Publications by authors named "Caglar Yilgor"

29 Publications

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Relative pelvic version displays persistent compensatory measures with normalised sagittal vertical axis after deformity correction.

Spine Deform 2021 Apr 29. Epub 2021 Apr 29.

Institut de la Colonne Vertébrale, Spine Unit 1, Bordeaux University Hospital, Bordeaux, France.

Purpose: A normal sagittal vertical axis (SVA) after spinal deformity correction can yield mechanical complications of up to 30%. Post-operative compensatory pelvic orientation can produce a normal SVA. We assess relative pelvic version (RPV), an individualised measure, for persistent post-operative compensatory measures.

Methods: Adult spinal deformity (ASD) patients who were treated operatively, with a normal SVA (< ± 50 mm) at 6-week follow-up were included, who were then followed-up after 2 years. These only included patients with fusion of > 4 vertebrae extending to L5 or below. Six-week subgroups were made regarding pelvis orientation, relative pelvic version (RPV: anteversion, aligned, moderate or severe retroversion) with analysis of patient-related outcome measures (PROMs), complications and spino-pelvic sagittal parameters.

Results: At 6 weeks, 140 patients met the inclusion criteria, 5 (3.6%) patients had anteversion, 59 (42.1%) were aligned, 60 (42.9%) had moderate retroversion and 16 (11.4%) patients had severe retroversion. Follow-up after 2 years demonstrated increased RPV in all groups except the severe RPV group who were more likely to develop SVA > 50 mm. Complications occurred in all groups. Significant 2-year differences were observed between moderate and severe RPV for back pain and PROMs but not between other RPV groups.

Conclusion: Adult spinal deformity patients with a normal SVA after spino-pelvic instrumentation carry a significant risk of retroversion progression post-operatively, followed by increased positive sagittal balance. Relative pelvic version (RPV) measurements when categorised into anteversion, aligned, moderate retroversion and severe retroversion at 6 weeks were predictive of PROMs at 2 years.
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http://dx.doi.org/10.1007/s43390-021-00345-zDOI Listing
April 2021

Evaluation of Global Alignment and Proportion Score in an Independent Database.

Spine J 2021 Apr 12. Epub 2021 Apr 12.

Department of Orthopedic Surgery, Barnes-Jewish Institute of Health, Washington University, St Louis, Missouri, USA.

Background Context: Sagittal spinopelvic alignment has been associated with patient-reported outcome measures and mechanical complication rates. Recently, it was claimed that linear numerical values of pelvic tilt and lumbar lordosis measurements may be misleading for patients that have different magnitudes of pelvic incidence. The use of "relative" measurements embedded in a weighted scoring of Global Alignment and Proportion (GAP) was proposed.

Purpose: The purpose was to evaluate the GAP score in an independent database.

Study Design/setting: Retrospective Cohort Study PATIENT SAMPLE: Adult spinal deformity patients who underwent ≥7 levels posterior fusion to the pelvis between 2004 to 2014 were included.

Outcome Measures: Mechanical Complication Rates METHODS: Demographic, clinical, surgical and radiographic patient characteristics were recorded. Cochran-Armitage tests were used to compare mechanical complication rates in GAP categories. Uni and multi-variable logistic regression analyses were used to obtain crude and adjusted Odds Ratios, of predictor (GAP categories) and the outcome (mechanical complication), and Risk Ratios were calculated. The diagnostic performance of the GAP score was tested using the area under the receiver operating characteristic curve, sensitivity, specificity, positive predictive value, negative predictive value and accuracy in predicting mechanical complications.

Results: 322 patients (285F, 37M) with a mean age of 58.2±9.6 were analyzed. Mean follow-up was 69.7 months (range 24 to 177). Mechanical complications occurred in 52.2% of the patients. Mechanical complication rates in proportioned (GAP-P), moderately (GAP-MD) and severely disproportioned (GAP-SD) patients were 21.8%, 55.1% and 70.4%, respectively. AUC for the GAP score, at 2 years, was 0.682 (95% CI, 0.624 to 0.741, p<0.001). AUC at minimum 5 years follow-up was similar at 0.708, while AUC at minimum 7- and 12-years follow-up were 78.5 and 90.7, respectively. Having a postoperative spinopelvic alignment of GAP-MD and GAP-SD resulted in 2.5 and 3.2 folds of relative risk in incurring a mechanical complication when compared to having a proportioned spinopelvic state, respectively.

Conclusions: This study reports an association between the GAP Score and mechanical complications in an independent database. Increased association was noted as the years of follow-up increased. Aiming to achieve proportionate GAP Score postoperatively seems to be a viable option as lower GAP scores were associated with lower rates of mechanical complications, and vice versa.
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http://dx.doi.org/10.1016/j.spinee.2021.04.004DOI Listing
April 2021

Static and dynamic sagittal lumbar apex: a new concept for the assessment of lumbar lordosis distribution in spinal deformity.

Eur Spine J 2021 Feb 19. Epub 2021 Feb 19.

Spine Unit 1, Bordeaux University Hospital, Place Amelie Raba-Leon, 33076, Bordeaux, France.

Purpose: Sagittal lumbar apex has been demonstrated to be a key parameter in sagittal plane morphology. Our aim was to understand its behavior with postural changes, analyzing two different concepts of lumbar apex.

Materials And Methods: Prospective observational study with a cohort of patients presenting sagittal malalignment identified from a monocenter database of adult spinal deformities (ASD). Inclusion criteria were age > 30 years, SVA > 40 mm, and/or PT > 20. All patients had full-spine EOS radiographs in 2 different positions: (P1: natural position) and position 2 (P2: compensated position). Sagittal alignment, spinopelvic values, and two different methods of assessing lordosis apex location were analyzed in both P1 and P2 positions. Changes between P1 and P2 were compared using a paired t test with a significance level at p < 0.05.

Results: Twenty-five patients were recruited (21 women and 4 men). The mean age was 64.8 years (range 21-79). The patient's main compensation was based on an increase in the femoral shaft angle, and pelvic retroversion, with a subsequent decrease in sacral slope, and therefore of the lower lumbar arc. When the lumbar apex was calculated as the most anterior point touching the vertical line in a lateral radiograph, postural compensation changes modified its location usually shifting it to a more caudal position. When the lumbar apex was assessed as the most distant point of the global lumbar lordosis, its position remained stable regardless of compensation.

Conclusions: Postural changes can modify the location of the lumbar apex when understanding its location as the cornerstone of sagittal plane harmonic distribution. This concept can be useful as an additional sign to assess compensation. However, if the lumbar apex was calculated as the angular point of the global lordosis, its position remained stable regardless of postural changes. This concept can help to mold lumbar lordosis in ASD surgery.

Level Of Evidence Iv: Diagnostic: individual cross-sectional studies with consistently applied reference standard and blinding.
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http://dx.doi.org/10.1007/s00586-021-06767-7DOI Listing
February 2021

Toward the Development of a Comprehensive Clinically Oriented Patient Profile: A Systematic Review of the Purpose, Characteristic, and Methodological Quality of Classification Systems of Adult Spinal Deformity.

