Publications by authors named "Güney Yılmaz"

37 Publications

Excision of fibrous band and application of tension band plating in focal fibrocartilaginous dysplasia: A case report and literature review.

Acta Orthop Traumatol Turc 2021 Mar;55(2):184-188

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

Focal fibrocartilaginous dysplasia (FFCD) is a rare disease that can cause angular deformities of long bones. The common pathologic finding is a thick fibrotic band extending from epiphysis to metaphysis on one side of the bone. The tethering effect of the fibrotic band around the growth plate is thought to be the main etiology for the development and progression of the deformity. FFCD mostly affects the proximal tibia and the distal femur. The literature contains different treatment options. Here, we present the case of a 20-month-old girl with FFCD on the medial side of the distal femur causing varus deformity. Our treatment protocol included excision of the fibrotic band from the medial side and application of a two-hole plate for guided growth on the lateral side of the distal femur. Deformity correction was achieved rapidly with no complications. A literature review is also presented along with pathologic and magnetic resonance imaging findings.
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http://dx.doi.org/10.5152/j.aott.2021.20080DOI Listing
March 2021

Aponeurotic release of semimembranosus: A technical note to increase correction gained with hamstring lengthening surgery in cerebral palsy.

Acta Orthop Traumatol Turc 2021 Mar;55(2):177-180

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

Objective: The aim of this study was to determine the intraoperative corrective effect of the aponeurotic release of semimembranosus (SM) as a single procedure or an adjunct procedure to distal myotendinous release of semitendinosus (ST) and myofascial release of SM lengthening in the correction of knee flexion deformity in cerebral palsy (CP).

Methods: In this prospective study, 46 knees of 23 consecutive ambulatory patients (15 boys and 8 girls; mean age=8.33 years; age range=5-12 years) with spastic diplegic CP with a gross motor function classification system level (GMFCS) II or III were included. The patients were then divided into 2 groups. In group I, there were 10 patients (4 boys, 6 girls; mean age=8.6±2), and combined release of ST in the myotendinous junction and SM in the myofascial junction, followed by aponeurotic release of SM were carried out. In group II, there were 13 patients (2 girls, 11 boys; mean age=8±2.35), and aponeurotic release of SM was done first and followed by the combined release of ST in the distal myotendinous junction and the myofascial release of SM. Intraoperative popliteal angle (PA) measurements were recorded in each group.

Results: PA was reduced from 58.1°±7.6° (range=46°-75°) to 41.2°±8.8° (range=20°-54°) in group 1 and from 59.1°±11.3° (range=40°-87°) to 42.7°±10.8° (range=24°-64°) in group 2. No significant difference was observed between the groups in terms of reduction in PA (p=0.867). In group 1, adding the aponeurotic release of SM further reduced the PA to 31.7°± 8.5° (range=14°-47°) (p=0.002). In group 2, adding the myotendinous release of ST and myofascial release of SM further reduced the PA to 32.9°±7.2° (range=16°-44°) (p=0.004). There was no significant difference between the final PA values in the 2 groups (p=0.662). There was no difference in terms of early complications.

Conclusion: Aponeurotic release of SM is equally effective to reduce the intraoperative PA with combined myotendinous release of ST and myofascial release of SM. Combining all the 3 procedures provides a better correction without forceful manipulation or lengthening of the lateral hamstrings during the correction of knee flexion deformity in CP.
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http://dx.doi.org/10.5152/j.aott.2021.20184DOI Listing
March 2021

The efficacy of two-hole tension band plates in the treatment of lower extremity limb length discrepancy.

J Pediatr Orthop B 2021 Mar 8. Epub 2021 Mar 8.

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

The main purpose of our study was to investigate the efficacy of dual two-hole tension band plates in the treatment of lower extremity limb length discrepancy (LLD). We retrospectively reviewed patients who underwent epiphysiodesis utilizing dual two-hole tension band plates due to lower extremity LLD between January 2012 and June 2018. The efficacy of epiphysiodesis was defined as the inhibited percentage of the expected growth of the physis between two time intervals and was calculated between 0-6 months and 6-18 months as the primary outcome. The relationship of efficacy of epiphysiodesis with time intervals, bone segments, physeal coverage percentage by the screws, age and interscrew angle and physeal health was also assessed. A total of 11 patients' 17 bone segments (9 femurs and 8 tibias) with a mean age of 8.7 ± 2.3 were included. The mean efficacy of the epiphysiodesis in the first 6 months for femurs was 23 ± 20 % (range, 0-53%) and for tibias was 21 ± 19 % (range, 0-53%); between 6 and 18 months it was 27 ± 19 % (range, 0-56%) for femurs and 15 ± 19 % (range, 0-50%) for tibias. In the first 6 months, physeal coverage percentage by the screws (r = 0.503, P = 0.04) and age (r = -0.534, P = 0.027) had a strong correlation with the epiphysiodesis efficacy. Dual two-hole tension band plating has variable efficacy in the treatment of LLD. Age and physeal coverage percentage by the screws could be related to epiphysiodesis efficacy.
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http://dx.doi.org/10.1097/BPB.0000000000000861DOI Listing
March 2021

Correction of coronal plane deformities around knee in children with two-hole tension band plates.

Jt Dis Relat Surg 2021 6;32(1):177-184. Epub 2021 Jan 6.

Hacettepe Üniversitesi Tıp Fakültesi Ortopedi ve Travmatoloji Anabilim Dalı, 06100 Sıhhiye Ankara, Türkiye.

Objectives: This study aims to present the 10-year results and complications of two-hole tension band plate hemiepiphysiodesis for coronal deformities around knee in a large population from a single center.

Patients And Methods: Seventy-seven patients (46 boys, 31 girls; mean age 93±36 months; range, 22 to 181 months) who underwent temporary hemiepiphysiodesis around knee between January 2009 and January 2019 with two-hole tension band plates were retrospectively evaluated. Improvement of joint orientation angles and mechanical axis deviations, deformity correction rates, etiology groups, and complications were noted.

Results: A total of 166 bone segments (93 femurs, 73 tibias) were included in the study. Mean follow-up duration after the implantation was 36±17 (range, 12 to 88) months. Plates were removed at mean 18±8 (range, 7 to 47) months of implantation. Of the bone segments, 95.2% (n=158) responded successfully to the plates. Mean correction rate of mechanical lateral distal femoral angle in femoral valgum deformity was 0.94±0.43° (range, 0.17 to 2.22)/month and mean correction rate of mechanical medial proximal tibial angle in tibial valgum deformity was 0.62±0.36° (range, 0.11 to 1.55)/month. Mean correction rate of mechanical lateral distal femoral angle in femoral varum deformity was 1.3±0.8° (range, 0.48 to 2.92)/month and mean correction rate of mechanical medial proximal tibial angle in tibial varum deformity was 0.94±0.49° (range, 0.26 to 1.67)/month. The most common complication observed was rebound deformity seen in 41.2% (n=70) of the bone segments. Nine bone segments had persistent hemiepiphysiodesis despite plate removal. Four screw breakages (three metaphysial and one epiphysial) were observed.

