Publications by authors named "Cemalettin Aksoy"

31 Publications

Characteristics of femoroacetabular impingement morphology and relation with skeletal maturity among asymptomatic adolescents.

Acta Orthop Belg 2021 Mar;87(1):47-54

The aim of this study was to analyze presence of the morphological characteristics and prevalence of FAI in asymptomatic adolescents and assess the relation of skeletal maturation with development of FAI morphology. Abdominopelvic computed tomography (CT) of 265 adolescents (9-19 years old) who were admitted to the emergency department between 2011 and 2016 were evaluated retrospectively. Radial reformatted CT images from the femoral neck were created using the multiplanar reconstruction (MPR) method. The femoral neck was divided into 12 segments and alpha angle (AA), femoral head-neck ratio (FHNR) and center-edge angle (CEA) were measured from each segment. Additionally, images were evaluated for the physiological status (open or closed) of the triradiate- cartilage and proximal femoral epiphyses. 204 hips from 102 patients (32 females, 70 males) were retrospectively reviewed. There were 27 (26.5%) patients with cam-type morphology and 18 (17.6%) patients with pincer-type morphologies. No statistically significant difference was detected between the prevalences of cam and pincer morphologies between the two genders. Cam deformity was most frequently seen in anterosuperior segment. All of the patients (100%) with pincer-type morphology and 88% of the patients with cam-type morphology had closed triradiate cartilage, 89% of the patients with cam morphology and 83% with pincer morphology had open proximal femoral physis. Our results showed that prevalence of cam and pincer-type morphology in asymptomatic adolescents is similar to asymptomatic adults. Our findings also indicate that cam- and pincer-type FAI morphologies likely develop during late adolescence after closure of triradiate cartilage and before closure of proximal femoral physis. Level of Evidence - 3.
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March 2021

Rebound phenomenon after hemiepiphysiodesis: Determination of risk factors after tension band plate removal in coronal plane deformities of lower extremities.

J Pediatr Orthop B 2021 Jan;30(1):52-58

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

Risk factors for rebound phenomenon (ReP) have not been investigated in detail. Aim of this study is to investigate risk factors of ReP in lower extremity deformities after two-hole plate removal. Patients who underwent hemiepiphysiodes were retrospectively reviewed. Joint orientation angles of tibia and femur, deformity type, age of patient at initial surgery and plate removal, deformity correction rate, bone growth rate were noted. An increase of 5° or more in joint orientation angles in the direction of the initial deformity was considered ReP. A relationship between the patient parameters and ReP was evaluated. Ninety-four segments (55 femurs and 39 tibias) of 43 patients (15 males and 28 females) were included. ReP was observed in 56.2% of all valgus deformities (n = 73), and in 23.8% of varus deformities (n = 21). The ReP rate was 60% (n = 27) and 20% (n = 2) in femoral segments with preoperative valgus and varus deformities, respectively (P = 0.03). When gender, etiology, sides and age of implant application and removal were compared, there was no difference between ReP(+) and ReP(-) groups in femur and tibia. The correction rate of mechanical lateral distal femoral angle in ReP(-) and ReP(+) femurs was 0.7 ± 0.4°/month and 1.1 ± 0.3°/month, respectively (P = 0.01). Age at implant application and removal in the femoral valgus group was significantly lower in the ReP(+) group (P = 0.008 and P = 0.005, respectively). The ReP rate was higher in femoral segments with overcorrection (P = 0.008). The ReP rate was higher in femoral valgus deformities. Younger age at plate application and removal, higher correction rate in deformity and intentional overcorrection increased risk for ReP.
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http://dx.doi.org/10.1097/BPB.0000000000000786DOI Listing
January 2021

Lower-extremity rotational profile and toe-walking in preschool children with autism spectrum disorder.

J Pediatr Orthop B 2018 Nov;27(6):530-534

Department of Child and Adolescent Psychiatry, School of Medicine, Ankara University Autism Application and Research Center, Ankara University, Ankara, Turkey.

The aim of this study was to establish the torsional and toe-walking profiles of children with autism spectrum disorder (ASD), and to analyze the correlations between torsion, toe-walking, autism severity score, and age. In total, 79 consecutive children with autism were examined to determine their hip rotations, thigh-foot angle, degree of toe-walking, and autism severity. Femoral and tibial torsion values, of the preschool patients, were compared statistically with age-matched controls. The hip rotation profile of the patients was similar to the normal group. Nearly a half of the patients with ASD present excessive external tibial torsion. The difference in the tibial torsion between patients and normal children was statistically significant. A weak correlation was found only between tibial torsion and the autism severity score, but no correlation was found between the other parameters. External tibial torsion is the cardinal and persistent orthopedic manifestation among patients with ASD. Toe-walking is the second most common such manifestation and is an independent orthopedic feature in these patients. External tibial torsion may potentially contribute toward the described gait abnormalities in patients with ASD.
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http://dx.doi.org/10.1097/BPB.0000000000000519DOI Listing
November 2018

Genotypic-phenotypic features and enzyme replacement therapy outcome in patients with mucopolysaccharidosis VI from Turkey.