Neurosurgery 2021 May;88(6):1065-1073

Department of Orthopaedic Surgery, Radboud University Medical Center, Nijmegen, The Netherlands.

Background: Existing adult spinal deformity (ASD) classification systems are based on radiological parameters but management of ASD patients requires a holistic approach. A comprehensive clinically oriented patient profile and classification of ASD that can guide decision-making and correlate with patient outcomes is lacking.

Objective: To perform a systematic review to determine the purpose, characteristic, and methodological quality of classification systems currently used in ASD.

Methods: A systematic literature search was conducted in MEDLINE, EMBASE, CINAHL, and Web of Science for literature published between January 2000 and October 2018. From the included studies, list of classification systems, their methodological measurement properties, and correlation with treatment outcomes were analyzed.

Results: Out of 4470 screened references, 163 were included, and 54 different classification systems for ASD were identified. The most commonly used was the Scoliosis Research Society-Schwab classification system. A total of 35 classifications were based on radiological parameters, and no correlation was found between any classification system levels with patient-related outcomes. Limited evidence of limited quality was available on methodological quality of the classification systems. For studies that reported the data, intraobserver and interobserver reliability were good (kappa = 0.8).

Conclusion: This systematic literature search revealed that current classification systems in clinical use neither include a comprehensive set of dimensions relevant to decision-making nor did they correlate with outcomes. A classification system comprising a core set of patient-related, radiological, and etiological characteristics relevant to the management of ASD is needed.
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http://dx.doi.org/10.1093/neuros/nyab023DOI Listing
May 2021

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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http://dx.doi.org/10.1007/s00586-021-06752-0DOI Listing
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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http://dx.doi.org/10.1007/s43390-020-00246-7DOI Listing
March 2021

Development and Validation of a Multidomain Surgical Complication Classification System for Adult Spinal Deformity.

Spine (Phila Pa 1976) 2021 Feb;46(4):E267-E273

Department of Orthopaedic Surgery, University of California, San Francisco, CA.

Study Design: Prospective analysis of example cases.

Objective: The aim of this study was to analyze the accuracy and repeatability of a new comprehensive classification system for capturing complications data in adult spinal deformity.

Summary Of Background Data: Complications are common in adult spinal deformity surgery. However, no consensus exists on the definition or classification of complications in adult spinal deformity surgery. The lack of consensus significantly limits understanding of complications' effects on outcomes in surgery for adult spinal deformity.

Methods: Using a Delphi method, members of the International Spine Study Group, AO Spine, and the European Spine Study Group collaborated to develop an adult spinal deformity classification system. The multidomain classification system accounts for medical complications (cancer, cardiopulmonary, central nervous system, gastrointestinal, infectious, musculoskeletal, renal) and surgical complications (implant complications, radiographic complications, neurologic events, intraoperative events, and wound complications). Seventeen individuals ("event readers"), including spine surgeons, trainees, and research coordinators, used the new classification system two separate times to analyze complications in ten example cases. The accuracy and repeatability of the classification system were subsequently calculated based on the providers' responses for the example cases.

Results: The 10 example cases included 22 complications. Nearly 95% of complications were captured by >95% of the event readers. The system demonstrated good repeatability of 86.9% between the first and second set of responses provided by event readers.

Conclusion: The ISSG-AO Multi-Domain Spinal Deformity Complication Classification System for Adult Spinal Deformity demonstrated good accuracy and repeatability among both surgeons and research coordinators in capturing complications in adult spinal deformity surgery. The ISSG-AO system may be applied to help better understand the impact of complications on outcomes and costs in adult spinal deformity surgery.Level of Evidence: 5.
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http://dx.doi.org/10.1097/BRS.0000000000003766DOI Listing
February 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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http://dx.doi.org/10.1097/BRS.0000000000003643DOI Listing
November 2020

Effect of lumbar pedicle subtraction osteotomy level on lordosis distribution and shape.

Eur Spine J 2020 06 23;29(6):1388-1396. Epub 2020 Apr 23.

Spine Surgery Unit, Pellegrin University Hospital, Bordeaux, France.

Purpose: Little is known about the qualitative results (postoperative upper/lower lumbar arches distribution and lumbar apex or inflection point positioning) of lumbar pedicle subtraction osteotomies (L-PSO) depending on the level of L-PSO.

Methods: We conducted a retrospective analysis of prospectively collected data of adult deformity patients undergoing single-level L-PSO. We analyzed several variables in preoperative and postoperative sagittal radiographs: L-PSO level, Roussouly classification (R-type), inflection point (InfP), lumbar apex (LApex), spinopelvic parameters, lordosis distribution index (LDI = L4-S1/L1-S1), and number of levels in the lordosis (NVL). Comparisons between PSO levels were performed to determine lordosis distribution and sagittal shape using ANOVA test and Chi-squared statistics.

Results: A total of 126 patients were included in this study. L5-PSO mainly increased the lower lumbar arch, thereby increasing LDI. L4 increased upper/lower arches similarly. PSOs at and above L3 increased the upper lumbar arch, thereby decreasing LDI (P < 0.001). L4-PSO added 1 vertebra into the lordosis (NVL =  + 1.2 ± 2.2). PSOs above L3 added 2 vertebrae into the lordosis (NVL =  + 2.3 ± 1.4). Overall P = 0.007. PSOs above L4 shifted the LApex cranially in 70% of the cases (mean 1.12 levels) and the InfP in 85% of the cases (mean 2.4 levels). L5-PSO shifted the LApex caudally in 70% of the cases (mean - 1.1 levels) and the InfP in 50% of the cases (mean - 1.6 levels). Overall P < 0.006. The L-PSO level was not associated with a specific Roussouly-type P > 0.05.

Conclusions: The level of L-PSO influenced upper/lower lumbar arches distribution, and lumbar apex and inflection point positioning. The correct level should be chosen based on the individual assessment of each patient.
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http://dx.doi.org/10.1007/s00586-020-06421-8DOI Listing
June 2020

The effect of increasing body mass index on the pain and function of patients with adult spinal deformity.

J Spine Surg 2019 Dec;5(4):535-540

L'Institut de la Colonne Vertébrale, Bordeaux University Hospital, Bordeaux, France.

Background: Both adult spinal deformity (ASD) and obesity are growing concerns internationally. This study therefore aims to determine the effect of increasing body mass index (BMI) on the pain and function of patients with ASD.

Methods: A retrospective review of prospectively collected data from a multicentre European database was undertaken. Initially a univariate analysis was performed on the effect of BMI on the initial presentation of functional scores in patients with ASD. The functional scores included the Numerical Rating Scale (NRS) back and leg score, Core Outcome Measures Index (COMI) back score, SRS22 total score, Short Form 36 (SF-36) [general health, physical component score (PCS) and mental component score (MCS)] and Oswestry Disability Index (ODI) score (including all domains). Subsequently a multivariate analysis controlling for age, sex, comorbidities, employment status, smoking status and radiological parameters [coronal cobb, coronal balance, sagittal balance, global tilt, and pelvic incidence minus lumbar lordosis (PI - LL) mismatch] was performed.