Conclusion: Two-hole tension band plate hemiepiphysiodesis appears to be an effective and safe method for the correction of coronal deformities around knee.
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http://dx.doi.org/10.5606/ehc.2021.78879DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8073465PMC
January 2021

Osteochondral autograft transplantation of the femoral head in sequelae of developmental dysplasia of hip: A case report and review of the literature.

Jt Dis Relat Surg 2020 ;31(3):619-625

Hacettepe Üniversitesi Tıp Fakültesi Ortopedi ve Travmatoloji Anabilim Dalı, 06100 Sıhhiye, Ankara, Türkiye.

Although osteochondral autograft transplantation (OAT) in the knee and ankle has gained much popularity on the other hand the technique has rarely been applied in the femoral head. In this article, we present a 15-year-old female patient with unstable chondral lesion on the right femoral head. She had a history of open reduction for developmental dysplasia which resulted in avascular necrosis. She had coxa magna, breva and trochanteric overgrowth along with an unstable chondral lesion on the superolateral part of the femoral head. She underwent OAT for chondral lesion, femoral head reshaping and relative neck lengthening. Her Harris Hip Score improved from 55 to 90 in the 18 months of follow-up. The case is unique in a way that the autografts were harvested from the anterior part of the same femoral head that was already intended to be removed during osteochondroplasty.
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http://dx.doi.org/10.5606/ehc.2020.75135DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7607946PMC
February 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

Center-edge angle values in healthy children between 5 and 14 years old in Turkey.

Acta Orthop Traumatol Turc 2020 Jan;54(1):15-19

Department of Orthopaedics and Traumatology, Selcuk University, Konya,Turkey.

Objective: The aim of this study was to determine the center-edge angle (CEA) values according to age, gender and side in healthy children between 5 and 14 years old in Turkey and to find out the angular limit values for mild and severe dysplasia.

Methods: The data pool that was gathered to investigate the frequency of hip dislocation in children between 6 months and 14 years old in Turkey was used. The data pool consists of pelvis and lower abdomen radiographs obtained for reasons other than hip dysplasia. Lower abdomen/pelvis radiographies of children between 5 and 14 years old were extracted from the data pool and were evaluated. Distribution of CEA values according to age, gender and side was examined. Measurements were performed by a single investigator on computer by using a standard method. Reliability of the measurements was tested by three different investigators on randomly selected films by using the standard method.

Results: CEA values of 3192 hips of 1596 children, who had no hip pathology, were measured. Mean CEA value was found as 26.2°±5.5°. The mean CEA was 26.2°±5.3° in males (%54) and 26.2°±5.7° in females (%46) (p=0.224). Mean values for the right and left hips were 25.7°±5.4° and 26.6°±5.6°, respectively. CEA value of 449 (14%) hips of 333 (20.8%) children was at the limit of mild dysplasia and CEA value of 70 (2.2%) hips of 58 (3.6%) children was at the limit of severe dysplasia. CEA values had increased by age and mild and severe dysplasia limits were determined for every age group.

Conclusion: The mild and severe dysplasia values that are defined according to ages in Turkish population will guide the investigators in the diagnosis, follow-up and treatment planning of developmental dysplasia.

Level Of Evidence: Level IV, Diagnostic Study.
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http://dx.doi.org/10.5152/j.aott.2020.01.451DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7243687PMC
January 2020

Maxillary Sinus and Surrounding Bone Anatomy With Cone Beam Computed Tomography After Multiple Teeth Loss: A Retrospective Multicenter Clinical Study.

Implant Dent 2019 Jun;28(3):226-236

Associate Professor, Department of Periodontics, College of Dentistry, University of Illinois at Chicago, Chicago, IL.

Purpose: The aim of this multicenter study was to examine the residual alveolar bone anatomy and sinus mucosa pattern at maxillary sinus regions in multiple teeth loss.

Materials And Methods: This study was conducted with cone beam computed tomography images of 518 patients (267 females and 251 males) with multiple posterior maxillary teeth loss. Variables associated with sinus membrane (SM), sinus dimensions, ostium, septa, sinus neighborhood, alveolar bone height and ridge width, posterior superior alveolar artery, and adjacent roots were evaluated.

Results: No (58.2%) or flat (19.3%) thickening morphology was detected at most of the SMs. Membrane thickening and mucosal-like morphology was more prevalent for male patients (P = 0.005). The mean sinus width was relatively low (3.64 ± 3.33 mm) at the 5-mm level and showed an expected increase toward upper levels. Most of the sinus spaces were dimensionally average (39.5%) or wide (44.7%), and no effect of gender was observed in terms of sinus dimensions (P > 0.05).

Conclusion: Multiple teeth loss plays a role in creating an imaginary sinus anatomy constituted of a relatively narrow space compared with single-tooth loss cases, from 3.6-mm mean coronal width to 11.3 mm in the apical portion.
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http://dx.doi.org/10.1097/ID.0000000000000862DOI Listing
June 2019

Effectiveness of abduction orthosis for the treatment of acetabular dysplasia.

Eklem Hastalik Cerrahisi 2019 Apr;30(1):32-7

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

Objectives: This study aims to evaluate the effectiveness of full-time bracing in residual acetabular dysplasia (RAD) and the effect of previous Pavlik harness usage on the results of treatment with abduction orthosis.

Patients And Methods: We retrospectively reviewed 80 patients (9 males, 71 females; mean age 6±0.8 months; range, 5 to 7 months) with developmental dysplasia of the hip (119 dysplastic hips) treated with hip abduction orthosis. Patients with an acetabular index (AI) measurement of 30° and over who used full-time hip abduction brace for six months were included in the study. Acetabular index values were measured at the initiation, third, and sixth months of treatment and the effectiveness of abduction orthosis was evaluated. The patients were analyzed for the effect of prior Pavlik harness application on abduction orthosis treatment.

Results: Mean AI value of the dysplastic hips (n=119) was 33.4°±2.6°, which decreased to 28.5°±2.6° after treatment (p<0.001). The AI improvement in the first three-month period was significantly faster than the second three-month period (2.9°±1.9° vs. 1.9°±1°; p=0.013). No difference was observed in AI development between patients with or without prior Pavlik treatment (p=0.1). In patients with unilateral dysplasia, dysplastic hips improved significantly faster than normal hips (p<0.001). As a result of a mean follow-up duration of 20.2±9.8 months from the onset of brace treatment, 32 (32%) hips were grouped as normal, 49 (48%) as mildly dysplastic, and 22 (20%) as severely dysplastic based on Tönnis criteria.