Am J Med Genet A 2017 Nov 8;173(11):2954-2967. Epub 2017 Sep 8.

Hacettepe University Children Hospital, Division of Metabolism, Ankara, Turkey.

Mucopolysaccharidosis type VI (MPS VI) is a lysosomal storage disorder (LSD) characterized by a chronic, progressive course with multiorgan involvement. In our study, clinical, biochemical, molecular findings, and response to enzyme replacement therapy (ERT) for at least 6 months were evaluated in 20 patients with MPS VI. Treatment effects on clinical findings such as liver and spleen sizes, cardiac and respiratory parameters, visual and auditory changes, joints' range of motions, endurance tests and changes in urinary glycosaminoglycan excretions, before and after ERT were analyzed. ERT caused increased physical endurance and decreased urinary dermatan sulfate/chondroitin sulfate ratios. Changes in growth parameters, cardiac, respiratory, visual, auditory findings, and joint mobility were not significant. All patients and parents reported out an increased quality of life, which were not correlated with clinical results. The most prevalent mutation was p.L321P, accounting for 58.8% of the mutant alleles and two novel mutations (p.G79E and p.E390 K) were found. ERT was a safe but expensive treatment for MPS VI, with mild benefits in severely affected patients. Early treatment with ERT is mandatory before many organs and systems are involved.
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http://dx.doi.org/10.1002/ajmg.a.38459DOI Listing
November 2017

Functional results in periacetabular osteotomy: is it possible to obtain a normal gait after the surgery?

Hip Int 2017 Sep 19;27(5):449-454. Epub 2017 May 19.

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

Introduction: Gait analysis is one of the poorly understood dimensions of the functional results obtained after periacetabular osteotomy (PAO) due to dysplasia of the hip.

Materials And Methods: Spatiotemporal parameters as well as coronal and sagittal plane kinematics and moments were compared among three demographically similar groups of subjects: (i) 23 patients with excellent results according to the Harris Hip Score (HHS) (mean 6.6 years of follow-up); (ii) 12 patients with good and fair results according to the HHS (mean 9.3 years of follow-up); and (iii) 35 asymptomatic controls.

Results: 50% of the analysed sagittal plane kinematic parameters were significantly better (p<0.05) in the control group not only for the hip joint but also for the ipsilateral knee and ipsilateral ankle. A vast majority of the other evaluated gait parameters resulted similar among the groups (p>0.05).

Conclusions: In our experience, most of the gait parameters after PAO are close to those observed in control subjects; however, the obtained pattern cannot be classified as a completely normal gait. The excellence in terms of functional results seems not to be determined by the achievement of this theoretical goal.
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http://dx.doi.org/10.5301/hipint.5000494DOI Listing
September 2017

Multidisciplinary assessment of congenital insensitivity to pain syndrome.

Childs Nerv Syst 2016 Sep 21;32(9):1741-4. Epub 2016 Mar 21.

Department of Orthopaedics and Traumatology, School of Medicine, Hacettepe University, Altindag, 06100, Ankara, Turkey.

Background: Congenital insensitivity to pain and anhidrosis (CIPA) is a rare clinical condition characterized by the absence of normal subjective and objective responses to noxious stimuli in patients with intact central and peripheral nervous systems.

Case Presentations: Two patients with CIPA are reported. The first patient was a 13-year-old girl who presented to our hospital with multiple joint destructions secondary to osteomyelitis. The second patient was a 10-year-old boy who presented with multiple hand lesions and right leg osteomyelitis. Our patients were treated with multiple debridements and intravenous antibiotics according to our hospital protocol.

Conclusion: Early recognition of the disease is important. The treatment for this condition is focused more on the prevention of bone injuries and joint infection, as opposed to a cure. There are no standard techniques or guidelines available to treat this rare disease. Overall, effective CIPA treatment is built around family education and patient training.
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http://dx.doi.org/10.1007/s00381-016-3059-5DOI Listing
September 2016

One-year follow-up study of serial orthotic treatment in two cases with arthrogrypotic syndromes who have bilateral knee flexion contractures.

Prosthet Orthot Int 2016 Jun 5;40(3):388-93. Epub 2014 Aug 5.

Physical Therapy and Rehabilitation Department, Faculty of Health Sciences, Hacettepe University, Ankara, Turkey.

Background: The aim of this pilot study was to investigate the effectiveness of serial splinting in two children with bilateral knee flexion contractures due to arthrogrypotic syndrome.

Case Description And Methods: We evaluated the infants' passive knee extension limitation and motor development levels. Serial orthotic treatment was applied to decrease bilateral knee flexion contractures in the knees of the subjects. The follow-up period was up to 1 year.

