Publications by authors named "Altug Yucekul"

11 Publications

  • Page 1 of 1

How frequent should the radiographic examination be to monitor magnetically controlled growing rods? A retrospective look two to seven years postoperatively.

Eur Spine J 2021 Feb 8. Epub 2021 Feb 8.

Department of Orthopedics and Traumatology, Acibadem Mehmet Ali Aydinlar University School of Medicine, Icerenkoy, Kayisdagi Cd. No:32, Atasehir, 34684, Istanbul, Turkey.

Purpose: Magnetically controlled growing rods (MCGR) allow more frequent outpatient lengthenings to better mimic the physiological growth. The assessment of distractions with radiographs raised concerns regarding ionizing radiation exposure in growing children. The aim was to assess the necessity of radiographs after every lengthening of MCGR.

Methods: A retrospective analysis of 30 consecutive patients (19F, 11 M) treated in a single institution between 2011 and 2017. Planned radiographs were taken based on a protocol, updated over the years to involve less frequent acquisitions. Unplanned radiographs were obtained after a patient complaint or a significant clinical examination finding. Outcome measures were preoperative and postoperative radiographic measurements, and complications such as proximal and distal junctional kyphosis and failure, rod or actuator breakage, collapse of previously achieved height or failure to lengthen and worsening of deformity.

Results: Mean age at surgery was 7.5 (4-11) years. Mean follow-up was 45 (24-84) months. Mean number of lengthenings and radiographs per patient were 14.4 (8-23), and 13.2 (5-46), respectively. Nine patients (30%) experienced a total of 13 mechanical complications. Almost all complications were detected in unplanned radiographs. The probability of detecting a mechanical complication was significantly lower (p < 0.00001) in planned radiographs.

Conclusions: Radiographs taken after routine lengthenings of MCGR are not likely to reveal any significant finding, since only 0.9% of planned radiographs displayed a mechanical complication. Exposing growing children to radiation with an intention of checking the MCGR device after every lengthening could not be justified. Obtaining post-lengthening radiographs with a decreased frequency and after a significant complaint or clinical finding may be considered.
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February 2021

Intraoperative neuromonitoring practice patterns in spinal deformity surgery: a global survey of the Scoliosis Research Society.

Spine Deform 2021 Mar 23;9(2):315-325. Epub 2020 Nov 23.

Department of Orthopedics and Traumatology, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey.

Purpose: Although multimodal IONM has reached a widespread use, several unresolved issues have remained in clinical practice. The aim was to determine differences in approaches to form a basis for taking actions to improve patient safety globally.

Methods: A survey comprising 19 questions in four sections (demographics, setup, routine practices and reaction to alerts) was distributed to the membership of the SRS.

Results: Of the estimated 1300 members, 205 (~ 15%) completed the survey. Respondent demographics reflected SRS member distribution. Most of the respondents had > 10 years of experience. TcMEP and SSEP were available to > 95%. Less than 5% reported that a MD/PhD with neurophysiology background routinely examines patients preoperatively, while 19% would consult if requested. After an uneventful case, 36% reported that they would decrease sedation and check motor function if the patient was to be transferred to ICU intubated. Reactions to dropped signals that recovered or did not fully recover varied between attempting the same correction to aborting the surgery with no rods and returning another day, with or without implant removal. After a decrease of signals, 85.7% use steroids of varied doses. Of the respondents, 53.7% reported using the consensus-created checklist by Vitale et al. Approximately, 14% reported never using the wake-up test while others use it for various conditions.

Conclusion: The responses of 205 experienced SRS members from different regions of the world showed that surgeons had different approaches in their routine IONM practices and in the handling of alerts. This survey indicates the need for additional studies to identify best practices.
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March 2021

Thoracoscopic Vertebral Body Tethering for Adolescent Idiopathic Scoliosis: Follow-up Curve Behavior According to Sanders Skeletal Maturity Staging.