Results: A total of 1,004 patients were included in this study (166 male, 838 female). On univariate analysis a statistically significant (P<0.05) moderate correlation between NRS leg pain, ODI (walking, standing, sex life, social life and total score), SF-36 (physical component), sagittal balance, global tilt and age were recognised (P<0.05). A statistically significant low correlation was identified for all other outcomes, except coronal balance (P=0.640). On multivariate analysis BMI remained significantly related to all functional outcomes except ODI-pain and ODI-travelling (P>0.05).

Conclusions: Increasing BMI has a significant adverse effect on the pain and functioning of patients with ASD. Clinicians should recognise this association and treat patients accordingly.
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http://dx.doi.org/10.21037/jss.2019.11.12DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6989938PMC
December 2019

Ideal sagittal profile restoration and ideal lumbar apex positioning play an important role in postoperative mechanical complications after a lumbar PSO.

Spine Deform 2020 06 8;8(3):491-498. Epub 2020 Jan 8.

Spine Surgery Unit, Pellegrin University Hospital, Bordeaux, France.

Study Design: Retrospective analysis of prospectively collected data.

Objective: To determine the influence of postoperative ideal lordosis distribution and ideal sagittal harmony on mechanical complications in patients undergoing one-level lumbar pedicle subtraction osteotomy (L-PSO). Many variables have been associated with mechanical complications after L-PSO. However, the impact of restoring the ideal inflexion point, lumbar apex, and sagittal shape is still underexplored.

Methods: Analyzed risk factors were: age and patient-related variables, PSO level, interbody cages, rod material/diameter, number of rods, upper instrumented vertebra, lower instrumented vertebra, PI-LL mismatch, global tilt (GT), postoperative level of lumbar apex (LApex), postoperative level of inflexion point (InfxP), and postoperative type of Roussouly sagittal profile (R-type). These last variables were compared to ideal (based on pelvic incidence). Univariate and multivariate analyses were performed to identify risks for mechanical complications with a minimum 2-year follow-up.

Results: A total of 87 patients were included. Mean follow-up was 4.5 ± 1.7 years. 40.2% of the patients suffered postoperative mechanical complications (7 PJK, 4 PJF, 18 pseudoarthrosis/rod breakage, 6 screw pullout). Mean time for complications was 584 ± 416 days from surgery. Univariate analysis showed that age (63 vs 57 years; P = 0.04), BMI (28.1 vs 25.9; P = 0.024), preoperative-GT (50.7° vs 38.7°; P < 0.001), postoperative-GT (28.9° vs 23.4°; P = 0.018), postoperative LApex location mismatched from ideal (77.8% vs 22.2%; P = 0.036), and postoperative R-type mismatched from ideal (67.6% vs 22.6%; P < 0.001) were significantly related to mechanical complications. The independent factors selected by multivariate analysis were: postoperative R-type mismatched from ideal OR 11.3 (95% CI   3.9-32.6; P < 0.001), age OR 1.05 (95% CI 1-1.1; P = 0.03), and LApex matching OR 0.5 (95% CI 0.27-0.97; P = 0.04). The further the LApex was from its ideal position, the higher the risk of mechanical complications (P = 0.036).

Conclusions: Over other multiple suspected risk factors, proper lumbar apex position and ideal sagittal shape restoration played an important role in postoperative mechanical complications after L-PSO.

Level Of Evidence: III.
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http://dx.doi.org/10.1007/s43390-019-00005-3DOI Listing
June 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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http://dx.doi.org/10.2106/JBJS.RVW.19.00001DOI Listing
October 2019

Restoring the ideal Roussouly sagittal profile in adult scoliosis surgery decreases the risk of mechanical complications.

Eur Spine J 2020 01 22;29(1):54-62. Epub 2019 Oct 22.

Spine Surgery Unit, Hospital Universitario Vall d'Hebron, Barcelona, Spain.

Purpose: There are still no data proving whether restoring the ideal sagittal profile (according to Roussouly classification) in adult scoliosis (AS) patients leads to any additional benefit, especially regarding mechanical complications.

Methods: Retrospective analysis of operated AS patients recorded in a prospective multicenter database. Demographic and radiographic (preoperative and 6-week postoperative) data were analyzed. Patients with and without mechanical complications were compared looking especially at the surgical restoration of the ideal (based on Pelvic Incidence) sagittal profile. Univariate and multivariate analysis was performed to identify causes of mechanical complications at 2-year minimum follow-up.

Results: Ninty-six AS patients were analyzed. Thirty-nine patients suffered a mechanical complication (18 PJK, 11 pseudoarthrosis, 10 screw pull-out), and 57 patients had no mechanical complications. Postoperatively, 72% of patients not matching the ideal Roussouly-type suffered mechanical complications compared to 15% of matched patients (P < 0.001). Univariate analysis showed that older patients 64.9 ± 13 versus 40.7 ± 15.6 years (P < 0.001), higher postoperative Global Tilt (27° vs. 14.7°) and Pelvic Tilt (25° vs. 16°) (P < 0.001), upper instrumented vertebra at the thoracolumbar junction (62% vs. 21%) (P < 0.001), fixation to the Iliac (76% vs. 6%) (P < 0.001), and postoperative Roussouly-type mismatch (72% vs. 15%) (P < 0.001) significantly increased the rate of mechanical complications. Multivariate logistic regression analysis selected: postoperative Roussouly-type mismatch (OR = 41.9; 95%CI = 5.5-315.7; P < 0.001), iliac instrumentation (OR = 19.4; 95%CI = 2.6-142.5; P = 0.004), and age (OR = 1.1; 95%CI = 1.02-1.16; P = 0.004), as the most important variables.

Conclusions: Adult scoliosis surgery should restore the ideal Roussouly sagittal profile to decrease the rate of mechanical complications, especially in patients older than 65, instrumented to the pelvis. These slides can be retrieved under Electronic Supplementary Material.
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http://dx.doi.org/10.1007/s00586-019-06176-xDOI Listing
January 2020

Impact of Adult Scoliosis on Roussouly Sagittal Shape Classification.

Spine (Phila Pa 1976) 2019 02;44(4):270-279

Spine Surgery Unit, Hospital Universitario Vall d'Hebron, Barcelona, Spain.

Study Design: A retrospective analysis of data collected prospectively in an adult spine deformity multicenter database.

Objective: The aim of this study was to determine the impact of adult scoliosis (AS) on the type of Roussouly sagittal shape in terms of classification applicability, scoliosis modification of a patient theoretical sagittal shape, and coronal-sagittal deformity associations.

Summary Of Background Data: Roussouly described a four-type sagittal shape classification in healthy individuals, which has been also applied to patients with degenerative spinal disease. However, it remains uncertain if its principles can be applied to AS patients.

Methods: AS patients recorded in a prospective multicenter database of adult spinal deformity were included. Preoperative sagittal radiographs were analyzed using the KEOPS software to measure pelvic parameters, global sagittal alignment, and the various criteria used for the Roussouly classification. The different sagittal shape types were compared using the Chi-square and McNemars tests, and analysis of variance with Bonferroni correction.