Findings And Outcomes: At the end of serial orthotic treatment, improvement in bilateral passive extension limitation (for the first case, the increase in passive range of extension was approximately 75°, for the second case it was 45°) was achieved in both cases.

Conclusion: We believe that serial orthotic intervention is effective in patients with arthrogrypotic syndrome at the preoperative period or in patients who cannot be operated on. Further studies are needed for evaluation of effectiveness of this method.

Clinical Relevance: Our pilot study aimed to investigate the effectiveness of serial orthotic treatment in knee contractures due to arthrogrypotic syndrome in two infants which showed an improvement in range of extension.
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http://dx.doi.org/10.1177/0309364614541458DOI Listing
June 2016

Giant cell tumour of humerus: an unexpected lesion in a skeletally immature patient with Hodgkin's disease.

J Coll Physicians Surg Pak 2014 Mar;24 Suppl 1:S37-8

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

Giant cell tumour (GCT) of bone is a benign aggressive tumour of the bone. It typically presents in persons aged 20 - 40 years. It is rare in adolescents and children. In most cases, GCT of bone occurs in the metaphyseal and epiphyseal regions of long bones. However, in children with open physes, GCT of bone may be centered in the metaphysis and may abut the physis. GCT is most commonly found in the distal femur, proximal tibia, and distal radius. It is not reported after treatment of a cancer in childhood. To the best of authors' knowledge, the coexistence of giant cell tumour of the bone and Hodgkin disease has not been reported in the literature. We report an atypical case of giant cell tumour of humerus in a skeletally immature child treated for Hodgkin's disease (HD), which had initially presented as a bone cyst radiologically.
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http://dx.doi.org/03.2014/JCPSP.S37S38DOI Listing
March 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

Chronic recurrent multifocal osteomyelitis as the first presentation of acute lymphoblastic leukemia in a 2-year-old boy.

J Pediatr Hematol Oncol 2010 May;32(4):e151-2

Faculty of Medicine, Pediatric Hematology Unit, Ihsan Dogramaci Children's Hospital, Hacettepe University, Ankara/Turkey.

Summary: We present herein a 2-year-old boy who suffered from chronic recurrent multifocal osteomyelitis for 6 months and was later diagnosed as acute lymphoblastic leukemia. In view of the rarity of bilateral symmetric and multifocal lesions in osteomyelitis in children, we suggest that leukemia should be investigated with bone marrow aspiration in such patients, even if complete blood count parameters are normal, and there is no hepatosplenomegaly.
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http://dx.doi.org/10.1097/MPH.0b013e3181d1ec16DOI Listing
May 2010

A second patient with Tsukahara syndrome: type A1 brachydactyly, short stature, hearing loss, microcephaly, mental retardation and ptosis.

Am J Med Genet A 2010 Apr;152A(4):947-9

Department of Pediatrics, Clinical Genetics Unit, Hacettepe University, Ankara, Turkey.

In 1989, Tsukahara and colleagues described a single female with a provisionally unique pattern of malformation consisting of low intelligence, short stature, brachydactyly type A1, and characteristic facial features. We report on a second patient confirming Tsukahara syndrome as an established entity.
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http://dx.doi.org/10.1002/ajmg.a.33325DOI Listing
April 2010

Thrombomodulin and GFC levels in Legg-Calve-Perthes disease.

Hematology 2008 Dec;13(6):324-8

Department of Orthopedics and Traumatology, Hacettepe University Medical School, 06100 Sihhiye, Ankara, Turkey.

Legg-Calve-Perthes disease (LCPD) is a self-limited microvascular disorder leading to the occlusion of the femoral blood supply, which results in bone necrosis. Endothelial injury and hemostatic alterations may play a role in the microvascular compromise and decreased blood flow, which occur during the course of LCPD. Global fibrinolytic capacity (GFC) is a novel assay reflecting the overall fibrinolysis response resulting from the dynamic interactions of numerous stimulatory and inhibitory fibrinolytic molecules. Circulating soluble thrombomodulin (TM) reflects endothelial activation and/or injury. It is a cofactor in the clinically important protein C natural anticoagulant system. Beyond the coagulation pathway it is shown to have effects on biological events, especially inflammation. The aim of this study was to determine GFC and TM levels in LCPD patients. The study included 77 children in two groups. Group I consisted of 42 patients with LCPD and Group II (control) comprised 35 healthy children. Median (interquartile ratios) GFC and TM levels were significantly higher in the LCPD patients (Group I) (p<0.0001 and p=0.049, respectively). Circulating high levels of soluble TM may be associated with ongoing endothelial injury or ongoing inflammation during the disease course. Along with increased overall fibrinolytic response, increased TM may be a compensatory reaction to thrombosis. Further investigations are needed to elucidate the endothelial, anticoagulant, and fibrinolytic kinetics associated with the microvascular compromise and self-limiting nature of LCPD.
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http://dx.doi.org/10.1179/102453308X343509DOI Listing
December 2008

Sagittal plane analysis of the open and closed methods in children with displaced supracondylar fractures of the humerus (a radiological study).