Spine (Phila Pa 1976) 2020 Nov;45(22):E1483-E1492

Department of Orthopedics and Traumatology, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey.

Study Design: Retrospective analysis of prospectively collected data.

Objective: To report the follow-up curve behaviors in different Sanders staging groups.

Summary Of Background Data: Vertebral body tethering (VBT) is a growth modulation technique that allows gradual spontaneous follow-up curve correction as the patient grows. There is a lack of scientific evidence regarding appropriate patient selection and timing of implantation.

Methods: Patients were grouped into five as: Sanders 1, 2, 3, 4-5, and 6-7. Data were collected preoperatively, at the day before discharge, and at each follow-up. Outcome measures were pulmonary and mechanical complications, readmission, and reoperation rates. Demographic, perioperative, clinical, radiographic, and complication data were compared using Fisher-Freeman-Halton exact tests for categorical variables and Kruskal-Wallis tests for the continuous variables.

Results: Thirty-one (29 F, 2 M) consecutive patients with a minimum of 12 months of follow-up were included. The mean age at surgery was 12.1 (10-14). The mean follow-up was 27.1 (12-62) months. The mean preoperative main thoracic curve magnitude was 47° ± 7.6°. For all curves, preoperative and first erect curve magnitudes, bending flexibility, and operative correction percentages were similar between groups (for all comparisons, P > 0.05). The median height gained during follow-up was different between groups (P < 0.001), which was reflected into median curve correction during follow-up. Total curve correction percentage was different between groups (P = 0.009). Four (12.9%) patients had pulmonary and six (19.4%) had mechanical complications. One (3.2%) patient required readmission and two (6.5%) required reoperation. Occurrence of pulmonary complications was similar in Sanders groups (P = 0.804), while mechanical complications and overcorrection was significantly higher in Sanders 2 patients (P = 0.002 and P = 0.018).

Conclusion: Follow-up curve behavior after VBT is different in patients having different Sanders stages. Sanders 2 patients experienced more overcorrection, thus timing and/or correction should be adjusted, since Sanders 3, 4, and 5 patients displayed a lesser risk of mechanical complications.

Level Of Evidence: 3.
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November 2020

Team Approach: Contemporary Treatment of Congenital Scoliosis.

JBJS Rev 2019 10;7(10):e5

Acibadem Mehmet Ali Aydinlar University School of Medicine, Department of Orthopedics and Traumatology, Istanbul, Turkey.

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October 2019

Titanium mesh cage as an alternative reconstruction method for epiphyseal-sparing tumour resections in children.

J Pediatr Orthop B 2018 Jul;27(4):350-355

Department of Orthopaedics and Traumatology, Hacettepe University School of Medicine.

In this study, we introduced an alternative reconstruction option for epiphysis-sparing tumour resection in children. Eight patients with a malignant tumour in the diaphysis or metaphysis-diaphysis junction of a long bone underwent epiphysis-sparing intercalary resection. Reconstruction was performed using a titanium mesh cage filled with impacted cancellous bone allograft and autograft. A plate and screws were used to supplement the fixation. At the last follow-up, union was achieved in seven patients. Limb-length discrepancy occurred in three patients. Functional scores revealed a good functional outcome. This technique may be an alternative method for epiphyseal-sparing tumour resections in children.
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July 2018

Tri-layered composite plug for the repair of osteochondral defects: in vivo study in sheep.

J Tissue Eng 2017 Jan-Dec;8:2041731417697500. Epub 2017 Apr 13.

Department of Orthopedics and Traumatology, Faculty of Medicine, Hacettepe University, Ankara, Turkey.

