The effect of spinal correction surgery on the tractography data of the pain pathway in scoliosis patients: a preliminary report.

STUDY DESIGN: Cross-sectional study. OBJECTIVE: Pain in individuals with opered scoliosis is usually evaluated with a postural analysis or questionnaire. In this study, we evaluated pain in individuals with scoliosis who underwent spinal correction surgery by tractography and compared it with individuals with non-opered scoliosis and healthy individuals. DESIGN: Fifteen healthy individuals, 15 non-operated scoliosis patients and 15 operated scoliosis patients were included in the study. METHODS: All female participants in this prospectively planned study used their right hand as the dominant hand. Bilateral tractography analysis of the pain pathways was performed with DSI Studio software using brain magnetic resonance images (MRI) of the participants. Statistical analysis of the study was performed with IBM SPSS 23.0 and p<0.05 values were considered significant. RESULTS: It was observed that the tractography values of the operated scoliosis group were similar to the control group (p˃0.05). In the non-operated scoliosis group, tractography findings related to nerve conduction velocity such as fiber count, fiber ratio and axial diffusivity (AD) were found to be higher than the other two groups (p<0.05). Fractional anisotropy (FA) values of the unoperated scoliosis group were significantly different between the pain pathways projected from the right/left side of the body (p<0.05). CONCLUSION: The fact that the pain path tractography values of patients with scoliosis who underwent surgery were similar to those of healthy individuals may be evidence of decreased pain sensation reaching the brain. Surgery may be a good choice in the treatment of pain in patients with scoliosis.

Comparison of morphometric measurements of lumbar muscles on the convex and concave sides of curvature in idiopathic scoliosis.

It has always been wondered how the muscle volumes of the lumbar region are affected on the convex and concave sides of the curvature in idiopathic scoliosis (IS) and their possible differences compared to healthy individuals. Muscular changes in individuals with IS have generally been tried to be determined by measurements such as muscle cross-sectional area. However, since the changes in the locomotor system in scoliosis affect the anatomical structures of the muscles such as origin and insertion, the reliability of muscle cross-sectional area measurement decreases. Our aim in this study was to compare the psoas major (PM) and quadratus lumborum (QL) muscle volumes, which undergo the most changes on the concave and convex side of the curvature in scoliosis, within themselves and with healthy individuals. 34 women with scoliosis and 29 healthy women were included in this descriptive retrospective study. PM and QL muscle volumes were measured bilaterally on computed tomography (CT) images of individuals in both groups and recorded as mm3. Statistical analysis was performed with IBM SPSS 23.0, P < .05 was considered significant. In the IS group, both PM and QL muscle volumes were greater on the convex side of the curve (P < .001). When the IS group was compared with the control group, both muscle volumes were significantly lower in the IS group bilaterally than in the control group (P < .001). It was observed that individuals with IS developed atrophy in the lumbar muscles of both sides of the curve, mostly on the concave side of the curve, compared to healthy individuals. We think that these results will be important in planning appropriate physical therapy for individuals with IS.

Demonstrating the relationship of ultrasonographic parameters with disease activity and pain in lateral epicondylitis.

To evaluate the relationship of ultrasonographic evaluation parameters with pain, muscle strength and disease severity in lateral epicondylitis (LE). 64 people were included in present retrospective, cross-sectional study. Activity and rest pain was questioned with Visual Analog Scale (VAS). Also, Patient Rated Tennis Elbow Evaluation (PRTEE) and the maximum grip strength were evaluated. Hypoechoic region, neovascularity, cortical irregularity, enthesopathy and peritendinous fluid or bursitis were evaluated by ultrasonography. 48 of the patients were female and 16 were male. Mean age was 48.53 ±â€…6.12, body mass index was 27.70 ±â€…4.75. 55 (85.9%) hypoechoic region, 31 (48.4%) neovascularity, 21 (32.8%) cortical irregularity, 19 (29,7%) enthesopathy, and 18 (28.1%) peritendinous fluid or bursitis were detected by ultrasonography. When the ultrasonographic findings and clinical findings of the patients were compared, no significant difference was found between the hypoechoic region, cortical irregularity, enthesopathy and clinical findings (P > .05), while the extension grip strength was found to be significantly lower in patients with neovascularity (P = .045). In addition, patients with peritendinous fluid or bursitis, were found to be significantly lower in both flexion (P = .033) and extension (P = .023) grip strength, while PRTEE function (P = .021) subgroup and total (P = .038) scores were significantly higher. Hypoechoic region, cortical irregularities and enthesopathy were not evaluated to be associated with disease severity, pain and muscle strength. Neovascularity was found to be associated only with extension grip strength. Peritendinous fluid or bursitis was found to be associated with both flexion and extension grip strength and disease activity, but not associated with pain.