Arch Orthop Trauma Surg 2008 Jul 4;128(7):739-44. Epub 2007 Dec 4.

School of Medicine, Department of Orthopaedics and Traumatology, Zonguldak Karaelmas University, Esenköy, Kozlu, Zonguldak, Turkey.

Objectives: The aim of this study was to compare the radiological outcome of open and close reduction and osteosynthesis methods in the treatment of type II and III supracondylar humerus fractures in childhood with respect to the immediate post-operative reduction quality in sagittal plane.

Method: One hundred and forty four-pediatric patients with type IIb and III supracondylar humerus fractures treated at two centers between 1995 and 2005 were evaluated radiologically within a retrospective study. Seventy-six patients (54 boys, 22 girls, mean age 7.6, range 2-12) were treated by closed reduction and cross percutaneous pinning while 68 (49 boys, 19 girls, mean age 7.3, range 2-13) were treated by open reduction. The reduction quality of the open and closed groups was compared on immediate post-operative lateral radiographs by measuring of lateral humerocapitellar angle, anterior humeral line and anterior coronoid line criteria. The reduction quality was classified excellent, good, fair and poor according to the achievement of three, two, one or none of the criteria, respectively. Reductions classified as excellent and good were introduced as acceptable results.

Results: At least one criterion was achieved in all the patients of both the groups. The mean humerocapitellar angle was 30.1 degrees in closed reduction group while the mean of it was 29.8 degrees in open reduced group. Radiograph of 48 (63.1%) patients with closed reduction were found to display the anterior humeral line intersecting the middle one-third of capitellum while this criteria was 45 (66%) in open reduction group. The anterior coronoid line was disturbed in three patients in each of both the groups. The reduction quality was evaluated to be excellent in 32 patients, good in 31, fair in 13 at the closed reduction group while these evaluations were 31, 20 and 17 in open reduction group, respectively. Successful reduction was achieved in 74.9% of the patients in closed reduction group and 75% of the patients in open reduction group.

Conclusion: It is concluded that there was no significant difference between closed and open reductions of pediatric displaced supracondylar fractures with regard to the radiological criteria of reduction quality in sagittal plane.
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http://dx.doi.org/10.1007/s00402-007-0523-4DOI Listing
July 2008

Evaluation of risk factors in developmental dysplasia of the hip: results of infantile hip ultrasonography.

Turk J Pediatr 2007 Jul-Sep;49(3):290-4

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

In this study, risk factors of developmental dysplasia of the hip (DDH) were evaluated. History, clinical examination and risk factors for DDH of the babies were recorded. The hips were evaluated with ultrasonography. Infantile hip ultrasonography is one of the best methods for screening of DDH. Ultrasonography is easy, repeatable and provides visualization of the cartilage part of the hip joint. Graf's method of infantile hip ultrasonography was used to evaluate the hip in this study. Both hips of 371 babies and 32 unilateral hips of 32 babies were included in the study. In 403 babies, 14 (3.4%) had DDH. There were 5 type IIB, 7 type IIC, 1 type D, and 1 type IV hips. Physiological immaturity was present in 81 hips (19% of babies). According to risk factor analysis, the only risk factor in unilateral analysis was presence of oligohydramnios (odd ratio-OR: 11.8, confidence interval-CI: 2.7-52.7). In correlation analysis, there was a correlation between female gender and swaddling. There was overall increase in DDH in female babies who were swaddled compared to those who were not. The results of this study showed that the most important risk factor was oligohydramnios for DDH. Swaddling and female gender increased the risk of the disease, but further studies in larger series are necessary for the confirmation of these results.
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January 2008

Interruption of the blood supply of femoral head: an experimental study on the pathogenesis of Legg-Calve-Perthes Disease.

Arch Orthop Trauma Surg 2007 Aug 28;127(6):485-91. Epub 2007 Jun 28.

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

Introduction: The etiology of LCPD still is not clear. Thrombosis has been accused in the pathogenesis of LCPD but it is not proven until now. The aim of this study is to evaluate the results of single episode of obstruction of blood supply to the femoral heads of dogs.

Material And Method: Blood supply femoral heads of 45 dogs was interrupted with embolisation with gel foam. The radiologic appearances, macroscopic and microscopic specimes of the hips were evaluated and compared with the human specimens of 15 LCPD patients obtained at the time of femoral osteotomies.

Results: After one infarct, we demonstrated changes in femoral heads of puppies showing close resemblance to the findings of LCPD in human.