Cartilage defects are a source of pain, immobility, and reduced quality of life for patients who have acquired these defects through injury, wear, or disease. The avascular nature of cartilage tissue adds to the complexity of cartilage tissue repair or regeneration efforts. The known limitations of using autografts, allografts, or xenografts further add to this complexity. Autologous chondrocyte implantation or matrix-assisted chondrocyte implantation techniques attempt to introduce cultured cartilage cells to defect areas in the patient, but clinical success with these are impeded by the avascularity of cartilage tissue. Biodegradable, synthetic scaffolds capable of supporting local cells and overcoming the issue of poor vascularization would bypass the issues of current cartilage treatment options. In this study, we propose a biodegradable, tri-layered (poly(glycolic acid) mesh/poly(l-lactic acid)-colorant tidemark layer/collagen Type I and ceramic microparticle-coated poly(l-lactic acid)-poly(ϵ-caprolactone) monolith) osteochondral plug indicated for the repair of cartilage defects. The porous plug allows the continual transport of bone marrow constituents from the subchondral layer to the cartilage defect site for a more effective repair of the area. Assessment of the in vivo performance of the implant was conducted in an ovine model (n = 13). In addition to a control group (no implant), one group received the implant alone (Group A), while another group was supplemented with hyaluronic acid (0.8 mL at 10 mg/mL solution; Group B). Analyses performed on specimens from the in vivo study revealed that the implant achieves cartilage formation within 6 months. No adverse tissue reactions or other complications were reported. Our findings indicate that the porous biocompatible implant seems to be a promising treatment option for the cartilage repair.
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April 2017

Spinal Realignment for Adult Deformity: Three-column Osteotomies Alter Total Hip Acetabular Component Positioning.

J Am Acad Orthop Surg 2017 Feb;25(2):125-132

From the Department of Orthopaedic Surgery (Dr. Barry, Dr. Yucekul, Dr. Theologis, Dr. Hansen, and Dr. Deviren) and the Department of Neurosurgery (Dr. Ames), University of California, San Francisco, CA.

Introduction: A goal of adult spinal deformity surgery is correction of sagittal imbalance by increasing lumbar lordosis (LL), allowing a previously retroverted pelvis to normalize as evidenced by decreases in pelvic tilt (PT). Realignment of pelvic orientation may alter the position of preexisting total hip arthroplasties (THAs).

Methods: Twenty-seven patients with unilateral THA who underwent thoracolumbar fusions for adult spinal deformity from the pelvis to L1 or above were retrospectively reviewed (levels fused, 10.3 [range, 6 to 17]; age, 70 ± 9 years). Comparisons of preoperative and postoperative spinal deformity parameters, acetabular tilt (AT), and acetabular cup abduction angle (CAA) were performed, with subgroup analysis for those who had undergone three-column osteotomy and those who had not.

Results: Preoperative deformity was severe, with findings of a sagittal vertical axis >9 cm, PT >25°, and pelvic incidence-LL >20°. Postoperatively, AT decreased significantly (-7° ± 10°; P < 0.001), signifying relative acetabular retroversion. Comparing patients with three-column osteotomy versus those without, AT changes were greater in those with three-column osteotomy (11° ± 7° and -2 ± 10°, respectively; P = 0.024). AT was significantly correlated with changes of PT (r = 0.704; P < 0.001) and LL (r = -0.481; P = 0.011). AT decreased (ie, retroverted) 1° for every 3.23° of LL or 1.13° of PT correction. The coronal plane CAA did not change substantially.

Discussion: Spinal deformity correction, with techniques such as three-column osteotomy, result in significant THA acetabular component repositioning in the sagittal plane. Resultant decreased AT (ie, retroversion) theoretically may affect tribology, wear, and joint stability and warrants further investigation.
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February 2017

Modular cementless prosthetic reconstruction after resection of lower extremity malignant tumor.

Acta Orthop Traumatol Turc 2016 Dec 10;50(6):674-680. Epub 2016 Dec 10.

Hacettepe University, Faculty of Medicine, Ankara, Turkey.

Introduction: The aim of the study is to report the preliminary clinical and functional outcomes of a modular cementless tumor resection prosthesis system (Megasystem-C, Waldemar Link GmbH&Co. KG, Hamburg, Germany) in patients undergoing limb salvage surgery with wide resection in a lower extremity primary or metastatic malignant bone tumor.