Conclusion: Hip abduction orthosis may be used in patients with RAD between 6 to 12 months of age. Acetabular index improvement was faster in the first three months of brace treatment. Dysplastic hips improved faster than normal hips, and prior Pavlik harness treatment did not alter the effectiveness of orthosis.
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http://dx.doi.org/10.5606/ehc.2019.63718DOI Listing
April 2019

Correction of distal femoral valgus deformities with fixator-assisted plating: How accurate is the correction?

Acta Orthop Traumatol Turc 2019 Mar 13;53(2):100-105. Epub 2018 Dec 13.

Hacettepe University, Department of Orthopaedics and Traumatology, Turkey.

Objective: The aim of this study was to evaluate the results of fixator assisted correction of the distal femoral valgus deformities and the precision of the correction.

Methods: Seventeen extremities of 13 patients (7 women and 6 men; mean age: 16 ± 5.4 years) who had fixator assisted plating of the distal femur for genu valgum deformity were evaluated. Mechanical axis deviation (MAD) and mechanical lateral distal femoral angles (mLDFA) were measured pre-operatively and post-operatively. mLDFA was graded as perfect if it is between 85° and 90°(85° ≤ x ≤ 90°); overcorrection if it is between 91° and 95° (91° ≤ x ≤ 95°) and undercorrection if it is between 80° and 85° (80° ≤ x < 85°). Measurements beyond those limits were graded as a poor result. The position of the mechanical axis line with respect to center of the knee was graded from zone 1 to zone 4 pre-operatively and post-operatively.

Results: The mean follow-up period was 12.8 ± 3.7 months. The pre-operative and post-operative mLDFA was 70.5°±9.4° (range, 57°-82°) and 87.7° ± 3.5° (range, 80°-94°), respectively (p < 0.001). Based on post-operative standing radiographs, the correction was graded perfect in 12 femurs. The correction in three femurs were graded as overcorrection and graded as undercorrection in two femurs. Sagittal plane correction was also achieved in two femurs. Peroneal nerve decompression was done in three patients (5 extremities) with valgus deformity over 30°. The mechanical axes in all lower extremities were passing through zone 2 or more, pre-operatively, whereas the mechanical axes were in zone 2 or more in five extremities post-operatively.

Conclusion: Fixator assisted plating is an effective treatment modality in patients with distal femoral valgus deformity. Although the technique enables to obtain significant correction in coronal plane it has the disadvantages of over- and undercorrection. Thus, we advise intraoperative confirmation of the correction under fluoroscopic control.

Level Of Evidence: Level IV Therapeutic Study.
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http://dx.doi.org/10.1016/j.aott.2018.11.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6506810PMC
March 2019

Further delineation of spondyloepimetaphyseal dysplasia Faden-Alkuraya type: A RSPRY1-associated spondylo-epi-metaphyseal dysplasia with cono-brachydactyly and craniosynostosis.

Am J Med Genet A 2018 09 31;176(9):2009-2016. Epub 2018 Jul 31.

Division of Pediatric Genetics, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey.

Our understanding of the molecular basis of the genetic disorders of the skeleton has steadily increased, as the application of high-throughput sequencing technology has expanded. One of the newcomers is Spondyloepimetaphyseal dysplasia Faden-Alkuraya type. In this study, we aimed to further delineate the clinical, radiographic, and molecular findings of this entity in five affected individuals from two unrelated families. All patients have short stature, extremity deformities, facial dysmorphism and intellectual disability. The skeletal hallmarks include (a) mild spondylar dysplasia, (b) epimetaphyseal dysplasia of the long bones associated with coxa vara and genu valgum, (c) brachymesophalangy with cone-shaped epiphyses, and (d) craniosynostosis. Unlike the previously reported clinical findings, all patients except one are normocephalic, and all share the clinical findings including craniosynostosis, varying degrees of intellectual disability, facial dysmorphism, and skeletal findings including pes planus, prominent heels, and pectus deformity. Interestingly one of the patients presented with a cemento-ossifying fibrous lesion of the maxilla. Whole exome sequencing revealed a novel homozygous [c.377delT] [p.Ile126fs*] frameshift mutation at exon 2 in one family, while Sanger sequencing revealed a novel homozygous splice site mutation [c.516+2T>A] at exon 4/intron 4 border of RSPRY1 in the other family. In conclusion; we provide further evidence that Spondyloepimetaphyseal dysplasia Faden-Alkuraya type is a RSPRY1-associated skeletal dysplasia with a distinctive phenotype composed of spondyloepimetaphyseal dysplasia, cono-brachydactyly, and craniosynostosis along with recognizable facial features and intellectual disability.
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http://dx.doi.org/10.1002/ajmg.a.40427DOI Listing
September 2018

Treatment of the Lower Extremity Contracture/Deformities.

J Pediatr Orthop 2017 Jul/Aug;37 Suppl 1:S16-S23

*Shriners Hospitals for Children, Philadelphia, PA †Department of Pediatric Orthopedic Surgery, Karolinska University Hospital, Stockholm, Sweden ‡Department of Orthopaedic Surgery, Saga Handicapped Children's Hospital, Saga, Japan §Arthrogryposis Clinic, Turner Scientific and Research Institute for Children's Orthopedics, Saint Petersburg, Russia ††Turner Scientific and Research Institute for Children's Orthopedics §§Department of Foot and Ankle Surgery, Neuroorthopaedics and Systemic Disorders, Turner Scientific and Research Institute for Children's Orthopedics, Saint Petersburg **Yaroslavl Regional Children's Hospital, Yaroslavl, Russia ∥Department of Pediatric Orthopedics and Trauma Surgery, University Children's Hospital of Krakow, Krakow, Poland ¶ALYN Rehabilitation Hospital for Children and Adolescents, and Pediatric Orthopedic Service, Shaare-Zedek Medical Center #Faculty of Medicine, Selcuk University, Konya, and Faculty of Medicine, Erzincan University, Erzincan, Turkey ∥∥Department of Orthopedics and Traumatology, Medical School of Selcuk University ¶¶Konya Bozkir State Hospital ##Department of Orthopedics and Traumatology, Meram University Hospital and Selçuk University Faculty of Medicine, Konya, Turkey.

Lower extremity deformities of patients with arthrogryposis multiplex congenita present a wide spectrum of severity and deformity combinations. Treatment goals range from merely ensuring comfortable seating and shoe wear, to fully independent and active ambulation, but the overarching intention is to help realize the patient's greatest potential for independence and function. Treatment of hip and knee contractures and dislocations has become more interventional, whereas treatment of foot deformities has paradoxically become much less surgical. This article synopsizes the treatment strategies presented in September 2014 in Saint Petersburg, Russia at the second international symposium on arthrogryposis.
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http://dx.doi.org/10.1097/BPO.0000000000001005DOI Listing
October 2017

Treatment of the Upper Extremity Contracture/Deformities.

