The Efficiency of Simultaneous Systemic and Topical Use of Tranexamic Acid in Spinal Fusion Surgery.

BACKGROUND AND AIM: Multilevel posterior spinal fusion surgery in adults is associated with significant intra- and postoperative blood loss. Tranexamic acid (TXA) is an antifibrinolytic agent for reducing blood loss and allogenic blood transfusion. The purpose of this study was to evaluate the efficiency of TXA in reducing blood loss and improving hematologic parameters in adult patients undergoing posterior thoracic/lumbar instrumented spinal fusion surgery. PATIENTS AND METHODS: This is a retrospective observational study comparing the intra- and postoperative hemodynamic findings of two groups treated with and without TXA. The study included 112 adult patients receiving elective posterior thoracic/lumbar instrumented spinal fusion surgery. The patients were evaluated in terms of age, gender, type of surgery, intraoperative blood loss, pre- and postoperative hemoglobin (Hb) and hematocrit values, postoperative systemic anticoagulant use, intra- and postoperative use of blood products, and the volume of the drainage fluid as an indicator of postoperative blood loss. The TXA group received preoperative 10 mg/kg intravenous TXA, another dose of 10 mg/kg/h in isotonic solution during the operation, and local administration of TXA before the closure of the surgical site (1g in patients undergoing surgery in ≤3 segments, and 2g in patients undergoing surgery in ≥4 segment group). RESULTS: Intra- and postoperative blood loss and need for transfusion were significantly lower in the TXA group. Fifty-three of 112 patients required intra- and postoperative transfusion, and postoperative anticoagulants were given to 25/112 patients. The postoperative Hb level was lower, and the difference of pre- and postoperative Hb values was higher in the non-TXA group (not significant). CONCLUSION: Simultaneous systemic and topical application of TXA is a safe and efficient blood conservation strategy for adult patients undergoing major multilevel spinal surgery.

Treatment of Tibial and Femoral Bone Defects With Bone Transport Over an Intramedullary Nail.

OBJECTIVES: To evaluate the results of the bone transport over an intramedullary nail (BTON) technique for the treatment of segmental bone defects. DESIGN: Retrospective review of case series. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: We included 40 patients who underwent reconstruction of the lower limb with BTON technique between 2000 and 2018. The technique was performed in the tibial segments in 21 patients and in the femoral segments in 19 patients. INTERVENTION: The surgical technique was performed in 2 stages for patients with infected nonunion. Infection was eradicated in all patients at the first stage. For the BTON at the second stage, monolateral external fixators and circular external fixators were used for femoral and tibial defects, respectively. In cases of defects without any infection, debridement with a single-stage BTON was performed. MAIN OUTCOME MEASUREMENTS: Complications as well as radiological and clinical results were evaluated according to the criteria of Paley-Maar. RESULTS: Minor complications occurred in 11 patients: pin site problems (9), cellulitis (1), and skin detachment due to Schanz screw (1). Major complications occurred in 8 patients: docking site nonunion (4), early consolidation and Schanz screw failure (1), knee flexion contracture (1), and ankle equinus contracture (2). Four patients had osteomyelitis as residual sequelae. Bone score was excellent in 27 patients. Excellent functional results were obtained in 31 patients. CONCLUSIONS: The BTON technique is associated with low cost because of the short treatment period, low complication risk, and rapid rehabilitation and is not limited by the amount of bone transport. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Intraoperative Halo-Femoral Traction in Surgical Treatment of Adolescent Idiopathic Scoliosis Curves between 70° and 90°: Is It Effective?

STUDY DESIGN: A retrospective clinical study. PURPOSE: To analyze the surgical outcomes of intraoperative halo-femoral traction (HFT) in patients with adolescent idiopathic scoliosis (AIS) with Cobb angles between 70° and 90° and flexibility <35%. OVERVIEW OF LITERATURE: Numerous methods have been described to achieve adequate correction and successful results in the surgical treatment of AIS patients with a Cobb angle >70°. However, few studies have evaluated the results of HFT in AIS patients with Cobb angles between 70° and 90° and flexibility <35%. METHODS: The study comprised 24 AIS patients (18 females, six males; mean age, 17.4 years; mean preoperative Cobb angle, 80.1°; range, 70°-90°) who underwent surgery using intraoperative HFT. Neurological status was constantly assessed during the surgery using intraoperative neurophysiological monitoring. RESULTS: The mean follow-up period was 33.5 months. Radiographic outcomes demonstrated 85.7% correction of the major Cobb angle. Coronal and sagittal balance was achieved in all the patients, and shoulder levels were equalized. The traction was discontinued when a decrease in spinal cord potentials was observed during the surgery. CONCLUSIONS: Intraoperative HFT is an effective and reliable method for the management of scoliosis curves between 70° and 90°. The most significant advantages of the method are avoidance of the morbidities related to anterior surgery, osteotomy, or vertebral column resection; its contribution in helping achieve adequate reduction and optimum balance by the gradually increased corrective force, lack of any need for extreme correction force during instrumentation; and the high correction rates achieved.