Material And Methods: Fifty-two consecutive patients (33 male and 19 female; mean age 37.1 years (range, 16 to 79) with primary or metastatic lower extremity malignant bone tumor who underwent wide resection and reconstruction with cementless Megasystem-C system were included in the study. Patients were analyzed for age at diagnosis, gender, type and localization of the tumor, time of follow-up, patient and prosthesis survival, complications, oncological and functional outcomes.

Results: Mean follow-up time was 43.2 months (range, 8 to 66). Cumulative patient survival rate was 92.3 percent and cumulative prosthetic survival rate was 65.4 percent. 18 complications were recorded and 9 of them required revision (17.3 percent). Mean overall Musculoskeletal Tumor Society score score was 72.7 percent (range, 52 to 86). Subgroup analyzes demonstrated no difference in complication rates, overall patient or prosthetic survivals. Functional scores according to age, diagnosis and location of the reconstruction also were not significantly different.

Conclusion: The preliminary short-term follow-up results revealed that, the new generation modular cementless endoprosthetic system offers promising clinical and functional outcomes with reasonable complication rates.

Level Of Evidence: Level IV, Therapeutic study.
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December 2016

The dosimetric impact of implants on the spinal cord dose during stereotactic body radiotherapy.

Radiat Oncol 2016 May 25;11:71. Epub 2016 May 25.

Department of Radiation Oncology, Hacettepe University, Faculty of Medicine, Ankara, Turkey.

Background: The effects of spinal implants on dose distribution have been studied for conformal treatment plans. However, the dosimetric impact of spinal implants in stereotactic body radiotherapy (SBRT) treatments has not been studied in spatial orientation. In this study we evaluated the effect of spinal implants placed in sawbone vertebra models implanted as in vivo instrumentations.

Methods: Four different spinal implant reconstruction techniques were performed using the standard sawbone lumbar vertebrae model; 1. L2-L4 posterior instrumentation without anterior column reconstruction (PI); 2. L2-L4 anterior instrumentation, L3 corpectomy, and anterior column reconstruction with a titanium cage (AIAC); 3. L2-L4 posterior instrumentation, L3 corpectomy, and anterior column reconstruction with a titanium cage (PIAC); 4. L2-L4 anterior instrumentation, L3 corpectomy, and anterior column reconstruction with chest tubes filled with bone cement (AIABc). The target was defined as the spinous process and lamina of the lumbar (L) 3 vertebra. A thermoluminescent dosimeter (TLD, LiF:Mg,Ti) was located on the measurement point anterior to the spinal cord. The prescription dose was 8 Gy and the treatment was administered in a single fraction using a CyberKnife® (Accuray Inc., Sunnyvale, CA, USA). We performed two different treatment plans. In Plan A beam interaction with the rod was not limited. In plan B the rod was considered a structure of avoidance, and interaction between the rod and beam was prevented. TLD measurements were compared with the point dose calculated by the treatment planning system (TPS).

Results And Discussion: In plan A, the difference between TLD measurement and the dose calculated by the TPS was 1.7 %, 2.8 %, and 2.7 % for the sawbone with no implant, PI, and PIAC models, respectively. For the AIAC model the TLD dose was 13.8 % higher than the TPS dose; the difference was 18.6 % for the AIABc model. In plan B for the AIAC and AIABc models, TLD measurement was 2.5 % and 0.9 % higher than the dose calculated by the TPS, respectively.

Conclusions: Spinal implants may be present in the treatment field in patients scheduled to undergo SBRT. For the types of implants studied herein anterior rod instrumentation resulted in an increase in the spinal cord dose, whereas use of a titanium cage had a minimal effect on dose distribution. While planning SBRT in patients with spinal reconstructions, avoidance of the rod and preventing interaction between the rod and beam might be the optimal solution for preventing unexpectedly high spinal cord doses.
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May 2016

The Evolution of Sagittal Spinal Alignment in Sitting Position During Childhood.