Results: The classification was applicable to all of the 190 analyzed AS patients. In addition to Roussouly criteria, two parameters helped differentiate the different shapes: T10-L2 angle (24° ± 19 type-1; 14° ± 15 type-2; 3° ± 15 type-3; 0.4° ± 14 type-4; P < 0.001), and lordosis distribution index (90% ± 17 type-1; 83% ± 16 type-2; 73% ± 21 type-3; 63% ± 16 type-4; P < 0.001). AS changed the theoretical shape in 34% of the patients (P < 0.001). Curve etiology and curve pattern were not associated with any particular type of sagittal shape (P > 0.05). Type-1 was associated with older patients (P = 0.02), degenerative curves (P = 0.02), and greater PI-LL mismatch (P = 0.012). Types 3 to 4 were associated with younger age and idiopathic etiology (P < 0.001).

Conclusion: Roussouly four-type sagittal shape classification could be applied to AS patients. AS modified the theoretical type in one of every three patients. No particular association was found between the sagittal types and specific coronal deformities. Sagittal shape recognition in patients with AS will help restore the appropriate theoretical shape through surgery, which can eventually lead to better surgical outcomesLevel of Evidence: 2.
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http://dx.doi.org/10.1097/BRS.0000000000002800DOI Listing
February 2019

Relative pelvic version: an individualized pelvic incidence-based proportional parameter that quantifies pelvic version more precisely than pelvic tilt.

Spine J 2018 10 8;18(10):1787-1797. Epub 2018 Mar 8.

Department of Orthopedics and Traumatology, Acibadem Mehmet Ali Aydinlar University, Kayisdagi Caddesi 32, Istanbul, 34752, Turkey. Electronic address:

Background Context: Pelvic tilt (PT) is used as an indicator of pelvic version with increased values indicating retroversion and disability. The concept of using PT solely as an absolute numerical value can be misleading, especially for the patients with pelvic incidence (PI) values near the upper and lower normal limits. Relative pelvic version (RPV) is a PI-based individualized measure of the pelvic version. Relative pelvic version indicates the individualized spatial orientation of the pelvis relative to the ideal sacral slope as defined by the magnitude of PI.

Purpose: The aim of this study was to compare RPV and PT for their ability to predict mechanical complications and their correlations with health-related quality of Life (HRQoL) scores.

Study Design: A retrospective analysis of a prospectively collected data of adult spinal deformity patients was carried out. Mechanical complications (proximal junctional kyphosis or proximal junctional failure, distal junctional kyphosis or distal junctional failure, rod breakage, and implant-related complications) and HRQoL scores (Oswestry Disability Index [ODI], Core Outcome Measures Index [COMI], Short Form-36 Physical Component Summary [SF-36 PCS], and Scoliosis Research Society 22 Spinal Deformity Questionnaire [SRS-22]) were used as outcome measures.

Methods: Inclusion criteria were ≥4 levels fusion, and ≥2-year follow-up. Correlations between PT, RPV, PI, and HRQoL were analyzed using Pearson correlation coefficient. Pelvic incidence values and mechanical complication rates in RPV subgroups for each PT category were compared using one-way analysis of variance, Student t test, and chi-squared tests. Predictive models for mechanical complications with RPV and PT were analyzed using binomial logistic regressions.

Results: A total of 222 patients (168 women, 54 men) met the inclusion criteria. Mean age was 52.2±19.3 (18-84) years. Mean follow-up was 28.8±8.2 (24-62) months. There was a significant correlation between PT and PI (r=0.613, p<.001), threatening the use of PT to quantify pelvic version for different PI values. Relative pelvic version was not correlated with PI (r=-0.108, p>.05), being able to quantify pelvic version for all PI values. Compared with PT, RPV had stronger partial correlations with ODI, COMI, SF-36 PCS, and SRS-22 scores (p<.05). Discrimination performance assessed by area under the curve, percentage accuracy in classification, true positive rate, true negative rate, and positive and negative predictive values was better for the model with RPV than for PT. For average PI sizes, the agreement between RPV and PT were moderate (0.609, p<.001), whereas the agreement in small and large PI sizes were poor (0.189, p>.05; -0.098, p>.496, respectively). When analyzed by RPV, each PT "0," "+," and "++" category was further divided into two or three distinct subgroups of patients having different PI values (p=.000, p=.000, and p=.029, respectively). Relative pelvic version subgroups within the same PT category displayed different mechanical complication rates (p=.000, p=.020, and p=.019, respectively).

Conclusions: Pelvic tilt may be insufficient or misleading in quantifying normoversion for the whole spectrum of PI values when used as an absolute numeric value in conjunction with previously reported population-based average thresholds of 20 and 30 degrees. Relative pelvic version offers an individualized quantification of ante-, normo-, and retroversion for all PI sizes. Schwab PT groups were found to constitute inhomogeneous subgroup of patients with different mean PI values and mechanical complication rates. Compared with PT, RPV showed a greater association with both mechanical complications and HRQoL.
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http://dx.doi.org/10.1016/j.spinee.2018.03.001DOI Listing
October 2018

Metal Ion Release During Growth-Friendly Instrumentation for Early-Onset Scoliosis: A Preliminary Study.

Spine Deform 2018 01;6(1):48-53

Orthopedics and Traumatology, Hacettepe University, 06100 Sihhiye, Ankara, Turkey. Electronic address:

Background: Metal ions released from spinal instruments can cause localized debris and distribute systemically to settle on distant organs. Children with early-onset deformities live with metallic implants for a substantial amount of time. No research focused on metal distribution in growth-friendly instrumentations. The aim of this study was to compare age-matched growing rod (GR) and magnetically controlled growing rod (MCGR) groups to noninstrumented controls.

Methods: The study was designed as a multicenter, prospective, cross-sectional case series. GR and MCGR applications of three institutions were included. A total of 52 children were enrolled. Blood samples were collected between December 2014 and February 2015. Biochemical serum analyses were performed to trace and quantify titanium, vanadium, aluminum, and boron. The GR group included 15 children. Mean age was 10.7 (range 6-15). MCGR group included 22 children. Mean age was 8.5 (range 2-13). Fifteen age-matched nonoperated children formed the control group. The mean age was 10.4 (range 5-15). One-way analysis of variance, Kruskal-Wallis, and Mann-Whitney U tests were used for comparisons.

Results: The mean serum titanium level in control, GR, and MCGR groups were 2.8 ± 1.4, 7.3 ± 4.3, and 10.2 ± 6.8 μg/L, respectively. GR and MCGR group titanium levels were higher than controls' (p = .008 and p < .001). The mean serum vanadium level in control, GR, and MCGR groups were 0.2 ± 0.0, 0.2 ± 0.0, and 0.5 ± 0.5 μg/L, respectively. MCGR group vanadium level was higher than control (p < .001) and GR groups (p = .004). Mean serum levels in control, GR, and MCGR groups were, respectively, 5.4 ± 4.1, 8.1 ± 7.4, and 7.8 ± 5.1 μg/L for aluminum and 86.7 ± 2.7, 86.9 ± 2.5, and 85.0 ± 6.6 μg/L for boron. The distribution of aluminum and boron were similar across groups (p = .675 and p = .396).