Evaluation of cerebellum volume and trunk oscillation velocity in cases with adolescent idiopathic scoliosis: a preliminary report.

PURPOSE: It has been suggested that the cause of the balance disorder seen in adolescent idiopathic scoliosis (AIS) originates from the central nervous system. However, the extent of the balance problem and the dysfunction of which part of the central nervous system has not been investigated in detail. This study aimed to correlate the values obtained by balance analysis and cerebellum volume measurement in female individuals with AIS with healthy individuals. METHODS: Cerebellum volume was calculated via the cloud-based software " https://volbrain.upv.es " using brain magnetic resonance images of 27 healthy and 26 individuals with AIS. The duration of stay in the test positions, the movement strategy used during this time and the amount of postural sway were analyzed by using a computer-assisted force platform and compared statistically. RESULTS: Significant differences were found between the AIS and control groups in cerebellum total volume, vermis cerebelli volume (cm3), and trunk oscillation velocity (mm/s) parameters (p < 0.05). Cerebellum and vermis cerebelli volumes were found to be lower and trunk oscillation velocity was found to be greater in patients with AIS. CONCLUSION: Balance problems in patients with AIS are correlated with decreased cerebellum volume and increased trunk oscillation velocity.

Anthropometry of the knee of the Turkish population and the comparison to implant sizes in total knee arthroplasty.

BACKGROUND: Total knee arthroplasty (TKA) is one of the most common orthopaedic surgical procedures in the advanced stages of knee arthritis. OBJECTIVE: The purpose of this study was to define the sex differences in the Turkish population's morphological measurements of the distal femoral and proximal tibial surfaces that form the knee joint and to compare their compatibility with conventional prosthetic implants commonly used in TKA for advanced-stage knee arthritis. METHODS: Anthropometric data for a total of 240 knees from 240 patients were measured using 3-dimensional computed tomography (3D CT). All morphological data were compared with the dimensions of four conventional knee prostheses commonly used in Turkey. RESULTS: A comparison of the four tibial components revealed that the majority of female proximal tibias matched with smaller-sized tibial components, whereas those of males matched the larger sizes. Comparing the morphological data with similar values for the four femoral components currently used in Turkey, we found that all the prostheses had similar values. CONCLUSION: The four conventional prosthetic brands included in this study matched the distal femoral dimensions of both sexes. On the other hand, we need smaller size tibial components for our female population.

Clinical and Radiological Results of Oxford Phase-3 Medial Unicompartmental Knee Arthroplasty.

Purpose The aim of this retrospective study was to investigate the effectiveness of medial unicompartmental knee arthroplasty (UKA) by showing the results of the radiological and clinical outcomes of the patients. Materials and methods Seventy-two knees of 54 patients who underwent UKA between September 2005 and March 2011 for medial knee arthritis with a minimum follow-up of six months were evaluated. Range of motion (ROM), Hospital for Special Surgery (HSS) knee score, Knee Society Score (KSS), and Oxford Knee Score (OKS) were investigated both preoperatively and postoperatively. On the other hand, Oxford radiographic evaluation criteria were used to evaluate prostheses radiologically at the final follow-up. Results The average age was 53.4 years (47 to 79 years). The average follow-up time was 39.8 months (8 to 72 months). There was a significant difference between preoperative and postoperative ROM, HSS, and OKS (p<0.05). Radiologically, there was no sign of arthritis on the unoperated side of the knee or failure of prosthesis detected. Before the operation, the average clinical KSS was 63.2 and improved to 91.4 after the operation. In addition, the average functional KSS was 54.9 before the operation and improved to 86.5 after the operation. The average knee flexion degree was 109.1 before the operation and there was an improvement to 123.6 degrees after the operation. Before the operation, the average HSS score was 67.5 (range, 52 to 75) and improved to 89.9 (range, 85 to 100) at the final control examination. Conclusion This study supports the use of Oxford Phase 3 UKA, which has excellent clinical and radiological results in patients with medial knee arthritis.