Application of cement on strategic vertebrae in the treatment of the osteoporotic spine.

BACKGROUND CONTEXT: The application of pedicle screws with cement to strengthen the fixation of the osteoporotic spine has increasingly gained popularity. However, the technique has also led to an increase in cement-related complications. PURPOSE: The aim of the present study was to compare the clinical and radiological results of the patients with degenerative spinal pathologies who were treated with pedicle screws and cement injections on all segments versus those who were treated with cement injections only on the strategic vertebrae selected. STUDY DESIGN: A retrospective clinical study. PATIENT SAMPLE: The sample consists of 31 patients who underwent spinal surgery due to degenerative spinal pathologies. OUTCOME MEASURES: Patients were assessed for the adequate spinal fusion and cement-related complication parameters. METHODS: Thirty-one patients with a minimum follow-up period of 2 years were divided into two groups and evaluated. Group A consisted of 17 patients (14 females, 3 males; mean age: 68.1 years) with cemented pedicle screws and Group B consisted of 14 patients (12 females, 2 males; mean age: 67.2 years) with cemented screws on selected vertebrae alone. Selection of the strategic vertebrae was made by taking the most stressed regions in the fusion site into account. Prophylactic vertebroplasty was performed in all patients in Group A and on strategic segments in Group B to avoid an adjacent segment fracture. Early- and late-term complications during the follow-up period were recorded. RESULTS: Mean follow-up period was 51.8 (range: 31 to 80) months in Group A and 41.2 (range: 26 to 61) months in Group B. Cemented pedicle screws were bilaterally placed on 94 vertebrae in Group A. In Group B, cement was applied on 28 of 80 vertebrae. Including the prophylactic vertebroplasties, a total of 111 cement applications were performed in Group A and 38 in Group B. Cement embolism, symptomatic chest discomfort, and duration of surgery were significantly higher in Group A (p<.05). No adjacent segment fracture in the proximal or distal vertebra, implant failure, or loss of correction was seen throughout the follow-up period. CONCLUSIONS: The application of cemented pedicle screws on all segments of the osteoporotic spine increases the cement volume and rate of cement-related complications. Cementing the strategic vertebrae alone will enhance the fixation strength and endurance and decrease the complications caused by cement application.

Tibiotalocalcaneal arthrodesis by using proximal humeral locking plate.

OBJECTIVES: The aim of this study was to evaluate the short-term clinical and radiological results of tibiotalocalcaneal arthrodesis (TTCA) with proximal humeral locking plate. MATERIAL AND METHODS: Eight patients (7 female, 1 male; average age 53 years (range: 24-67)) who underwent TTCA with proximal humeral locking plate between 2009 and 2011, were retrospectively evaluated with AOFAS hindfoot scale and Maryland foot score system. The mean follow up was 32.6 months (range: 23-54). RESULTS: Complete fusion was achieved in 7 patients. Soft tissue infection was observed in 2 patients and reflex sympathetic dystrophy in 3 patients. All patients recovered with medical treatment. At the final follow-up, mean AOFAS Hindfoot score was 60 (range: 41-81) and Maryland Foot Score was 67.8 (range: 41-85). The satisfactory rates of AOFAS and MFS were found as 12.5% (1/8) and 50% (4/8), respectively. One patient had an incomplete union with 5 degrees of heel varus deformity and 5 degrees of equinus deformity was observed in another. There were no implant failure or deformation of the plate during the follow-up period. CONCLUSION: Our study suggests that proximal humeral plate may be an alternative for fixation in tibiotalocalcaneal fusion surgery.

The effect of growing rod lengthening technique on the sagittal spinal and the spinopelvic parameters.