Conclusions: Both GR and MCGR applications significantly release titanium and possibly aluminum. MCGR further releases vanadium. MCGR possibly releases more titanium than traditional GR. Time-dependent alterations of serum ion levels, structural properties of the MCGR device, and exposure caused by magnetic distraction processes warrant investigation.
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http://dx.doi.org/10.1016/j.jspd.2017.06.005DOI Listing
January 2018

Relative lumbar lordosis and lordosis distribution index: individualized pelvic incidence-based proportional parameters that quantify lumbar lordosis more precisely than the concept of pelvic incidence minus lumbar lordosis.

Neurosurg Focus 2017 Dec;43(6):E5

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

OBJECTIVE The subtraction of lumbar lordosis (LL) from the pelvic incidence (PI) offers an estimate of the LL required for a given PI value. Relative LL (RLL) and the lordosis distribution index (LDI) are PI-based individualized measures. RLL quantifies the magnitude of lordosis relative to the ideal lordosis as defined by the magnitude of PI. LDI defines the magnitude of lower arc lordosis in proportion to total lordosis. The aim of this study was to compare RLL and PI - LL for their ability to predict postoperative complications and their correlations with health-related quality of life (HRQOL) scores. METHODS Inclusion criteria were ≥ 4 levels of fusion and ≥ 2 years of follow-up. Mechanical complications were proximal junctional kyphosis/proximal junctional failure, distal junctional kyphosis/distal junctional failure, rod breakage, and implant-related complications. Correlations between PI - LL, RLL, PI, and HRQOL were analyzed using the Pearson correlation coefficient. Mechanical complication rates in PI - LL, RLL, LDI, RLL, and LDI interpreted together, and RLL subgroups for each PI - LL category were compared using chi-square tests and the exact test. Predictive models for mechanical complications with RLL and PI - LL were analyzed using binomial logistic regressions. RESULTS Two hundred twenty-two patients (168 women, 54 men) were included. The mean age was 52.2 ± 19.3 years (range 18-84 years). The mean follow-up was 28.8 ± 8.2 months (range 24-62 months). There was a significant correlation between PI - LL and PI (r = 0.441, p < 0.001), threatening the use of PI - LL to quantify spinopelvic mismatch for different PI values. RLL was not correlated with PI (r = -0.093, p > 0.05); therefore, it was able to quantify divergence from ideal lordosis for all PI values. Compared with PI - LL, RLL had stronger correlations with HRQOL scores (p < 0.05). Discrimination performance was better for the model with RLL than for PI - LL. The agreement between RLL and PI - LL was high (κ = 0.943, p < 0.001), moderate (κ = 0.455, p < 0.001), and poor (κ = -0.154, p = 0.343), respectively, for large, average, and small PI sizes. When analyzed by RLL, each PI - LL category was further divided into distinct groups of patients who had different mechanical complication rates (p < 0.001). CONCLUSIONS Using the formula of PI - LL may be insufficient to quantify normolordosis for the whole spectrum of PI values when applied as an absolute numeric value in conjunction with previously reported population-based average thresholds of 10° and 20°. Schwab PI - LL groups were found to constitute an inhomogeneous group of patients. RLL offers an individualized quantification of LL for all PI sizes. Compared with PI - LL, RLL showed a greater association with both mechanical complications and HRQOL. The use of RLL and LDI together, instead of PI - LL, for surgical planning may result in lower mechanical complication rates and better long-term HRQOL.
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http://dx.doi.org/10.3171/2017.8.FOCUS17498DOI Listing
December 2017

Global Alignment and Proportion (GAP) Score: Development and Validation of a New Method of Analyzing Spinopelvic Alignment to Predict Mechanical Complications After Adult Spinal Deformity Surgery.

J Bone Joint Surg Am 2017 Oct;99(19):1661-1672

1Department of Orthopedics and Traumatology, Acibadem University, Istanbul, Turkey 2Spine Research Unit, Comprehensive Spine Center, Acibadem Maslak Hospital, Istanbul, Turkey 3Spine Surgery Unit, Bordeaux University Hospital, Bordeaux, France 4Department of Biostatistics, Ankara University, Ankara, Turkey 5Spine Center Division, Department of Orthopedics and Neurosurgery (F.K.), and Spine Center Division, Department of Research and Development (A.F.M.), Schulthess Klinik, Zurich, Switzerland 6Spine Surgery Unit, Hospital Universitario La Paz, Madrid, Spain 7Ankara ARTES Spine Center, Ankara, Turkey 8Spine Surgery Unit, Hospital Vall d'Hebron, Barcelona, Spain.

Background: The restoration of normal sagittal alignment is a critical goal in adult spinal deformity surgery to achieve favorable outcomes and prevent mechanical complications. Schwab sagittal modifiers have been accepted as targets for appropriate alignment, but addressing these targets does not always prevent high mechanical complication or revision rates. This may be because the linear absolute numerical parameters do not cover the whole pelvic incidence spectrum and the distribution of lordosis, pelvic anteversion, and negative malalignment are not considered as potential causes of failure. The aim of the present study was to develop and validate a score based on pelvic-incidence-based proportional parameters to better predict mechanical complications.

Methods: Two hundred and twenty-two patients (168 women and 54 men) followed for ≥2 years after posterior fusion at ≥4 levels were included in the study. The mean age (and standard deviation) was 52.2 ± 19.3 years (range, 18 to 84 years), and the mean duration of follow-up was 28.8 ± 8.2 months (range, 24 to 62 months). The global alignment and proportion (GAP) score was developed and validated in groups of patients randomly assigned to derivation (n = 148, 66.7%) and validation (n = 74, 33.3%) cohorts. GAP score parameters were relative pelvic version (the measured minus the ideal sacral slope), relative lumbar lordosis (the measured minus the ideal lumbar lordosis), lordosis distribution index (the L4-S1 lordosis divided by the L1-S1 lordosis multiplied by 100), relative spinopelvic alignment (the measured minus the ideal global tilt), and an age factor. Proximal and distal junctional kyphosis and/or failure, rod breakage, and other implant-related complications were considered mechanical complications. The predictive accuracy of the GAP score was analyzed using receiver operating characteristic (ROC) analyses. Associations between GAP categories and mechanical complications and revisions were analyzed using Cochran-Armitage tests.

Results: In the validation cohort, 32 patients (43%) experienced mechanical complications and 17 (23%) underwent mechanical revision. The area under curve for the GAP score predicting mechanical complications was 0.92 (standard error [SE] = 0.034, p < 0.001, 95% [confidence interval [CI] = 0.85 to 0.98). Postoperatively, patients with a proportioned spinopelvic state according to the GAP score had a mechanical complication rate of 6% while those with a moderately or severely disproportioned spinopelvic state had rates of 47% and 95%, respectively.

Conclusions: The GAP score is a new pelvic-incidence-based proportional method of analyzing the sagittal plane that predicts mechanical complications in patients undergoing surgery for adult spinal deformity. Setting surgical goals according to the GAP score may decrease the prevalence of mechanical complications.
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http://dx.doi.org/10.2106/JBJS.16.01594DOI Listing
October 2017

Lack of improvement in health-related quality of life (HRQOL) scores 6 months after surgery for adult spinal deformity (ASD) predicts high revision rate in the second postoperative year.