J Pediatr Orthop 2017 Jul/Aug;37 Suppl 1:S9-S15

*Department of Hand Surgery, Texas Scottish Rite Hospital for Children, Dallas, TX †Arthrogrpyosos Clinic, Turner Scientific and Research Institute for Children's Orthopedics §Department of Foot and Ankle Surgery, Neuroorthopaedics and Systemic Disorders, Pediatric Orthopedic Institute n.a. H. Turner, Saint-Petersburg, Russia ∥Departments of Pediatric Orthopedics and Radiodiagnosis, Faculty of Medicine, Cairo University, Cairo, Egypt ‡Plastic & Reconstructive Surgery School, Università degli Studi di Milano ¶Hand Surgery & Rehabilitation Department Ospedale San Giuseppe, MultiMedica Group, Milan, Italy #Department of Hand Surgery, Birmingham Children's Hospital, Birmingham, UK **Department of Orthopedics and Traumatology, Medical School of Selcuk University ††Faculty of Medicine, Selcuk University §§Konya Bozkir State Hospital, Konya ‡‡Faculty of Medicine, Erzincan University, Erzincan, Turkey.

Patients with arthrogryposis multiplex congenita have a characteristic upper extremity resting posture consisting of internal rotation of the shoulders, elbow extension, flexed wrists, thumb-in palm deformities, and variable degrees of finger contractures. Treatment of these patients is aimed at improving independence and performance of activities of daily living. Although each area needs to be assessed independently for the most appropriate surgical procedure, often multiple areas can be addressed at the same operative setting. This limits the number of anesthetic exposures and cast immobilization time. The following is a synopsis of treatment strategies presented at the second international symposium on Arthrogryposis which took place in St Petersburg in September 2014.
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http://dx.doi.org/10.1097/BPO.0000000000001002DOI Listing
October 2017

Short-term results of early (before 6 months) open reduction of dislocated hips in arthrogryposis multiplex congenita.

J Pediatr Orthop B 2016 Nov;25(6):509-13

Department of Orthopaedics, Selcuk University, Konya, Turkey.

The aim of this study was to report the results of early open reduction of hip dislocations in infants with arthrogryposis multiplex congenita. Seven patients who were under 6 months of age at the time of hip reduction, with a mean follow-up period of 47.5±11.3 months after surgery, were included in this study. Four of seven patients (six of 13 hips) required additional hip surgeries during their follow-up. The short-term results of early open reduction of hips were not promising as most of the patients required additional hip surgeries.
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http://dx.doi.org/10.1097/BPB.0000000000000371DOI Listing
November 2016

Percutaneous double-button fixation method for treatment of acute type III acromioclavicular joint dislocation.

Acta Orthop Traumatol Turc 2015 ;49(3):241-8

Bezmialem Vakıf University Faculty of Medicine, Department of Orthopedics and Traumatology, İstanbul, Turkey.

Objective: The aim of this study was to evaluate the functional and radiological results of patients treated with the percutaneous double-button technique for acute acromioclavicular (AC) joint dislocation.

Methods: A retrospective evaluation was performed of 13 patients surgically treated for acute Type III AC joint dislocation with the percutaneous double-button fixation method. The coracoclavicular (CC) distance of the affected side was compared with that of the healthy side on anterior-posterior radiographs obtained at the final follow-up. In the functional evaluation, Disabilities of the Arm, Shoulder and Hand (DASH), Constant, and visual analog scale (VAS) scores were used.

Results: The 13 patients in the study included 12 males and 1 female with a mean age of 43.4 years (range: 22-60 years). The mean follow-up period was 13.61 months (range: 9-24 months). The mean CC distance on the operated side was 9.23 mm (range: 8-15 mm), and when compared with the healthy side, no statistically significant difference was observed. Preoperative Constant scores of a mean of 30.3 (range: 18-42) increased to 84.4 (range: 70-90) at the final follow-up. Preoperative DASH scores had a mean of 14.1 (range: 11-28) and decreased to 0.4 (range: 0-3) at the final follow-up (p<0.001). Mean preoperative VAS score was 6.0 (range: 5-8), which decreased to 0.6 (range: 0-3) at the final follow-up (p<0.001).

Conclusion: The percutaneous double-button fixation technique is a safe, practical, and effective fixation method that can be used as an alternative to arthroscopic and open methods for acute Type III AC joint dislocations.
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http://dx.doi.org/10.3944/AOTT.2015.14.0230DOI Listing
May 2016

Convex Hemiepiphysiodesis: Posterior/anterior in-situ Versus Posterior-only With Pedicle Screw Instrumentation: An Experimental Simulation in Immature Pigs.

J Pediatr Orthop 2016 Dec;36(8):847-852

*Department of Orthopedics and Traumatology, Cankaya Hospital †Hacettepe University Faculty of Medicine Orthopedics and Traumatology Department §Hacettepe University Faculty of Medicine Department of Histology & Embryology, Ankara ‡Kent Hospital Orthopedics and Traumatology Department, Izmir ∥Acibadem Maslak Hospital, Comprehensive Spine Center, Istanbul, Turkey.

Study Design: Experimental study.

Background: Convex growth arrest (CGA) has been commonly used in the treatment of long-sweeping congenital deformities of the immature spine. As there are major drawbacks about the anterior procedure in the conventional CGA method, a new modification has been documented that using only posterior spinal approach with pedicle screw instrumentation. The aim of the study was to compare posterior-only CGA using pedicle screws with combined anterior/posterior in-situ CGA for the findings in histologic, radiologic, and manual palpation examinations in an immature pig model.

Methods: Twelve 10-weeks old pigs were grouped into 2. In group 1, posterior-only, pedicle screw instrumented CGA was performed on the left side of L1-L4 vertebrae. In group 2, conventional combined posterior and anterior CGA was performed to the left side of L1-L4 vertebrae without instrumentation. All animals were killed twelve weeks after surgery. T11-L5 segments were en-bloc resected and radiologic, histologic, and manual palpation examinations were done.

Results: Marked scoliotic (12.2±2.5 and 9.2±1.3 in group 1 and 2, respectively) and kyphotic (11.2±1.0 degrees for the group 1 and 12±5.2 degrees for the group 2, respectively) deformities were noted in both groups, which were caused by hemiepiphysiodesis effect. Anterior and posterior parts of group 2 and posterior part of group 1 demonstrated fusion in histologic and radiologic analyzes. In anterior part of the group 1, marked narrowing on the disk spaces and thinning of growth plates were noted in radiologicg examination, chondrocyte degeneration, and newly-formed bone trabeculae in disk-space were noted in histological examination. In manual palpation, no motion was detected in group 1 and motion was detected in only one segment of one animal in group 2.

Conclusions: Anterior growth of the vertebrae can be controlled by application of posterior transpedicular screws and rod. Such an effect can eliminate the need for anterior surgical intervention in convex hemiepiphysiodesis procedures.

Clinical Relevance: The instrumented CGA technique provides a satisfactory epiphysiodesis effect both anteriorly and posteriorly, as previously demonstrated by clinical studies.
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http://dx.doi.org/10.1097/BPO.0000000000000565DOI Listing
December 2016

The need for Achilles tenotomy in the Ponseti method: Is it predictable at the initiation or during the treatment?