C7-T1 anterior closing wedge bone-disc-bone osteotomy for the treatment of cervical hyperlordosis in muscular dystrophy: a new technique for correction of a rare deformity.

STUDY DESIGN: A new surgical technique of cervical closing wedge osteotomy to correct an extension deformity of the cervical spine in patients with muscular dystrophy presenting clinically with debilitating hyperlordosis is described, and 3 cases are reported. OBJECTIVE: To describe a new surgical technique with emphasis on the clinical results and the effect of osteotomy on sagittal balance, gaze angle, and spinopelvic parameters. SUMMARY OF BACKGROUND DATA: Previous reports of cervical osteotomy essentially have described opening wedge (extension osteotomy) for correction of severe flexion deformities. To the authors' knowledge, C7-T1 closing wedge osteotomy to correct hyperextension deformity due to muscular dystrophy in the cervical spine has not been described previously. METHODS: Three male patients aged 16, 16, and 21 years presented with cervical hyperlordosis due to Becker muscular dystrophy. There was upward deviation of forward gaze in all patients. Anterior closing wedge (bone-disc-bone) osteotomy of C7-T1 was performed followed with a posterior release correction and instrumented stabilization. The chin-brow angle was visualized with the aid of fluoroscopy during the operation. After closure and posterior fixation, patient was turned supine again and the osteotomy site was grafted and fixed with a plate to further strengthen the construct and to prevent any translation. RESULTS: The gaze angles and both sitting and standing postures of the patients markedly improved. There was documented fusion at the osteotomy sites. The patients were free of complaints at the last follow-up. CONCLUSION: Bone-disc-bone closing wedge osteotomy done at C7-T1 level is a technically demanding procedure but results in significant acute clinical and radiological improvement in patients with hyperextension deformity of the cervical spine. LEVEL OF EVIDENCE: 4.

Protruded and nonprotruded subungual exostosis: Differences in surgical approach.

BACKGROUND: In subungual exostosis surgery, repair of the damaged nail bed and surgical excision of the mass without damaging the nail bed is important. The ideal method of surgery is still unclear. This study is done to qualify the effects of different surgical methods on outcome measures in different types of subungual exostosis. MATERIALS AND METHODS: Fifteen patients, operated with a diagnosis of subungual exostosis between January 2008 and June 2012, were evaluated. Protruded masses were excised with a dorsal surgical approach after the removal of the nail bed and nonprotruded masses were excised through a"fish-mouth" type of incision. RESULTS: The mean age of the patients in protruded subungual exostosis group was 17.3 years (range 13-22 years) and this group consisting of seven female and two male patients. The patients were followed up for a mean of 14.1 ± 4.8 months. The mean age of the patients in the nonprotruded subungual exostosis group was 14.6 years (range 13-16 years) and consisting of six female patients. The patients were followed up for a mean of 11.6 ± 2.9 months. The results were positively affected by changing the surgical approach depending on whether or not the exostosis is protruded from the nail bed. All patients had healthy toe nails in the postoperative period without any signs of recurrence. CONCLUSIONS: In patients with a protruded subungual exostosis, the mass should be removed by a dorsal approach with the removal of the nail and injury to the nail bed should be repaired. In patients with a nonprotruded subungual exostosis, the mass should be excised through a "fish-mouth" type incision at the toe tip without an iatrogenic damage.

Axial plane analysis of Lenke 1A adolescent idiopathic scoliosis as an aid to identify curve characteristics.