Eur Spine J 2017 08 30;26(8):2160-2166. Epub 2017 Mar 30.

Orthopedic Spinal Surgery Unit 1, Bordeaux Pellegrin Hospital, Bordeaux, France.

Purpose: ASD is assessed radiologically with the spinopelvic parameters and clinically with HRQOL scores. The revision rate after ASD surgery is high and usually occurs during the first or second postoperative year. The aim of this study is to find clinical or radiological factors that could predict revision surgery in the second postoperative year.

Materials And Methods: Inclusion criterion: ASD patients operated on by instrumented posterior fusion with more than 2 years follow-up were enrolled prospectively. Additional criterion was no revision surgery during the first postoperative year. From a multicenter database of 560 operated ASD patients, 164 patients met these criteria. The patients were divided into two groups depending on the need of revision surgery during the second postoperative year. Preoperative, 6-month, 1-year and 2-year data were collected and compared for both groups.

Results: A total of 22 patients needed revision surgery and 142 did not. All revisions were for mechanical complications (non-fusion and implant related). Preoperatively, there was a significant difference between the groups (no revision vs. revision) for age (48 vs. 60 years), ODI (37 vs. 53), and SVA (29 vs. 76 mm), respectively. At 6 months, a significant difference in sagittal alignment was found, though HRQOL scores were similar. At 1 year, the no revision group scores improved, whereas the revision group scores remained stable or worsened. At 2 years, the no revision group scores remained stable. Comparing 6- and 12-month data, patients with improved, stable and worsened HRQOL scores had 8, 15 and 28% revision rates, respectively.

Conclusion: The revision rate at the second-year post-surgery (13.4%) remains high and demonstrated that a 2-year follow-up is mandatory. In addition to usual risk factors for mechanical complications in ASD surgery, stabilization or worsening of the HRQOL scores between the 6th and 12th month postop was highly predictive of revision rate. This observation is beneficial for ASD patient follow-up as clinical symptoms clearly precede mechanical failure.
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http://dx.doi.org/10.1007/s00586-017-5068-9DOI Listing
August 2017

Global tilt and lumbar lordosis index: two parameters correlating with health-related quality of life scores-but how do they truly impact disability?

Spine J 2017 04 1;17(4):480-488. Epub 2016 Nov 1.

Spine Unit 1, Bordeaux University Hospital, Place Amélie Raba-Léon, 33076 Bordeaux, France.

Background Context: Many radiological parameters have been reported to correlate with patient's disability including sagittal vertical axis (SVA), pelvic tilt (PT), and pelvic incidence minus lumbar lordosis (PI-LL). European literature reports other parameters such as lumbar lordosis index (LLI) and the global tilt (GT). If most parameters correlate with health-related quality of life scores (HRQLs), their impact on disability remains unclear.

Purpose: This study aimed to validate these parameters by investigating their correlation with HRQLs. It also aimed to evaluate the relationship between each of these sagittal parameters and HRQLs to fully understand the impact in adult spinal deformity management.

Study Design: A retrospective review of a multicenter, prospective database was carried out.

Patient Sample: The database inclusion criteria were adults (>18 years old) presenting any of the following radiographic parameters: scoliosis (Cobb ≥20°), SVA ≥5 cm, thoracic kyphosis ≥60° or PT ≥25°. All patients with complete data at baseline were included.

Outcome Measures: Health-related quality of life scores, demographic variables (DVs), and radiographic parameters were collected at baseline.

Methods: Differences in HRQLs among groups of each DV were assessed with analyses of variance. Correlations between radiographic variables and HRQLs were assessed using the Spearman rank correlation. Multivariate linear regression models were fitted for each of the HRQLs (Oswestry Disability Index [ODI], Scoliosis Research Society-22 subtotal score, or physical component summaries) with sagittal parameters and covariants as independent variables. A p<.05 value was considered statistically significant.

Results: Among a total of 755 included patients (mean age, 52.1 years), 431 were non-surgical candidates and 324 were surgical candidates. Global tilt and LLI significantly correlated with HRQLs (r=0.4 and -0.3, respectively) for univariate analysis. Demographic variables such as age, gender, body mass index, past surgery, and surgical or non-surgical candidate were significant predictors of ODI score. The likelihood ratio tests for the addition of the sagittal parameters showed that SVA, GT, T1 sagittal tilt, PI-LL, and LLI were statistically significant predictors for ODI score even adjusted for covariates. The differences of R values from Model 1 were 1.5% at maximum, indicating that the addition of sagittal parameters to the reference model increased only 1.5% of the variance of ODI explained by the models.

Conclusion: GT and LLI appear to be independent radiographic parameters impacting ODI variance. If most of the parameters described in the literature are correlated with ODI, the impact of these radiographic parameters is less than 2% of ODI variance, whereas 40% are explained by DVs. The importance of radiographic parameters lies more on their purpose to describe and understand the malalignment mechanisms than their univariate correlation with HRQLs.
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http://dx.doi.org/10.1016/j.spinee.2016.10.013DOI Listing
April 2017

Osteotomies/spinal column resection in paediatric deformity.

Eur J Orthop Surg Traumatol 2014 Jul 21;24 Suppl 1:S59-68. Epub 2014 May 21.

Department of Orthopaedics and Traumatology, Istanbul Florence Nightingale Hospital, Istanbul, Turkey.

The spinal deformities in paediatric population differ from those in the adult population. Vertebral osteotomies are indicated when the deformity is too rigid to be corrected either with instrumentation alone or with the addition of soft tissue releases. When surgical intervention is to be carried out, correcting the deformity and ceasing progression should be aimed at as well as allowing further growth and improving pulmonary function. Osteotomies in the spine surgery should aim to achieve an appropriate balance in both sagittal and coronal planes. Varied clinical and radiological scenarios necessitate different osteotomy types. The purpose of this article is to introduce each osteotomy type and discuss their indications, prerequisites and complications. Osteotomy options for correcting spinal deformities are Ponte osteotomy, Smith-Petersen osteotomy, pedicle subtraction osteotomy, bone-disc-bone osteotomy and vertebral column resection. All the osteotomy types are technically demanding. Appropriate selection of the type of the osteotomy depends on the surgeons' experience, type of the deformity, magnitude of the curve, remaining growth potential and operative goals. Neuromonitoring should be an indispensible part of the procedure. Spine osteotomies are effective procedures for the treatment of paediatric spine deformities if experienced surgical team performs them.
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http://dx.doi.org/10.1007/s00590-014-1477-1DOI Listing
July 2014

Semitendinosus snapping: analysis of movement, electromyographic activities, muscle strength and endurance, motor control and joint position sense.

Muscles Ligaments Tendons J 2013 Jul 11;3(3):166-72. Epub 2013 Aug 11.