J Pediatr Orthop B 2015 Jul;24(4):341-4

Department of Orthopaedics, Faculty of Medicine, Selcuk University, Konya, Turkey.

The aim of this study was to determine whether the need for tenotomy can be predicted at the initiation or during the treatment of the clubfoot treatment according to the Ponseti method. One hundred and eight feet of 77 babies who required tenotomy and who did not were compared statistically according to the parameters of sex, side, bilaterality, presentation day, number of casts, Pirani scores, and the percentage change in Pirani scores, respectively. The mean number of casts required, the initial Pirani scores, and the percentage change in Pirani scores were significantly different between the groups that required tenotomy and the groups that did not (P=0.0001). Pirani scores at the beginning and the percentage change in Pirani scores during the treatment can be used to estimate the need for Achilles tenotomy.
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http://dx.doi.org/10.1097/BPB.0000000000000194DOI Listing
July 2015

Reconstruction of foot and ankle defects with a free anterolateral thigh flap in pediatric patients.

J Reconstr Microsurg 2015 Mar 28;31(3):225-32. Epub 2015 Jan 28.

Department of Orthopedics and Traumatology, Medical School of Selcuk University, Konya, Turkey.

Background: There are a limited number of published studies describing reconstruction with an anterolateral thigh (ALT) flap following lower extremity injury in pediatric patients. The aim of this study was to present our experiences with the application of a free ALT flap not only in the reconstruction of soft tissue defects around the pediatric foot and ankle but also in patients with bone, tendon, and ligament injuries that require repair.

Materials And Methods: Reconstruction with a free ALT flap was performed in 11 pediatric patients (mean age, 8.9 years; range, 3-15 years) between November 2010 and February 2013. The modes of injury were as follows: six traffic accidents, three firearm accidents, one agricultural machinery accident, and one bicycle chain accident. A retrospective evaluation of the applied surgical procedures was performed: flap size, perforator type and number, placement area, site of anastomosis, closure of the donor site, complications, and flap survival.

Results: The mean size of the skin flap was 83.2 mm(2) (range, 48-117 mm(2)). Except for two patients, there were two perforators in the obtained flaps, which were 75% musculocutaneous and 25% septocutaneous. To strengthen the Achilles tendon in one patient, the ALT, together with the fascia lata, was raised as a composite flap. This flap was used as a "sensate flap" in three patients with defects in the heel area and as a "perforator flap" in seven patients. Anastomosis was performed in the anterior tibial artery in five patients and in the posterior tibial artery in six patients. Primary closure was performed for the donor site in all patients. Due to venous thrombus after 24 hours in one patient, reexploration was performed, and blood flow was regained with a vein graft. In the same patient, partial necrosis developed on the lateral edge of the flap; after debridement of the necrotic areas, closure was performed with a split thickness skin graft. After the ALT flap procedure, the primary flap survival rate was 90.9%.

Conclusion: The free ALT flap could be a safe, reliable, and aesthetically appealing option for foot/ankle resurfacing in children after traumatic soft tissue loss. The ALT flap can cover a far greater area and provide the versatility needed to optimize soft-tissue coverage.

Clinical Question/level Of Evidence: Level IV.
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http://dx.doi.org/10.1055/s-0034-1395888DOI Listing
March 2015

Surgical treatment of Achilles tendon ruptures: the comparison of open and percutaneous methods in a rabbit model.

Ulus Travma Acil Cerrahi Derg 2014 Sep;20(5):311-8

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

Background: This study was intended to investigate the healing properties of open and percutaneous techniques in a rabbit model and compare histological, electron microscopical, and biomechanical findings of the healed tendon between the groups.

Methods: Twenty-six rabbits were randomly assigned to two groups of thirteen rabbits each. Percutaneous tenotomy of the Achilles tendon (AT) was applied through a stab incision on the right side 1.5 cm above the calcaneal insertion in all animals. Using the same Bunnell suture, the first group was repaired with the open and the second group was repaired with the percutaneous method. ATs were harvested at the end of eight weeks for biomechanical and histological evaluation.

Results: When the sections were evaluated for fibrillar density under electron microscopy, it was noted that fibrils were more abundant in the percutaneous repair group. The tendon scores in the percutaneous group were less than the open group indicating closer histological morphology to normal. The difference was not significant (p=0.065). The mean force to rupture the tendon was 143.7± 9.5 N in percutaneous group and 139.2±8.2 N in the open group. The difference was not significant (p=0.33).

Conclusion: Percutaneous techniques provide as good clinical results as the open techniques do. The healing tendon shows better findings in histological and electron microscopical level with percutaneous technique.
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http://dx.doi.org/10.5505/tjtes.2014.42716DOI Listing
September 2014

Reconstruction of multiple fingertip injuries with reverse flow homodigital flap.

Injury 2014 Oct 17;45(10):1569-73. Epub 2014 Jun 17.

Selçuk University, Selçuk School of Medicine, Department of Orthopaedics and Traumatology, Campus of Alaeddin Keykubat, Selçuklu 42075, Konya, Turkey.

Aim: Hand trauma may lead to multiple fingertip defects, causing functional restrictions. We evaluated the use of reverse-flow homodigital flap reconstruction of the distal phalanx and pulp defects associated with multiple finger injuries.

Methods: We retrospectively evaluated 11 male patients who presented at our emergency department (January 2011-March 2013) with multiple fingertip injuries and who were treated with a reverse-flow homodigital flap. Evaluations included age, sex, defect size, flap survival rate, complications, cold intolerance, two-point discrimination, range of motion (ROM), quick disabilities of the arm, shoulder, and hand (DASH) score, and return to work time.

Results: Completely, 22 reverse-flow homodigital flaps were applied to at least two fingertip injuries at the distal phalanx. Ten flaps survived postoperatively. The exception was partial flap loss on one finger. The mean follow-up was 14.2 months. At the final follow-up, the mean static two-point discrimination value was 10.3mm. Mean ROMs of interphalangeal joints were 65.31° (distal) and 105.77° (proximal). Donor sites were covered with full-thickness skin grafts from the wrist or antecubital area. There were no complications related to the donor site and no development of cold intolerance in any finger. The mean quick DASH score was 4.12. All patients returned to work in an average of 8.3 weeks.

Conclusions: The reconstruction of multiple fingertip injuries with reverse-flow homodigital flaps is a safe, effective method that can be combined with other local finger flaps. These flaps can be applied to two consecutive fingers without reducing finger length or function.
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http://dx.doi.org/10.1016/j.injury.2014.06.009DOI Listing
October 2014

Surgical treatment of scoliosis in osteogenesis imperfecta with cement-augmented pedicle screw instrumentation.

J Spinal Disord Tech 2014 May;27(3):174-80

*Department of Orthopaedics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE †Shriners Hospital for Children, Philadelphia, PA ‡Department of Pediatrics, Division of Genetics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE.