Conclusion: Obstruction of the femoral head caused by single artificial emboli caused changes in the femoral head similar to LCPD. The cause of the obstruction is obscure, intravascular and/or extravascular pathologies need specific attention, further studies focusing especially on the coagulation system are needed.
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http://dx.doi.org/10.1007/s00402-007-0367-yDOI Listing
August 2007

Safety and efficacy of posterior instrumentation for patients with congenital scoliosis and spinal dysraphism.

J Pediatr Orthop 2007 Jun;27(4):380-6

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

Objective: Instrumentation and correction of severe congenital scoliosis, particularly in patients with spinal dysraphism, has been reported to cause a high potential rate of neurological compromise after instrumentation. The aim of this study was to evaluate the safety and efficacy of posterior instrumentation and correction of congenital scoliosis with accompanying spinal dysraphism.

Level Of Evidence: Level IV therapeutic studies.

Methods: Retrospective x-ray measurements to analyze the efficacy and the evaluation of hospital charts to document the intraoperative and postoperative complications were performed for a consecutive patient series. Scoliosis Research Society-22 questionnaire was used to analyze the health-related quality of life.

Results: Twenty-two patients (18 girls and 4 boys) formed the basis of the study. The average age was 12 years (range, 7-18 years) and the average follow-up period was 3.2 years (range, 2-10 years). The types of spinal dysraphism were diastematomyelia in 20 patients and syringomyelia with tethered cord in 2 patients. Twelve patients had previous surgery and 3 patients had simultaneous surgeries for spinal dysraphism. Posterior instrumentation with/without anterior release and fusion was performed in all patients. Major curve was corrected from an average of 71 degrees to 40 degrees (correction rate, 43.6%). The compensatory curve was corrected from an average of 47 degrees to 25 degrees (correction rate, 46.8%). The average loss of correction at final follow-up was 2.2 degrees for major curve and 3.5 degrees for the compensatory curve. The average scores for the 5 domains of Scoliosis Research Society-22 questionnaire were 3.5 for function, 3.9 for pain, 3.5 for self-image, 3.6 for mental health, 3.9 for satisfaction, and 3.6 for total. Neurological monitoring was conducted by using the wake-up test in all patients. The overall complication rate was 31%, including neurological compromise in 2 patients (9%).

Conclusions: Spinal instrumentation was effective for the control of deformity with a relatively higher rate of complications. However, with respect to high complication rate, the ideal solution for managing the congenital cases is still to prevent the progression of the curve with early intervention by using the optimal surgical approach for that particular patient.
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http://dx.doi.org/10.1097/01.bpb.0000271334.73643.81DOI Listing
June 2007

[Closed reduction in the treatment of developmental dysplasia of the hip].

Acta Orthop Traumatol Turc 2007 ;41 Suppl 1:25-30

Department of Orthopedics and Traumatology (Ortopedi ve Travmatoloji Anabilim Dali), Medicine Faculty of Hacettepe University, Ankara, Turkey.

One of the standard treatment methods for developmental dysplasia of the hip is closed reduction followed by immobilization in a hip spica cast. This treatment is performed before achievement of independent walking, under general anesthesia and with arthrographic control. Avoidance of forced reductions and immobilization of the hip with extreme positions is of utmost importance during the procedure. Development of avascular necrosis (AVN) of the femur head is the main parameter affecting the late outcome of the procedure. All modifiable factors should be influenced in favor of the patient to avoid AVN. This method appears to be satisfying with acceptable rates of AVN when applied by experienced pediatric orthopedic surgeons.
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November 2008

Treatment results of pediatric osteosarcoma: twenty-year experience.

J Pediatr Orthop 2007 Mar;27(2):241-6

Department of Pediatric Oncology, Institute of Oncology, Hacettepe University, Ankara, Turkey.

The objectives of the study were to compare the results of surgical procedures, amputation and limb-sparing surgery, and to assess the influence of preoperative chemotherapeutic regimens on the survival of pediatric patients with osteosarcoma. We retrospectively analyzed 69 patients treated at our institution between January 1985 and April 2004. The primary treatment modalities were limb-sparing surgery or amputation with or without preoperative chemotherapy. The need for postoperative chemotherapy was determined by the histological response, the tumor margins, and the burdens created by the metastatic disease. The age range was 5.3 to 18.6 years (median, 13.3 years); with a male-female ratio of 0.9. The most common lesion site was the femur, found in 39 patients. Fourteen of the patients had metastases involving the lungs or other bones at the time of diagnosis. Preoperative chemotherapy was done in 45 patients. Most of the patients were treated with cisplatin + adriamycin (27/69, 39.1%). Forty-two patients were surgically treated by amputation and 19 with limb-sparing surgery. Four patients had surgical resection of masses located at sites other than the extremities, and in 4 patients, surgery was not possible. The overall survival rate for the whole group was 32.6%. The overall survival rates were 27.2% and 66.9% for the patients treated with amputation and limb-sparing surgery, respectively. Osteosarcoma has a poor prognosis. Based on our 20-year experience, limb-sparing surgery as surgical management and the cisplatin + adriamycin preoperative chemotherapy regimen seem to be a promising modality for the patients with osteosarcoma.
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March 2007

[Treatment of simple bone cysts with methylprednisolone acetate in children].