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

A female ballet with a history of two-years of semi-tendinosus (ST) snapping was assessed. On physical examination snapping was observed during hyperextension of the knee. Neither any history of trauma nor treatment was recalled. Magnetic resonance imaging (MRI), movement analysis, onset timing of ST and Bisceps Femoris (BF), motor control, isokinetic muscle strength and endurance, joint position sense (JPS) were assessed. The MRI findings were normal. There were abnormal oscillations observed during hyperextension of the snapping knee compared to healthy side. There were no isokinetic muscle strength nor do muscle endurance differences. The motor control and JPS deficits were greater on the snapping knee than the healthy side. ST onset timing was earlier than BF on the snapping side. Snapping of the semitendinosus tendon has an adverse affect on JPS, motor control and onset timing of the knee muscles.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3838325PMC
July 2013

Fusionless instrumentation in growing spine and adjacent segment problems: an experimental study in immature pigs.

Spine (Phila Pa 1976) 2013 Dec;38(25):2156-64

*Department of Orthopaedics and Traumatology, Hacettepe University, Faculty of Medicine, Ankara, Turkey †Biomechanics Laboratory, Hacettepe University, School of Sports Science and Technology, Ankara, Turkey ‡Department of Pathology, Hacettepe University, Faculty of Medicine, Ankara, Turkey §Experimental Research and Application Center, Cukurova University, Adana, Turkey; and ¶Vocational School of Social Sciences, Hacettepe University, Ankara, Turkey.

Study Design: Experimental study.

Objective: To compare the effects of fusionless instrumentation (FI) and instrumented fusion (IF) on the adjacent segment in an immature pig model.

Summary Of Background Data: Observations reveal proximal junctional kyphosis after FI. Possible reasons are stress concentration, repeated distractive forces, and/or soft tissue damage done in the index surgery. It was speculated that FI can decrease stressors to the junctional area by preserving the spinal mobility in some manner; however, this has not been proven to date.

Methods: Thirteen piglets of 10- to 14-week age were used. FI and IF were performed on 7 and 3 piglets, respectively, and 3 piglets formed the control group. Control piglets did not undergo any surgical procedures. T11-L4 instrumentation, decortication, and grafting were applied to IF piglets. In FI groups, however, L1-L2 was left uninstrumented and unfused using T11-T12 and L3-L4 levels as anchors to the growing construct. A total of 4 lengthening procedures were performed: 1 in the index operation and 3 more, once in each lengthening procedure monthly, for 3 months. Four months after the index operations, all piglets were killed and the adjacent segment motion capabilities, disc, and facets were evaluated with radiographical, magnetic resonance imaging, biomechanical, and histological analyses.

Results: Comparison of proximal junctional Cobb angles of the postindex (mean: 21, range: 17-27) and presacrification (mean: 21, range: 11-31) radiographs in the FI group revealed no difference (P> 0.05). In magnetic resonance imaging, both surgical group proximal adjacent discs showed degeneration to some degree that was statistically indifferent (P = 0.903). Biomechanical evaluation revealed restriction of adjacent segment motion in all directions for both groups; however, this negative effect was significantly less in FI group (P < 0.01). Degeneration observed in histological evaluation in adjacent discs and facets of FI group was significantly lower (P = 0.00).

Conclusion: In this quadruped straight spine model, in comparison with IF applications, FI is closer to normal physiology even after several lengthening procedures regarding the adjacent segment discs, facet joints, and motion, when interpreting the radiological, biomechanical, and histological results altogether.
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http://dx.doi.org/10.1097/BRS.0000000000000026DOI Listing
December 2013

Effects of the fusionless instrumentation on the disks and facet joints of the unfused segments: a pig model.

J Pediatr Orthop 2014 Mar;34(2):185-93

Departments of *Orthopaedics †Pathology, Faculty of Medicine, Hacettepe University, Ankara ‡Experimental Research and Application Center, Cukurova University, Adana, Turkey.

Background: Growing rod (GR) is a state-of-the-art procedure favored when curvatures of the spine cannot be managed nonoperatively in early-onset scoliosis. Although some postulate that multiple distractions and/or relative immobilization of the unfused segments affect the health of disk and facet joint (FJ) and cause degeneration and/or spontaneous fusion, this has not thoroughly been investigated. In this study, changes in the unfused segment after a spine-based fusionless instrumentation (SBFI) are investigated and compared with the control (CG) and instrumented fusion (IF) groups.

Methods: A total of 13 piglets, 10 to 14 weeks of age, were used. SBFI and IF were performed on 7 and 3 piglets, respectively, and 3 formed the CG. In SBFI, lengthening procedures of 5 mm were applied once monthly for 3 months, and, after 4 months, all piglets were euthanized. Histologic sections of the unfused disks and FJ were analyzed, and morphometric histologic analysis was performed.

Results: On the basis of the Gries criteria, unfused disk median grades were 1, 2, and 4 for control, SBFI, and IF, respectively, that revealed a statistical difference (P<0.001). Unfused FJ median grades were 1 and 2 for control and SBFI, respectively, that revealed a statistical difference (P<0.001). The mean hypertrophic zone (HZ) heights were 69.78, 84.20, and 66.14 μm; HZ chondrocyte cell widths were 19.03, 18.76, and 17.36 μm; and HZ chondrocyte cell heights were 15.01, 15.04, and 12.42 μm in the CG, SBFI, and IF groups, respectively. Statistically, for HZ heights, SBFI was different compared with CG and IF (P<0.001), and, for HZ chondrocyte cell widths and heights, IF was different compared with CG and SBFI (P<0.001).

Conclusions: Morphometric analysis in this study supports the findings that SBFI preserves the growth potential of the spine. Furthermore, changes in the HZ heights show that distractive forces stimulate the apophyseal growth of the axial skeleton describing how the growth rate of the spine in GR might surpass the normal growth rate. Overall, although some degenerative changes are observed, SBFI and repeated distractions alone are not solely responsible for FJ arthrosis and disk degeneration, given that they are structurally preserved.

Clinical Relevance: GR and regular lengthening procedures do not impair disk health and preserve the growth potential of the spine if it is applied with a meticulous technique.
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http://dx.doi.org/10.1097/BPO.0b013e3182972404DOI Listing
March 2014

Comparison of magnetic resonance imaging findings with arthroscopic findings in discoid meniscus.

Knee Surg Sports Traumatol Arthrosc 2014 Feb 22;22(2):268-73. Epub 2013 Jan 22.

Department of Orthopaedics and Traumatology, Faculty of Medicine, Hacettepe University, Sihhiye, Ankara, 06100, Turkey.

Purpose: It is widely accepted that although valuable in the diagnosis of the discoid meniscus and tears, magnetic resonance imaging (MRI) can be insufficient in determining the type of the tear. This study calculates the sensitivity and specificity of MRI in determining the presence and absence of tears and how these values differ for different types of tears.