PURPOSE: The aim of this retrospective clinical study is to evaluate the effect of growing rod lengthening technique on sagittal balance in relationship with the spinopelvic parameters, in early onset scoliosis (EOS). METHODS: Twenty-three patients (18 female, 5 male), with a mean age of 8.3 years during the operation (range 3.2-12.2), with EOS due to various etiologies were operated using growing rod (8 single, 15 dual) technique, between the years 2007 and 2011. The patients were operated in two different institutions and were evaluated retrospectively via the parameters on the radiographic charts including the mean curve angle, T1-S1 distance, cervical lordosis, thoracic kyphosis, lumbar lordosis, sagittal and coronal balance, pelvic tilt, sacral slope and pelvic incidence. The parameters were measured in the preoperative and the early postoperative periods and during the last follow-up. The data obtained from the measurements were evaluated statistically. Complications were also noted. RESULTS: The mean follow-up period was 34.2 months (range 24-57.6). The mean thoracic kyphosis angle was 53.6° (range 25°-119°) preoperatively, 39.6° (range 20°-61°) early postoperatively (p < 0.05) and 39.9° (range 21°-65°) during the last follow-up (p < 0.05). The mean lumbar lordosis angle was -46.1° (range -67° to -13°) preoperatively, -41° (range -64° to -11°) early postoperatively (p > 0.05) and -39.7° (range -62° to -16°) during the last follow-up (p > 0.05). Average sagittal balance was measured as 0.2 cm (range -7 to 24.7 cm) preoperatively, -0.1 cm (range -6.6 to 8.5 cm) initial postoperatively (p > 0.05) and -0.2 cm (range -7.3 to 13.5 cm) during the last follow-up (p > 0.05). The average pelvic incidence was found as 46.4° (range 27°-83°) preoperatively, 45.2° (range 28°-78°) (p > 0.05) early postoperatively and 45.7° (range 28°-82°) during the last follow-up (p > 0.05). We have encountered complications in 14 patients. These consisted of eight rod fractures, seven screw pull-outs, four hook dislodgements, three proximal junctional kyphosis, two screw nut loosening, one lamina fracture, one skin slough, one superficial wound infection and one deep wound infection. CONCLUSION: Significant improvement was found in the global thoracic kyphosis angle, by comparing the preoperative, the early postoperative and the last follow-up parameters statistically (p < 0.05). There was no statistically significant improvement in the spinopelvic parameters (p > 0.05). We claim that growing rod technique doesn't provide statistically significant improvement, in the sagittal spinal and the spinopelvic parameters, except for the kyphosis, in the treatment of EOS patients.

Osteotendinous repair of bilateral spontaneous quadriceps tendon ruptures with the Krackow technique in two patients with chronic renal failure.

Although unilateral traumatic quadriceps tendon rupture is a relatively frequent pathology, bilateral non-traumatic spontaneous ruptures are uncommon and are usually associated with chronic renal failure, hyperparathyroidism, gout, and systemic lupus erythematosus. This paper aimed to discuss two patients with chronic renal failure treated with the Krackow suture technique for spontaneous bilateral quadriceps tendon rupture.

Early mobilization with customized TLSO brace in thoracolumbar burst fractures.

OBJECTIVE: This study aimed to research the effectiveness of customized thoracolumbosacral orthosis treatment for stable burst type thoracolumbar vertebral fractures without neurological deficits. METHODS: The study included 26 patients (14 males, 12 females; mean age: 46.03 years; range: 18 to 64 years) conservatively treated for thoracolumbar (T11-L2) burst type vertebral fractures according to Denis classification between 2002 and 2009. Etiology were a fall from various heights in 12 patients (46.2%), motor vehicle accidents as an occupant in 7 (26.9%) and as a pedestrian in 4 (15.4%), and simple fall in 3 (11.5%). None of the patients had neurologic deficit and no damage was found in the posterior ligamentous complex in MRI evaluations. Denis pain and functional scales were used in the clinical evaluation. Local kyphosis angle, sagittal index and height loss percentage were measured in the radiologic evaluation. Post-fracture and follow-up values were compared. Mean follow-up period was 41.30 (range: 14 to 80) months. RESULTS: Mean pain and functional scores were 1.65 and 1.15 points, respectively, at the final follow-up. Twenty patients returned to their pre-trauma work and activities completely and six patients with small limitations. Mean period for returning to work was 3.64 (range: 2 to 6) months. Local kyphosis angle, sagittal index and height loss percentage values increased significantly at follow-up (p<0.05). CONCLUSION: The conservative treatment of stable thoracolumbar burst fractures is widely accepted. Early mobilization with customized TLSO brace appears to produce effective functional results despite loss of vertebral body height.