Acta Orthop Traumatol Turc 2005 ;39(5):411-5

Department of Orthopedics and Traumatology (Ortopedi ve Travmatoloji Anabilim Dali), Medicine Faculty of Hacettepe University, 06100 Sihhiye, Ankara, Turkey.

Objectives: Steroid injections represent one of the simple treatment alternatives for simple bone cysts in pediatric age group. The aim of this study was to evaluate the results of steroid injections in the treatment of simple bone cysts.

Methods: Thirteen children (9 boys, 4 girls; mean age 9 years; range 4 to 14 years) with simple bone cysts were treated primarily with injection of methylprednisolone acetate with the use of the two-needle technique. The cysts were localized in the proximal humerus (n=7), femoral intertrochanteric region (n=4), and the proximal one-third of the femur (n=1). Four patients had fractures before treatment. Each patient received a maximum of three injections at six-week intervals, each consisting of 120-160 mg of methylprednisolone acetate. The patients were monitored by plain radiographs obtained in the sixth week, third month, sixth month, and at the end of a year followed by annual radiographic evaluations. Cyst healing was assessed according to the Neer classification. The mean follow-up was five years (range 1 to 11 years).

Results: Treatment with methylprednisolone acetate resulted in complete healing in five patients (38.5%) and healing with residual lesions in six patients (46.2%). One patient (7.7%) did not respond to steroid treatment and one patient developed recurrence. The results were satisfactory (84.6%) in patients with complete healing and healing with residual lesions, and unsatisfactory in two patients (15.4%). No procedure-related complications were encountered.

Conclusion: Our results suggest that treatment with steroid injections offers satisfactory outcome in simple bone cysts in children, and thus, is worthy of consideration before more aggressive methods are to be applied.
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December 2006

The effect of temporary hemiepiphyseal stapling on the growth plate: a radiologic and immunohistochemical study in rabbits.

J Pediatr Orthop 2005 May-Jun;25(3):336-41

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

The purpose of this study was to investigate the effect of temporary hemiepiphyseal stapling on the bone geometry and proliferative activity of the physis in immature rabbits. Proximal medial epiphyseal stapling of the right tibia was performed in 46 6-week-old New Zealand white rabbits. The rabbits were assigned randomly into two groups. In group 1, the staples were inserted extraperiosteally and the rabbits were killed at the end of 3 weeks. In group 2, the staples were fixed subperiosteally (group IIA) or extraperiosteally (group IIB), the staples were removed at the end of 3 weeks, and the rabbits were killed at the end of 6 weeks. The articular line-diaphysis angle (ALDA) was significantly increased with 3 weeks of stapling. After the removal of staples, while ALDA continued to worsen in group IIA, it improved in group IIB. Bone was observed to bridge the physis in group IIA. However, the proliferative activity of the physis continued. Temporary hemiepiphyseal stapling is a safe and effective method for control of physeal growth of long bones before skeletal maturity. However, it is of paramount importance not to disturb the periosteum during stapling.
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http://dx.doi.org/10.1097/01.bpo.0000152906.23669.d8DOI Listing
July 2005

Radiological outcome of proximal femoral varus osteotomy for the treatment of lateral pillar group-C Legg-Calvé-Perthes disease.

J Pediatr Orthop B 2005 Mar;14(2):88-91

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

Results from 26 hips of 24 Legg-Calvé-Perthes disease patients were evaluated retrospectively. There were 22 male and two female patients in the study group. The mean age of the patients was 8.3 years and the mean follow-up was 13.03 years. All the patients were older than 6 years of age and all of them had lateral pillar group C hips. The patients were treated with intertrochanteric uniplanar varus osteotomy. All the patients were mature at the time of the last evaluation. Radiological end results were evaluated according to Stulberg's classification. Six hips healed with spherical congruency (Stulberg class 1 or 2), 19 with aspherical congruency (Stulberg class 3 or 4) and one with aspherical incongruency (Stulberg class 5). Six of 14 hips treated before 9 years of age healed with spherical congruency but all hips treated after 9 years of age healed with Stulberg class 3, 4 or 5 results. Trochanteric overgrowth was evident in 20 hips. The results of this radiological outcome study showed that Herring class C hips treated with proximal femoral varus osteotomy had a poor outcome, especially after 9 years of age in this group of patients.
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http://dx.doi.org/10.1097/01202412-200503000-00005DOI Listing
March 2005

Convex growth arrest in the treatment of congenital spinal deformities, revisited.