Methods: This study is a retrospective review of 10 years of our experience with arthroscopic discoid meniscus treatment between 1999 and 2009. MRI findings were compared with the intraoperative arthroscopic findings in 52 patients with 50 lateral and two medial discoid menisci of which 24 were complete and 28 were incomplete. Tears were classified into six groups: (1) no tear, (2) simple horizontal tear, (3) radial tear, (4) combined horizontal tear, (5) complex tear and (6) longitudinal tear. Sensitivity, specificity, positive and negative predictive values of MRI were calculated for each group separately and for the presence and absence of tears in general. In addition, the effect of age, type of discoid meniscus, and presence and absence of shift on the distribution of tear types were analysed.

Results: MRI was found to be 100 % specific and 97.8 % sensitive for determining the presence or absence of a tear with a negative predictive value of 85.7 % and a positive predictive value of 100 %. The specificities were 80 % for simple horizontal, 50 % for radial, 66.7 % for combined horizontal, 55.6 % for complex and 14.3 % for longitudinal tears, whereas the sensitivities were 66.7 % for simple horizontal, 96.9 % for radial, 87.5 % for combined horizontal, 94.6 % for complex and 100 % for longitudinal tears. The presence and absence of shift and type of the discoid were found to affect the distribution of the tear type.

Conclusions: MRI is successful in determining the presence or absence of tears in discoid menisci; however, its ability to determine the tear type is questionable. Complete discoid menisci were found to have tendency towards having a simple horizontal or longitudinal tear, whereas incomplete discoid menisci tend to have radial or combined horizontal tears. Determination of the shift prior to surgery is important since it alters the surgical technique.
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http://dx.doi.org/10.1007/s00167-013-2371-9DOI Listing
February 2014

Evaluation of acetabular development after Dega acetabuloplasty in developmental dysplasia of the hip.

J Pediatr Orthop B 2013 Mar;22(2):91-5

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

The Dega acetabuloplasty is considered to be safe and effective in the treatment of hip pathologies, but the number of clinical follow-up series in the literature is not sufficient. The aim of our study was to identify the alterations in acetabular development in 35 patients (43 hips) with developmental dysplasia of the hip who were treated with Dega acetabuloplasty. This study is a retrospective review of 7 years of one surgeon's experience with Dega acetabuloplasty performed between May 2002 and January 2010. A total of 35 patients (43 hips) were evaluated, with an average of 58 months (range 25-108 months) of follow-up. Dega acetabuloplasties that were performed for neuromuscular or other conditions and patients who had a follow-up period of less than 2 years were excluded. Open reduction was performed and femoral shortening or varus osteotomy was added whenever the surgeon considered it necessary. The preoperative mean acetabular index (AI) was 35° (range 27-53°), and the mean age of operation was 35 months (range 18-65 months). The mean AI in the early postoperative period was 20° (range 10-34°). At the last follow-up, all patients were pain-free and had unlimited physical activity with no limp, with an improvement in AI to 13° (range 5-23°). An improvement of 7° was observed in AI within the follow-up period. The maximum improvement was 17° and occurred within an 83-month period. In 42 of 43 (98%) of the hips, the AI improved; in one of 43 (2%) of the hips, it remained unchanged and in none of hips did the AI worsen over time. This study is one of the largest series in the English-language orthopedic literature to report that Dega osteotomy is effective in improving the AI and femoral coverage, and that the index further improves over the course of the follow-up period.
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http://dx.doi.org/10.1097/BPB.0b013e32835c2a7dDOI Listing
March 2013

Is expansion thoracoplasty a safe procedure for mobility and growth potential of the spine? Spontaneous fusion after multiple chest distractions in young children.

J Pediatr Orthop 2012 Jul-Aug;32(5):483-9

Department of Orthopaedics, Faculty of Medicine, Hacettepe University, Ankara, Turkey.

Background: Expansion thoracoplasty (ET) is claimed to be a spine-sparing procedure because of the fact that the spine is not exposed directly and intervention toward the spinal column is not performed. It is also recommended in cases of primary spine deformities without rib fusion/aplasia and when the primary problem is not in the thorax itself. The aim of this study was to report spontaneous spinal fusion after multiple thoracic distractions in patients with congenital thoracospinal deformities who have undergone ET in early childhood.

Methods: In our clinic, between May 2003 and March 2010, ET treatment was started in 11 patients who had congenital spinal deformity along with thoracic asymmetry due to fused ribs. The lengthening procedures for 6 of them are still ongoing. This study includes 5 of these patients who had undergone 3-dimensional computed tomography (3D-CT) scans. Four of these patients underwent a CT scan as part of the graduation protocol and 1 was ordered a 3D-CT because a newly formed bony fusion of the ribs was observed in a lengthening procedure.

Results: The mean age of the patients (4 F, 1 M) was 4.2 years (range, 2 to 8 y) at the time of the index operation. The mean number of lengthening procedures was 9.4 (range, 7 to 13). The mean follow-up period was 73 months (range, 60 to 96 mo). All 5 patients in the latest follow-up were evaluated by x-ray and 3D-CT scans of the whole spine. The CT scans confirmed spontaneous spinal fusion in the thoracic spine.

Conclusions: We speculate that distraction-based, growth-friendly instrumentations are not risk-free for spinal health and motion, even when the instrumentation is not primarily on the spine.

Level Of Evidence: Level IV.
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http://dx.doi.org/10.1097/BPO.0b013e318257d3a9DOI Listing
November 2012

Simultaneous forequarter amputation and radical mastectomy for metastatic breast carcinoma in a male patient: a case report.

J Korean Surg Soc 2011 Dec 25;81 Suppl 1:S6-S11. Epub 2011 Nov 25.

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

Although the majority of forequarter amputations are performed for high-grade bone and soft tissue sarcomas or extensive osteomyelitis of the upper extremity, this radical operation may also be indicated for the curative treatment of recurrent breast cancer and for the palliation of locally advanced breast cancer. We report a male patient with metastatic breast adenocarcinoma who underwent simultaneous mastectomy and forequarter amputation for the management of both his primary and metastatic disease.
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http://dx.doi.org/10.4174/jkss.2011.81.Suppl1.S6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3267069PMC
December 2011

Tissue engineering strategies in ligament regeneration.

Stem Cells Int 2012 25;2012:374676. Epub 2011 Dec 25.

Department of Orthopedics and Traumatology, Hacettepe University Faculty of Medicine, Sihhiye, 06100 Ankara, Turkey.

Ligaments are dense fibrous connective tissues that connect bones to other bones and their injuries are frequently encountered in the clinic. The current clinical approaches in ligament repair and regeneration are limited to autografts, as the gold standard, and allografts. Both of these techniques have their own drawbacks that limit the success in clinical setting; therefore, new strategies are being developed in order to be able to solve the current problems of ligament grafting. Tissue engineering is a novel promising technique that aims to solve these problems, by producing viable artificial ligament substitutes in the laboratory conditions with the potential of transplantation to the patients with a high success rate. Direct cell and/or growth factor injection to the defect site is another current approach aiming to enhance the repair process of the native tissue. This review summarizes the current approaches in ligament tissue engineering strategies including the use of scaffolds, their modification techniques, as well as the use of bioreactors to achieve enhanced regeneration rates, while also discussing the advances in growth factor and cell therapy applications towards obtaining enhanced ligament regeneration.
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http://dx.doi.org/10.1155/2012/374676DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3253484PMC
August 2012