This was a retrospective case series analysis of 38 patients with SA. Patients were divided into two groups: SA with myelomeningocele (group 1) and without myelomeningocele (group 2). Between-group comparisons in terms of the features of the SA, impairments in associated systems, impact on gross motor function, need for surgery, and association with prenatal screening and maternal gestational diabetes were evaluated. RESULTS: The majority of comorbidities were orthopedic and neurological in nature. Impairments in sphincter control and independent transferring were more prevalent in group 1, resulting in lower function. Scoliosis, kyphosis, and hip dislocation/subluxation were the most common orthopedic problems, with a higher prevalence of kyphosis in group 1. The requirement for neurosurgery was significantly higher in group 1. CONCLUSIONS: Orthopedic and neurological comorbidities are commonly associated with SA and are more prevalent in the presence of a myelomeningocele. As the impairments impact a child's ability for maximum function, early identification and intervention is required to correct or ameliorate the impairment. LEVEL OF EVIDENCE: Level IV.

Two level pedicle substraction osteotomies for the treatment of severe fixed sagittal plane deformity: computer software-assisted preoperative planning and assessing.

PURPOSE: To evaluate the efficacy of two level pedicle substraction osteotomies (PSOs) planned preoperatively with a computer software, in the patients with severe fixed sagittal plane deformities. METHODS: In the literature, there are studies indicating that two level PSOs may be required in severe cases. However, the results of two level PSOs preoperatively planned with computer software-assistance have not yet been reported in the English literature. Severe fixed sagittal plane deformities of 11 patients are described. Preoperative surgical planning was done with the aid of a computer software. Two level PSOs were indicated after the process. After the application of the indicated surgical technique, clinical and radiological results were evaluated in the preoperative, the early postoperative periods and during the last follow-up. RESULTS: The mean sagittal vertical axis was found as 190.5 (range 161-220) mm in the preoperative period, 23.5 (range -27 to 61) mm in the early postoperative period (P < 0.001) (87.7 % correction) and 34.5 (range -3 to 55) mm during the last follow-up (P < 0.001). The mean pelvic tilt (PT) significantly decreased from 38.3° (range 21°-63°) preoperatively to 23.8° (range 18°-42°) postoperatively (P = 0.008) and to 27.5° (range 17°-42°) during the last follow-up (P = 0.042). The mean lumbar lordosis (LL) was 2.8° (range -29° to 20°) preoperatively, -35.6° (range -54° to 23°) early postoperatively (P < 0.001) and -33.6° (range -52° to 20°) during the last follow-up (P < 0.001). The average amount of bleeding was 5345 (range 2600-7415) ml. CONCLUSION: Although a statistically significant correction was obtained, the mean PT and PI-LL value could not be restored in physiological limits during the last follow-up. Thus, two level PSOs performed after computer software (surgimap) assisted preoperative planning failed to correct severe fixed sagittal plane deformities. Besides, this procedure is of possible risks for major complications such as a result of excessive bleeding. We recommend that two level PSOs should be rarely indicated, but preferred as an alternative technique only in the most severe cases.

The effect of vertical expandable prosthetic titanium rib on growth in congenital scoliosis.

AIMS: In the treatment of thoracic insufficiency syndrome, the main aim is to maintain spinal and thoracic growth in order to continue respiratory functions. Vertical expandable prosthetic titanium rib (VEPTR) device application is a method of choice especially in the congenital cases with a thoracic deformity. In our study, we evaluated the effect of VEPTR on growth in congenital scoliosis. MATERIALS AND METHODS: Four female patients in whom VEPTR was applied were retrospectively evaluated. Anteroposterior (AP) and lateral Cobb angles that were measured preoperatively and during the last control, space available for lung (SAL), T1-S1 and T1-T12 distances, coronal and sagittal balances were compared. RESULTS: Four female patients in whom VEPTR was applied were retrospectively evaluated. AP and lateral Cobb angles that were measured preoperatively and during the last control, SAL, T1-S1, and T1-T12 distances, coronal and sagittal balances were compared. CONCLUSIONS: VEPTR may provide a good correction, and we observed a growth in the spine height and SAL following the treatment of congenital deformities. Long-term, multicenter, prospective studies that compare the spinal height, respiratory functions, the severity of the deformity, and the spinal balance are required in order to evaluate the efficacy of VEPTR.

Piriformis syndrome: treatment of a rare cause of posterior hip pain with fluoroscopic-guided injection.

INTRODUCTION: Piriformis syndrome involves the irritation of the piriformis muscle due to various reasons that are primarily related to anatomical variation or sciatic nerve compression due to contraction caused by overuse. In this study, we aimed to define an injection method that is easy to apply, safe, simple and repeatable. MATERIALS AND METHODS: We administered percutaneous lidocaine and depomedrol injections into the hips of 28 patients (14 men and 14 women) under fluoroscopic control. Bipolar injections of the piriformis muscle were performed at the medial pole, the intersection of the sciatic notch and the sacroiliac joint, and at the lateral pole of the femoral insertion region. Each injection was 5 cc, and the contrast agent was observed after the dyeing process. RESULTS: Clinical examinations were performed before and 6 weeks after the injections. The average of Harris Hip Score increased from a pre-injection score of 44.5 to a post-injection score of 68.5, and the Visual Analog Scale scores decreased from 8.3 to 4.2 (p<0.05). COMMENTS: Our findings lead to the conclusion that fluoroscopy-guided percutaneous local anaesthetic and corticosteroid injection is a simple and effective piriformis syndrome treatment that can feasibly be effectively performed by orthopaedic surgeons.