BACKGROUND CONTEXT: Adolescent idiopathic scoliosis (AIS) is a complex three-dimensional (3D) deformity of the spine involving deviations in the frontal plane, modifications of the sagittal profile, and rotations in the transverse plane. Although Lenke classification system is based on 2D radiographs and includes sagittal thoracic and coronal lumbar modifiers, Lenke et al. suggested inclusion of axial thoracic and lumbar modifiers in the analysis. PURPOSE: To analyze axial plane of Lenke 1A curves to identify curve characteristics. STUDY DESIGN: Retrospective study. PATIENT SAMPLE: Seventy patients (49 women, 21 men) with Lenke Type 1A idiopathic scoliosis were analyzed. OUTCOME MEASURES: Coronal, sagittal, and axial parameters were measured from plain radiographs that were obtained at initial medical examination of the patients. METHODS: Coronal and sagittal plane and whole spine segmental vertebra rotations from thoracic 1 to lumbar 5 were evaluated in 70 AIS patients with Lenke 1A curves by using Drerup method. Three different subgroups were identified according to magnitude and direction of lower end vertebra (LEV) rotation. RESULTS: In Group 1 (Lenke 1A1), the direction of LEV rotation was same with other vertebrae in the main curve and the magnitude of the LEV rotation was less than -0.5°. In Group 2 (Lenke 1A2), the rotation of LEV was between -0.5° and 0.5° and so was accepted as neutral. In Group 3 (Lenke 1A3), the rotation of LEV had opposite direction with vertebrae in the main curve and the magnitude of LEV rotation was more than 0.5°. The mean thoracic Cobb angle of patients with Lenke 1A idiopathic scoliosis was 51.1° (range 37°-80°), whereas the mean lumbar Cobb angle was 16.4° (range 0°-32°). The mean angle of trunk rotation of the patients was 5.7° (range 1°-16°). In terms of maximum thoracic vertebra rotation, the mean rotation angle of Lenke 1A idiopathic curves was -18.9° (range -(9.8°-44.7°)). The mean maximum lumbar vertebra rotation was 4.5° (range -7.2° to 15.1°). CONCLUSIONS: Addition of axial plane analysis to conventional coronal and sagittal evaluations in patients with Lenke 1A curves may reveal inherent structural differences that are not apparent in single planar radiographic assessments and may necessitate a different surgical strategy.

The use of intralaminar screws in patients with spinal deformity.

STUDY DESIGN: Retrospective study. OBJECTIVE: To demonstrate that intralaminar screws (ILS) can be used as supplements in spinal deformity surgery in the thoracic and lumbar levels in pediatric and adult patients. SUMMARY OF BACKGROUND DATA: Rigid posterior fixation of the spine is generally accomplished using pedicle screws, hooks, or wires. ILSs are useful tools when other spinal fixation techniques have failed or the bony anatomy precludes hook or screw placement. MATERIALS AND METHODS: All spinal deformity patients (primary/revision) operated between 2007 and 2011 were retrospectively reviewed. The patients with ILS were included in the study. The anteroposterior and lateral standing x-rays were evaluated in terms of preoperative and postoperative coronal and sagittal deformities. The number and level of ILS, intraoperative complications, and postoperative complications were noted. RESULTS: There were 20 patients (12 male and 8 female). The mean age was 21.75 years. The mean follow-up period was 17.4 months. Fifty-seven ILS were inserted. Seventeen screws were used in the uppermost to lowermost levels. Forty screws were used in the middle. There was 1 lamina fracture and screw pull out (1.75%). There were 3 canal violations (corrected intraoperative) and 2 instrument prominences which required implant removal. The mean preoperative/postoperative cobb angles were 78.5 degrees/27.8 degrees and the mean preoperative/postoperative kyphosis angles were 57.2 degrees/32.5 degrees, respectively. The loss of correction was 1.2 degrees. There were no neurological deficits and no instrument failures. CONCLUSIONS: ILS are safe and effective when used in deformity correction. However, biomechanical studies and randomized controlled trials are needed to conclude whether ILS will be considered a first-line technique, or will remain a technique for salvage situations.