Study Design: A retrospective study.

Objective: To report the early postoperative results of scoliosis surgery in osteogenesis imperfecta (OI) patients utilizing all pedicle screw constructs and present a novel cementing technique to increase pedicle screw purchase in the osteoporotic OI spine.

Summary Of Background Data: Scoliosis surgery utilizing hooks and wire systems have high complication rates in OI. Pedicle screw fixation systems have the biomechanical advantage of 3-column fixation, and cement augmentation of pedicle screws provides additional pull-out strength in the osteoporotic OI spine.

Methods: The clinical and radiologic results of 10 consecutive OI patients treated with all pedicle screw instrumentation and fusion were retrospectively reviewed. The radiologic data included preoperative and postoperative major curve measurements: major curve Cobb angle, global coronal balance (GCB), apical vertebral translation (AVT), and the lowest instrumented vertebral (LIV) tilt. Operative findings included blood loss, surgery time, and additional procedures. All patients received intravenous pamidronate therapy preoperatively to increase bone mineral density.

Results: Ten patients with OI were operated on between 2005 and 2009. Seven had cement-augmented pedicle screw insertion at the proximal and distal foundations. The mean hospital stay was 10±7.5 days (range, 4-27 d) and the average follow-up period was 25.7±13.1 months (range, 14-50 mo). Mean preoperative and postoperative major Cobb angles were 83.7±23.8 and 40.3±14.6 degrees, respectively (48% correction; P<0.05). Mean preoperative and postoperative GCB deviations were 26.7±18.6 and 14.1±13.3 mm, respectively (P=0.097). Mean preoperative and postoperative AVTs were 69.3±29.1 and 29±12.2 mm, respectively (P<0.05). Preoperative and postoperative LIV tilts were 18.5±8.9 and 5.2±3.9 degrees, respectively (P<0.05). At the latest follow-up, the mean major curve Cobb angle was 37.7±13.1 degrees, the GCB deviation was 13.8±5.1 mm, the AVT was 31.7±13.3 mm, and the LIV tilt was 11.3±8.8 degrees. There was no difference between the early postoperative and the latest follow-up major curve Cobb angle, GCB deviation, AVT, or LIV tilt, indicating maintenance of correction. The mean blood loss was 23,75 mL (range, 800-45,00 mL). The mean operative time was 375.4 minutes (range, 262-491 min). The mean postoperative Scoliosis Research Society-22 patient-based outcome scores were 4.6±0.7 (out of 5). There were no instrumentation failures or permanent neurological deficits in this series.

Conclusions: Pedicle screw instrumentation in OI scoliosis is safe and effective. Cement augmentation in these patients may help to increase the pedicle pull-out strength and decrease the screw failure rates, especially at the proximal and the distal ends of instrumentation.
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http://dx.doi.org/10.1097/BSD.0b013e3182624b76DOI Listing
May 2014

Safety and efficacy of instrumented convex growth arrest in treatment of congenital scoliosis.

J Pediatr Orthop 2014 Apr-May;34(3):275-81

*Hacettepe University Hospitals, Hacettepe University Medical School §Ankara Spine Center †Silvan Government Hospital, Diyarbakir ‡Kent Hospital, Izmir ∥Bilim University Hospital, University Medical School, Istanbul, Turkey.

Background: Anterior and posterior convex hemiepiphysiodesis is a widely used surgical alternative in the treatment of congenital scoliosis. This procedure has the disadvantage of the need for both anterior and posterior approaches. Furthermore, outcomes may be unpredictable. Posterior convex growth arrest (CGA) with pedicle screws at each segment on the convex side may obviate the need for anterior surgery and provides more predictable outcomes. This study retrospectively evaluates the safety and efficacy of instrumented posterior CGA in congenital scoliosis.

Methods: Patients who had posterior CGA with convex pedicle screw instrumentation for congenital scoliosis were evaluated retrospectively. Thirteen patients (6 male, 7 female) were included in the study. Preoperative, early postoperative, and last follow-up standing posteroanterior and lateral x-rays were evaluated. Cobb angles were recorded for the instrumented segment (main curve). Global thoracic kyphosis was measured between T2 and T12 on sagittal plane. These values were compared preoperatively, postoperatively, and at last follow-up. The T1-S1 vertical height and the height between the concave side pedicles of the upper and lower end vertebra of the main curve was also determined and recorded as the concave height.

Results: The average follow-up was 56.1±10 months (range, 36 to 74 mo) and the average age of the patients at the time of operation was 64.5±30.1 months (range, 15 to 108 mo). All patients were Risser zero at the time of surgery. The average curve magnitude was 49±10.9 degrees (range, 34 to 68 degrees) preoperatively, 38.3±9.7 degrees (range, 28 to 58 degrees) early postoperatively, and 33.5±12.4 degrees (16 to 52 degrees) at last follow-up. There was a significant difference between the preoperative and early postoperative main curve Cobb angle measurements (P=0.001). The average concave height was 94.2±20.2 mm in the early postoperative period and 104.7±21.7 mm at last follow-up (P=0.003). The average T1-S1 height was 292.1±67.1 mm in the early postoperative period and 363.9±94.5 mm at last follow-up (P=0.005). There was at least ≥5 degrees improvement in 9 of the 12 patients in the follow-up period after the index procedure. In 3 patients, the curve did not change and the correction was maintained. Curve progression was observed in 1 patient due to a technical error. There were no wound infections or instrumentation failures during follow-up.

Conclusions: Instrumented CGA can safely be used in long sweeping curves of immature spines. Using this technique; thoracotomy, anterior procedure, and 2-stage surgery can be avoided. Moreover, it guarantees some degree of correction in all patients because of the instrumentation effect, eliminating the unpredictable nature of classic CGA.

Level Of Evidence: Therapeutic level IV study.
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http://dx.doi.org/10.1097/BPO.0000000000000090DOI Listing
May 2015

Correction of lower extremity angular deformities in skeletal dysplasia with hemiepiphysiodesis: a preliminary report.

J Pediatr Orthop 2014 Apr-May;34(3):336-45

*Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE †Benha Medical School, Benha, Egypt ‡Department of Orthopaedic Surgery, Clinical Hospital Centre Zagreb, School of Medicine, University of Zagreb, Zagreb, Croatia.

Background: Lower extremity angular deformities are common in children with skeletal dysplasia and can be treated with various surgical options. Both acute correction by osteotomy with internal fixation and gradual correction by external fixation have been used with acceptable results. Recently, the Guided Growth concept using temporary hemiepiphysiodesis for correction of angular deformities in the growing child has been proposed. This study presents the results of temporary hemiepiphysiodesis using eight-Plates and medial malleolus transphyseal screws in children with skeletal dysplasia with lower extremity angular deformities.