J Pediatr Orthop 2004 Nov-Dec;24(6):658-66

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

The authors studied 32 patients to delineate the reliability of well-defined but frequently extended indications to define the ideal patient who will benefit from convex growth arrest. Mean age at the time of convex growth arrest was 29 (range 6-72) months, and average follow-up was 40 (24-120) months. Mean Cobb angle was 55 degrees (31-105 degrees) before surgery and 50 degrees (13-107 degrees) at final follow-up. Thirteen patients (41%) had a true epiphysiodesis effect, while 15 (47%) had fusion and 4 (12%) had progression. The age at surgery, magnitude, length and location of the curve, presence of intraspinal anomaly, and presence of sagittal plane or rib deformity were investigated in terms of the outcome, but none of these parameters was found to have an effect on the outcome. In conclusion, convex growth arrest is a safe and effective method in the management of the young patients with congenital spinal deformities. It can be performed for the balanced and cosmetically acceptable deformities of patients younger than 5 years of age regardless of the type, length, magnitude, and location of the curve, the existence of associated rib fusion, or the presence of sagittal plane abnormality.
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http://dx.doi.org/10.1097/00004694-200411000-00013DOI Listing
June 2005

The accuracy and reliability of estimation of lateral pillar height in determining the herring grade in Legg-Calvé-Perthes disease.

J Pediatr Orthop 2004 Nov-Dec;24(6):651-3

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

The amount of the preserved lateral pillar height (LPH) for assigning Herring grades is estimated during daily practice in Perthes disease. Despite this estimation, Herring classification has been reported to have a good interobserver agreement. The purpose of this study was to investigate whether the amount of preserved LPH has an effect on interobserver agreement. The results of surgeons' estimates were compared with objective measurement results. Good agreement was found among three experienced pediatric orthopaedic surgeons in 50 patients (1 vs. 2, kappa=0.527; 2 vs. 3, kappa=0.526; 1 vs. 3, kappa=0.539). Twenty of these cases had a ratio of the LPH scattered between 0.45 and 0.60 and 0.90 and 0.99 (transition between group B and C, and group A and B). When the borderline cases were evaluated separately, the interobserver reliability was poor (1 vs. 2, kappa=0.194; 2 vs. 3, kappa=0.256; 1 vs. 3, kappa=0.154), which may be explained by misperception of the preserved LPH. If the Herring classification is to be used as the prognostic indicator for deciding among the treatment alternatives, and LPH is the major determinant of the management, measurements should be used instead of estimates, especially in borderline cases.
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http://dx.doi.org/10.1097/00004694-200411000-00011DOI Listing
June 2005

Comparison between braced and non-braced Legg-Calvé-Perthes-disease patients: a radiological outcome study.

J Pediatr Orthop B 2004 May;13(3):153-7

Department of Orthopaedics and Traumatology, Hacettepe University Faculty Of Medicine, Sihhiye, 06530 Beysukent, Ankara, Turkey.

Twenty-three hips of 23 Legg-Calvé-Perthes-disease (LCPD) patients treated with abduction orthosis and 28 hips of 25 non-braced LCPD patients were evaluated radiologically retrospectively. The mean age of the brace group was 6.82 years and the mean follow-up was 12.30 years. The mean age and mean follow-up were 7.03 and 17.85 years for non-braced patients, respectively. The hips were evaluated according to lateral pillar classification. There were eight Herring A, 15 Herring B and five Herring C hips in the non-braced patients group; and there were five Herring A, 11 Herring-B and seven Herring C hips in the brace group. The groups were similar in terms of mean age, mean follow-up, sex distribution and lateral pillar grade. Patients' end results were evaluated according to Stulberg classification. All Herring A patients healed with Stulberg class 1 or 2, either braced or non-braced. Fifty-three percent of non-braced hips and 65% of the hips treated with brace healed with satisfactory radiological outcome. There were no significant differences between the groups in terms of end result. The overall results of this study suggest that Herring's lateral pillar classification is a useful system for the prediction of the long-term outcome of the disease and that there was no significant difference between the braced and non-braced patients in terms of radiological end result.
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http://dx.doi.org/10.1097/00009957-200405000-00003DOI Listing
May 2004

Lumbar pedicle morphology in the immature spine: a three-dimensional study using spiral computed tomography.

Spine (Phila Pa 1976) 2002 Nov;27(22):2472-6

Department of Orthopaedics, Hacettepe University, Ankara, Turkey.

Study Design: A cross-sectional study was conducted.

Objective: To investigate the pediatric pedicle morphology with the help of modern computed tomography technology.

Summary Of Background Data: The use of pedicular screws recently has gained popularity because of their ability to provide three-dimensional correction of spinal deformity. Extensive work has been published on the pedicle morphology of the adult and adolescent thoracolumbar spine. Less is known about the pedicle morphology of children.

Methods: A total of 21 patients ages 5 to 10 years underwent standard spiral computed tomography of the abdomen. The patients were grouped according to age: Group 1 (5 to 8 years of age) and Group 2 (9 to 10 years of age). Images were reformatted, and multiplanar reconstructions were used to attain images of lumbar pedicles on sagittal, coronal, and transverse planes. The measurements included the inner and outer pedicle diameters on the transverse plane, the pedicle angle on both the transverse and sagittal planes, and pedicle length.