Spine (Phila Pa 1976) 2015 Jul;40(13):E787-93

*Department of Orthopaedics and Traumatology, Hacettepe University Faculty of Medicine, Ankara, Turkey; and †Yeditepe University Pharmacoepidemiology and Pharmacoeconomics Research Center, Istanbul, Turkey.

Study Design: This is a cross-sectional descriptive study.

Objective: The purposes of this study are to describe normative data of the sagittal plane in the sitting position within the pediatric population and document the evolution of sagittal alignment during the growth.

Summary Of Background Data: Surgical procedures addressing the deformity aim to make the maximal correction on the coronal and transverse planes and to restore the physiological curves on the sagittal plane. Prerequisite for sagittal plane reconstruction is to know the physiological values.

Methods: Children between 3 and 17 years of age, followed by pediatrics unit for nonskeleton disease with lateral radiographs of the entire spine and pelvis on sitting positions, were included to the study. Children with history of surgery or disease that may affect spine development were excluded. Children were evaluated in 4 age groups (3-6, 7-9, 10-12, and 13-17 yr) in terms of spinal sagittal alignment on sitting position.

Results: Of the screened, 124 children (49 girls, 75 boys) were included. Descriptive statistics of all possible segmental angles were summarized. Thoracic kyphosis and lumbar lordosis values were lower on sitting position than on standing position. Thoracic segmental angulations steadily increased from T1-T2 to midthoracic segments and then decreased in caudal direction. Moreover, lumbar segmental angulations steadily increased in cephalocaudal direction. Sacral slope, L4-S1 angulation, and T1-T12 and T1-S1 distance tend to increase as the age increases.

Conclusion: Sagittal spinal alignment in the sitting position is different than that in the standing position and it changes as the child grows. There is a statistically significant difference between different age groups, especially at the cervicothoracic, thoracolumbar, and lumbosacral junctions. These findings should be taken into consideration for young nonambulatory patients who require spinal instrumentation and/or fusion.

Level Of Evidence: 2.
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July 2015

Lipoma arborescens of the knee.

Knee Surg Sports Traumatol Arthrosc 2015 Aug 22;23(8):2196-2201. Epub 2014 Apr 22.

Department of Orthopaedics, University of Missouri-Kansas City, 2301 Holmes Street, Kansas City, MO, USA.

Purpose: Lipoma arborescens (LA) is a benign lesion described as replacement of mature fat cells with sub-synovial tissue, which causes the formation of villous projections. Underlying inflammatory conditions might predispose LA. This study demonstrates the treatment, post-operative survey and MRI demonstrations of this rare entity.

Methods: Five patients (6 knees) diagnosed and treated with arthroscopic (5/6) and open (1/6) synovectomy were reviewed retrospectively. An additional mini-transquadricipital incision is used for excision of the extensive suprapatellar lesions. The patients had post-operative follow-ups at first and sixth months and then yearly. Radiographs and MRI of the affected knees were taken at the final follow-up.

Results: The median follow-up was 59 (4-105) months. Major symptom was painless swelling of the joint. The presenting age was under 18 years in four patients. Recurrent lesions were detected in MRI scan of three patients with JRA, ARF and Tbc. Two out of three were located adjacent to the posterior capsule. The median of the Kujala questionnaire scores was 88 (74-95), and the median of the Knee Society Clinical Rating System scores was 95 (80-100) at the final follow-up.

Conclusions: Lipoma arborescens should be considered in the differential diagnosis of paediatric patients who have painless swelling of the knee joint. The lesion is totally curable. However, underlying persistent disease might aggravate the inflammatory process and might cause recurrent lesions. Although resecting the lesion adjacent to the posterior capsule of the knee joint is technically demanding, arthroscopic treatment is an effective procedure and transquadricipital approach may help resection of the extensive lesions in suprapatellar pouch.

Level Of Evidence: Case series, Level IV.
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August 2015