Methods: Twenty-nine patients (50 lower extremities) with skeletal dysplasia of different types were treated for varus or valgus deformities at 2 centers. The mean age at the time of hemiepiphysiodesis was 10±2.9 years. A total of 66 eight-Plates and 12 medial malleolus screws were used. The average follow-up time between the index surgery and the latest follow-up with the eight-Plate in was 25±13.4 months. Erect long-standing anteroposterior and lateral view radiographs were obtained for deformity planning before the procedure. Angular deformities on radiograph were evaluated by mechanical axis deviation, mechanical lateral distal femoral angle, medial proximal tibial angle, and lateral distal tibial angle. Mechanical axis deviation was also expressed as a percentage to one half of the width of the tibial plateau, and the magnitude of the deformity was classified by determining the zones through which the mechanical axis of the lower extremity passed. Four zones were determined on both the medial and lateral side of the knee and the zones were labeled 1, 2, 3, and 4, corresponding to the severity of the deformity. A positive value was assigned for valgus alignment and a negative for varus alignment.

Results: Patients were analyzed in valgus and varus groups. There was correction in 34 of 38 valgus legs and 7 of 12 varus legs. In the valgus group, the mean preoperative and postoperative mechanical lateral distal femoral angles were 82.1±3.7 and 91.1±4.9 degrees, respectively (P<0.001). The mean preoperative and postoperative medial proximal tibial angles were 98.5±8 and 87.8±7.1 degrees, respectively (P<0.001). Six patients with bilateral ankle valgus deformities (12 ankles) underwent single-screw medial malleolus hemiepiphysiodesis. The mean preoperative and postoperative lateral distal tibial angles were 73.9±8.7 and 86.1±6.8 degrees, respectively (P<0.001). The numbers of plates in each anatomic location were not enough to make statistical conclusions in varus legs. Four patients in the valgus group and 3 patients in the varus group did not benefit from the procedure. Mechanical axes were in zone 2 or over in 94% of the legs preoperatively, whereas postoperatively, only 23% of the legs had mechanical axes in zone 2 or over in varus and valgus groups.

Conclusions: Growth modulation with an eight-Plate is a relatively simple surgery and has low risk of mechanical failure or physeal damage. It can be performed in very young patients, which is an important advantage in skeletal dysplasia. Screw purchase is reliable even in the abnormal epiphysis and metaphysis. Our results show that Guided Growth using eight-Plates in skeletal dysplasia is safe and effective.

Level Of Evidence: Level IV.
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http://dx.doi.org/10.1097/BPO.0000000000000089DOI Listing
May 2015

Acetabular index values in healthy Turkish children between 6 months and 8 years of age: a cross-sectional radiological study.

Acta Orthop Traumatol Turc 2013 ;47(1):38-42

Department of Orthopaedics and Traumatology International Kent Hospital, İzmir, Turkey.

Objective: The aim of this study was to determine the normal acetabular index values in children between 6 months and 8 years of age based on sex, age and side and to define the cutoff values for mild and severe acetabular dysplasia.

Methods: The records collected from the data pool that was gathered to define the prevalence of untreated congenital hip dislocation in Turkish children between 6 months and 14 years of age was used. The acetabular index was measured on pelvic and abdominal radiographs of children between 6 months and 8 years of age, taken in 19 different cities for non-dysplasia related causes. The distribution of the index values based on age, sex and side.

Results: Thirty-three hips of 21 children (0.75%) out of 2788 children were found to be subluxated or luxated. Acetabular index values of 5534 hips of 2767 children were measured. Acetabular index values of 723 (13%) hips of 493 children (17.8%) were found to be between 1 and 2 standard deviations. Acetabular index values of 147 hips (2.65%) of 118 children (4.3%) were calculated to be above 2 standard deviations. There was a negative correlation between the acetabular index and age.

Conclusions: The study defines the normal acetabular index values in healthy Turkish children between 6 months and 8 years of age and the expected acetabular index values for mild and severe dysplasia.
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http://dx.doi.org/10.3944/aott.2013.2832DOI Listing
August 2013

Long-segment posterior instrumentation and fusion with freeze-dried allograft in congenital scoliosis.

Acta Orthop Traumatol Turc 2012 ;46(4):275-80

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

Objective: The aim of this study was to evaluate the effectiveness of long-segment posterior instrumentation and allograft application in obtaining fusion in congenital scoliosis.

Methods: Twenty-one patients with congenital scoliosis who were treated with long-segment posterior instrumentation (>6 levels) and freeze-dried allograft and followed up for more than 24 months were reviewed. Six patients were excluded from the study due to anterior procedures. Fifteen patients with congenital scoliosis (13 females, 2 males; mean age: 12.2 ± 3 years, range: 7-17 years) were retrospectively reviewed. Mean follow-up time was 30.9 ± 9.4 (range: 24 to 48) months. Six patients had laminectomy either due to previous posterior surgeries or to address intraspinal pathologies during the posterior fusion procedure. Preoperative, postoperative and final follow-up anteroposterior and lateral spine X-rays were reviewed. Fusion was graded according to the classification reported by Bridwell et al.

Results: Two patients were graded as 'no fusion' (pseudarthrosis), four patients as 'probably fused', and nine patients as 'definitely fused'. The major curve was corrected from an average of 68 ± 18.6 to 39.3 ± 12.2 degrees (p<0.001). Mean correction lost in the major curve was an average of 4.5 ± 5.2 degrees in the latest follow-up. There was significant correction in the compensatory curve (preoperative 37.9 ± 13.2 degrees, postoperative 20.2 ± 6.6 degrees; p=0.001). Preoperative and postoperative global thoracic kyphosis were 39.5 ± 13.3 and 32.3 ± 7.9 degrees, respectively (p=0.018). Preoperative and postoperative global lumbar lordosis was 36.3 ± 7.4 and 36.1 ± 8.9 degrees, respectively (p=0.883). Successful fusion was detected in %86.7 of patients in the final follow-up.

Conclusion: The usage of allograft alone to achieve fusion increases the rates of pseudarthrosis while additional anterior procedure decreases the pseudarthrosis rate in patients with congenital scoliosis that require long-segment posterior instrumentation. Further studies should be performed to assess the efficacy of the usage of polysegment pedicle screw instrumentation.
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http://dx.doi.org/10.3944/aott.2012.2776DOI Listing
January 2013

Comparative analysis of hook, hybrid, and pedicle screw instrumentation in the posterior treatment of adolescent idiopathic scoliosis.

J Pediatr Orthop 2012 Jul-Aug;32(5):490-9

Department of Orthopaedics, Alfred I. duPont Hospital for Children, Nemours Children's Clinic, Wilmington, DE 19899, USA.

Background: Spinal instrumentation in adolescent idiopathic scoliosis (AIS) aims to correct spinal deformity and maintain long-term spinal stability until bony healing is ensured. The purpose of this study was to compare the minimum 2-year postoperative radiographic and clinical results of posterior spine correction and fusion with all-hook instrumentation versus hybrid segmental instrumentation versus pedicle screw instrumentation for AIS from a single institution.