Results: The smallest pedicle lengths were 24 mm for Group 1 and 25 mm for Group 2. When the average values were considered, the smallest lengths were at L5 and the longest at L3. The smallest diameter was at L1 (2.3 mm for Group 1 and 3 mm for Group 2), whereas L5 had the largest diameter (6.17 mm for Group 1 and 8.72 mm for Group 2). In the transverse plane, the pedicle angle increased from L1 to L5 in both groups. In the sagittal plane, the angulations followed an opposite trend.

Conclusions: The inner transverse diameter of the lumbar pedicle, particularly in young children, is smaller than previously reported. Insertion of screws currently available commercially screws seems to be safe in the L4-L5 pedicles of children ages 5 to 8 years, and in the L3-L5 pedicles of older children. Custom-made screws might be considered for upper levels for safe application.
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http://dx.doi.org/10.1097/00007632-200211150-00010DOI Listing
November 2002

Reliability and necessity of dynamic computerized tomography in diagnosis of atlantoaxial rotatory subluxation.

J Pediatr Orthop 2002 Nov-Dec;22(6):763-5

Hacettepe University Faculty of Medicine, Sihhiye Ankara, Turkey.

Dynamic computerized tomography (DCT) has been accepted to be the standard diagnostic method of atlantoaxial rotatory subluxation (AARS) although its reliability and reproducibility has not been shown yet. The purpose of this study was to evaluate the intraobserver reproducibility and interobserver reliability of DCT. Standard DCT scans of 18 patients with acute torticollis and 12 normal subjects were examined two times in between a time interval of 1 month by three specialists and a last-year resident to define any existing AARS. The interobserver reliability kappa coefficient was -0.015 (poor) for the first examination and 0.327(fair) for the second one. The intraobserver reproducibility kappa coefficients were 0.135 (slight), -0.204 (poor), 1.00 (almost perfect), and 0.474 (moderate) respectively. It was found that DCT has a poor reliability and reproducibility in diagnosing AARS in patients with acute torticollis. Therefore, its routine use is not cost effective in patients with acute torticollis where the deformity usually resolves by a simple cervical mobilization.
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March 2003

Posteromedial approach and posterior plating of the tibia.

J Trauma 2002 Oct;53(4):722-4

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

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http://dx.doi.org/10.1097/00005373-200210000-00017DOI Listing
October 2002

Bipositional MR imaging vs arthrography for the evaluation of femoral head sphericity and containment in Legg-Calvé-Perthes disease.

Clin Imaging 2002 Sep-Oct;26(5):342-6

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

Eleven hips of 10 patients with Legg-Calvé-Perthes disease (LCPD) were examined by arthrography and magnetic resonance (MR) imaging. Arthrogram and MR images were obtained with the hips in neutral position and in 20 degrees flexion-abduction and internal rotation. Modified arthrographic index (AI) was used for the evaluation of sphericity and acetabulum head index (AHI) was used for the assessment of containment. According to AI, there is no significant difference between the arthrograms and coronal MR imaging, but the difference between the coronal and sagittal MR imaging was significant. There was no statistical difference between the arthrograms and MR measurements in terms of AHI. Anterior flattening of the femoral head and the effect of hip flexion in the containment at the sagittal plane could be demonstrated clearly in sagittal MR imaging. Even if there was significant flattening in coronal plane, the sphericity of the head was preserved in the sagittal plane. Bipositional MR imaging is comparable to arthrography for the demonstration of sphericity and containment of the femoral head in both coronal and sagittal planes in LCPD.
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http://dx.doi.org/10.1016/s0899-7071(02)00446-1DOI Listing
January 2003

Thoracic paravertebral leiomyosarcoma: rare but it does occur.

Spine (Phila Pa 1976) 2002 Jun;27(12):E301-3

Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey.

Study Design: Marginal resection of a paraspinal tumor in the thoracic vertebra was performed.

Objective: To document a very rare pathology for a paraspinal tumor.

Summary Of Background Data: Primary leiomyosarcoma of the spine or paravertebral space is extremely rare. A case of a patient who was operated on for a mass in the spinal canal and whose pathology was reported to be leiomyosarcoma is presented.

Methods: Marginal resection of the paravertebral mass was performed.

Results: The pathology of the tumor was reported as leiomyosarcoma.

Conclusion: Leiomyosarcomas may develop at any site where smooth muscle cells are present. However, primary leiomyosarcoma of the spine or paravertebral space is extremely rare. Leiomyosarcoma, although rare, should be kept in mind as one of the possible diagnoses when a patient with a paraspinal tumor is presented.
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http://dx.doi.org/10.1097/00007632-200206150-00024DOI Listing
June 2002
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