Intramedullary osteosynthesis of instable intertrochanteric femur fractures with Profin® nail in elderly patients.

OBJECTIVE: The aim of this study was to retrospectively analyze the radiologic and functional results of patients with instable intertrochanteric femur fractures treated with Profin® nails. METHODS: This study included 32 patients (24 female, 8 male; mean age: 70.7 years; range: 65 to 96 years) who were treated with Profin® nails for instable intertrochanteric fractures. Fractures were caused by a simple fall in 30 patients and pedestrian accident in two. Eleven patients had Type 31-A2 and 21 patients had Type 31-A3 fractures according to the AO/OTA classification. Results were evaluated clinically and radiologically. Mean follow-up period was 17.3 (range: 12 to 23) months. RESULTS: Good or acceptable reduction was achieved in 93.7% of our patients. Mean surgery duration was 28.2 (range: 22 to 75) minutes and mean blood loss was 215 (range: 150 to 320) cc. Complete union was achieved in all patients at a mean of 17.6 (range: 15 to 22) weeks. Postoperative mean collodiaphyseal angle was 125.5 (range: 122 to 130) degrees and there was no significant difference with follow-up values (p>0.05). Twenty-two patients were able to walk with support and 10 without support after surgery. Mean Oxford hip score was 23.70 (range: 14 to 39) points. One year mortality rate was 18.75%. CONCLUSION: Good functional and radiologic results can be achieved using Profin® nails for unstable intertrochanteric femur fractures in elderly patients.

The results of open reduction and screw or K-wire fixation for isolated type II radial head fractures.

OBJECTIVES: We evaluated the functional and radiographic results of patients treated with open reduction and screw or K-wire fixation for isolated Mason type II radial head fractures. METHODS: The study included 21 patients (14 men, 7 women; mean age 36 years; range 25 to 58 years) who were treated with open reduction followed by mini screw (n=11) or K-wire (n=10) fixation for isolated type II radial head fractures. Functional results were evaluated using the modified Morrey functional rating index. Radiographically, osteoarthritis or heterotopic ossification were investigated. The mean follow-up was 30.5 months for K-wire fixation, and 32.1 months for screw fixation. RESULTS: Union was achieved in all the patients, within a mean of 6.2 weeks with screw fixation, and 5.8 weeks with K-wire fixation. The range of motion of elbow flexion-extension and pronation-supination were 131.4 degrees and 144.4 degrees with screw fixation, and 127.5 degrees and 146.5 degrees with K-wire fixation, respectively. The mean Morrey index was 94.5 (range 73 to 100) with screw fixation, yielding excellent or good results in 10 patients. One patient whose result was fair had a 2-mm step-off on the joint surface, resulting in osteoarthritis. The mean Morrey index was 92.1 (range 73 to 100) in the K-wire group, with excellent or good results in nine patients, and fair in one patient. All the patients returned to preinjury work in a mean of 11.7 weeks and 12.5 weeks in screw and K-wire groups, respectively. Heterotopic ossification was not observed. The two fixation groups were similar with respect to union time, joint range of motion, Morrey score, and time to return to work (p>0.05). CONCLUSION: Our results suggest that both methods provide sufficient fixation resulting in similar functional results in isolated type II radial head fractures.

Rhomboid excision and Limberg flap for managing pilonidal sinus: results of 102 cases.

PURPOSE: Although many methods of surgical and nonsurgical approaches for treatment of pilonidal sinus have been proposed, an optimal treatment modality has not been achieved yet. The aim of this study was to determine advantages, disadvantages, and long-term results of rhomboid excision and Limberg flap procedure. METHOD: One hundred ten patients who had been treated with rhomboid excision and Limberg flap procedure for primary or recurrent pilonidal sinus were invited to the hospital. One hundred two patients responded and were asked about their complaints and satisfaction with treatment. Physical examination was performed on each patient, and their hospital records were reviewed. RESULTS: Three patients developed seroma with negative bacterial cultures, two patients had partial wound dehiscence, and one patient had purulent discharge. Mean length of hospital stay was 3.7 days, and mean time to return to normal activity was seven days. Five patients developed recurrence (4.9 percent) and except for these patients, all of the patients were satisfied with the final result. CONCLUSION: Rhomboid excision and Limberg flap procedure can be performed for managing primary or recurrent pilonidal sinus with a low complication rate, short hospital stay, short time to return to normal activity, and good long-term results.