Convex short segment instrumentation and hemi-chevron osteotomies for Putti type 1 thoracic hemivertebrae: a simple treatment option for patients under 5 years old.

STUDY DESIGN: A case series depicting the results of a novel surgical technique. OBJECTIVE: To prove that a minimally invasive surgical technique can effectively control and even correct congenital scoliosis caused by a fully segmented hemivertebra. SUMMARY OF BACKGROUND DATA: Congenital hemivertebrae have been treated by anterior and posterior growth arrest with/without fusion, anterior and posterior hemivertebrectomy, transpedicular hemivertebra excision, and transpedicular hemiepiphysiodesis. These approaches are complex and require experience. There is a need for a simple treatment method to treat these deformities. METHODS: Twelve patients under 5 years of age with Putti type1 hemivertebrae were treated by posterior convex short segment instrumentation, partial chevron osteotomies, and fusion. Scoliosis, segmental scoliosis, kyphosis, segmental kyphosis, trunk shift were measured both preoperatively and postoperatively. RESULTS: The mean correction of the segmental curve was 6 degrees (21%) which was maintained at the latest follow-up. The average final correction of the main curve was 23%. The trunk shift was 1.8 cm (range, 1-3 cm) preoperative and 1.4 cm (range, 0-2.5 cm) at the latest follow-up. The segmental angle of kyphosis averaged 11 degrees (range, -12 to 20 degrees) preoperative, and 14 degrees (range, 0-29 degrees) at the latest follow-up assessment. The values of the total thoracic kyphosis (T2-T12) were 29.5 degrees (range, 10-46 degrees) preoperative, 31 degrees (range, 10-44 degrees) postoperative, and 32 degrees (range, 16-45 degrees) at the last follow-up resulting in a mean improvement of 2 degrees. This improvement continued at the latest follow-up with a mean increase of 3 degrees. CONCLUSIONS: Transpedicular instrumentation is ideal for early correction in young children. The new posterior approach is much less invasive than the combined approaches or other posterior vertebrectomies and is well tolerated even in very young patients. The fusion segment is kept short. The deformities seem to stop progressing and this can avoid development of severe local deformities and secondary curves.

Kyphectomy for congenital kyphosis due to meningomyelocele: a case treated with a modified approach to skin healing.

This study is a case report of a meningomyelocele patient with congenital kyphosis who was treated with kyphectomy and a special approach to soft tissue healing. The objective of this study is to show a step by step approach to surgical treatment and postoperative care of a meningomyelocele patient with congenital kyphosis. In meningomyelocele the incidence of kyphosis is around 12-20%. It may cause recurrent skin ulcerations, impaired sitting balance and respiratory compromise. Kyphectomy has first been described by Sharrard. This surgery is prone to complications including pseudoarthrosis, skin healing problems, recurrence of deformity and deep infections. A 15-year-old male presented with congenital kyphosis due to meningomyelocele. He had back pain, deformity and bedsores at the apex of the deformity. The wound cultures showed Staphylococcus epidermidis colonisation at the apex. He was given appropriate antibiotic prophylaxis. During surgery, the apex of the deformity was exposed through a spindle-shaped incision. After instrumentation and excision of the apex, correction was carried out by cantilever technique. Two screws were inserted to the bodies of L3 and T11. After the operation, the skin was closed in a reverse cross fashion. He was sent to hyperbaric oxygen treatment for prevention of a subsequent skin infection and for rapid healing of skin flaps post operation. The patient's deformity was corrected from a preoperative Cobb angle of 135°-15° postoperative. The skin healed without any problems. Preoperative culture and appropriate antibiotic prophylaxis, spindle-shaped incision, reverse cross-skin closure and postoperative hyperbaric oxygen treatment can be useful adjuncts to treatment in congenital kyphosis patients with myelomeningocele to prevent postoperative wound healing and infection problems. Reduction screws and intracorporeal compression screws help to reduce the amount of screws and aid in corection of the deformity.