Methods: A total of 105 patients with AIS who underwent a posterior spinal fusion with segmental pedicle screw (35), hook (35), or hybrid (35) instrumentation were sorted and matched according to the following criteria: similar age at surgery, identical Lenke curve types, curve magnitude, and Risser grade. Patients were evaluated before, immediately after, and at 2 years after surgery for radiographic parameters, complications, and outcome, as well as on the basis of the Scoliosis Research Society (SRS) questionnaire.

Results: The age and Risser grade, major curve Cobb angle, apical vertebral rotation (AVR), apical vertebral translation (AVT), lowest instrumented vertebral tilt, global coronal and sagittal balance, lumbar lordosis, and thoracic kyphosis were determined as part of preoperative evaluation. All 3 groups showed significant differences between the preoperative and postoperative major curve Cobb angle, lowest instrumented vertebral tilt, AVT, and AVR. At the latest follow-up, lumbar lordosis, thoracic kyphosis, and global coronal and sagittal balance remained similar among the 3 groups. Major curve Cobb angle, AVT, and AVR were significantly different--the hook group's measurements were significantly higher than the other groups, but there was no difference between the pedicle screw and hybrid groups. Major curve correction rate was significantly different among all groups (screw=71.9%±13.8%, hybrid=61.4%±16.6%, hook=48.1%±19.7%) (P<0.001). The pedicle screw group had the least amount of correction loss but there was no statistically significant difference between groups (screw=2.6±6.7 degrees, hybrid=4.5±7.4 degrees, hook=4.4±6.2 degrees) (P=0.35). The hook group had the least amount of AVT correction, but the screw group and the hybrid groups were similar (pedicle=67.3%±15.5%, hybrid=57.5%±22.4%, hook=39.9%±32.5%) (P<0.001). Surgery time and blood loss were higher in the screw group. No differences in global SRS-22 scores were demonstrated between the patients treated with pedicle screw, hybrid, and hook constructs; however, the satisfaction domain was higher in the screw group at the latest follow-up.

Conclusions: Pedicle screw and hybrid instrumentations offer significantly better spinal deformity correction than hook constructs in major curve coronal correction, AVT, and AVR. Patients with pedicle screw instrumentation had the greatest curve correction percentage, maintenance of this correction in the coronal and sagittal planes, and higher patient satisfaction by the SRS outcome scores. Global SRS-22 scores were similar at 2-year follow-up in all groups.

Level Of Evidence: Therapeutic level III retrospective comparative study.
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http://dx.doi.org/10.1097/BPO.0b013e318250c629DOI Listing
November 2012

Outcomes of posterior titanium spinal instrumentation in neuromuscular scoliosis patients.

Eklem Hastalik Cerrahisi 2012 Apr;23(1):30-4

Department of Orthopedics and Traumatology, Medical Faculty of Pamukkale University, Kınıklı, Denizli, Turkey.

Objectives: In this study, we aimed to characterize the outcomes of posterior spinal fusion (PSF) using titanium instrumentation in neuromuscular scoliosis (NMS) patients with a special focus on deformity correction and correction maintenance.

Patients And Methods: Between 2002 and 2004, nine patients (5 girls and 4 boys; mean age 14.9±2.3 years; range 11 to 19 years) with NMS who underwent PSF using titanium instrumentation were retrospectively analyzed. The mean height at surgery was 154.6±14.2 cm (range, 136-173 cm) and the mean weight was 59.4±19.2 kg (range, 26-114 kg). The mean follow-up duration was 3.7 years (range, 2-5 years). Preoperative data included demographics, curve type, and surgical indication. Rod size, fusion levels, duration of the operation (min), estimated blood loss (cc), and length of stay in hospital (day) were also evaluated intraoperatively. Postoperative data included correction of deformity, maintenance of correction, and complications. Radiographic measurements were obtained from standing posterior-anterior and lateral spinal radiographs at preoperative, postoperative (at first week after standing; i.e. first erect) and last follow-up visits. The data obtained were analyzed using descriptive statistic methods (mean, standard deviation, median, frequency and percentage).

Results: Dramatic improvements in the spinal deformities were observed in the patients with NMS who underwent PSF using titanium instrumentation. Mean preoperative Cobb angle was reduced from 69.7 degrees to 16.2 degrees at first erect following surgery (at first week; 77% correction). Two-year follow-up revealed that this correction sustained (mean 14.8 degrees). However, moderate to severe postoperative complications requiring careful monitoring were reported.

Conclusion: Our study results showed that PSF with titanium instrumentation in pediatric NMS patients demonstrated satisfactory outcomes during the follow-up period. However, further large-scale studies with a long-term follow-up results are required to generalize the results regarding PSF using titanium instrumentation in these patients.
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April 2012

Adolescent Blount disease in obese children treated by eight-plate hemiepiphysiodesis.

Eklem Hastalik Cerrahisi 2012 Apr;23(1):20-4

Department of Orthopedics and Traumatology, Medical Faculty of Pamukkale University, Kınıklı, Denizli, Turkey.

Objectives: The aim of this study is to evaluate the outcomes of eight-plate (Orthofix) use during hemiepiphyseodesis operation for growth modulation in obese children with adolescent Blount disease.

Patients And Methods: Six limbs of five consecutive patients who underwent lateral proximal tibial eight-plate (Orthofix) hemiepiphysiodesis were evaluated. The body mass index (BMI) was >30 and the severity of the deformity was in Zone III according to the Mielke and Stevens definition. The mechanical medial proximal tibial angle (MPTA) and the mechanical axis deviation (MAD) were measured preoperatively, postoperatively, and at last follow-up. The outcome of the procedure was established by the degree of tibia vara correction degree at final plate removal or skeletal maturity.

Results: Mean age of the patients and mean BMI at the time of surgery was 13 years (range 12 to 14) and 33.5 kg/m2 (range 31 to 36), respectively. Patients were followed for an average of 22 months (range 13 to 31). Preoperative and last follow-up mean values for MPTA were 81 and 80 degrees, respectively. Outcome of the procedure showed two extremities demonstrated progression of the tibia vara (mean of 6.5 degrees), two extremities had no correction of the deformity, and the remaining two extremities showed minimally improvement (mean 3 degrees). The procedure failed to correct the tibia vara in all extremities and all patients were scheduled for an osteotomy to treat the deformity.

Conclusion: We do not recommend the use of a tension band plate hemiepiphyseodesis (eight-plate, Orthofix) to treat severe adolescent Blount disease in obese children.
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April 2012

Long-term outcome and quality of life of patients with unstable pelvic fractures treated by closed reduction and percutaneous fixation.

Ulus Travma Acil Cerrahi Derg 2011 May;17(3):261-6

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

Background: Treatment of unstable pelvic fractures has evolved recently, and percutaneous treatment has become the choice of treatment in most cases. The aim of this study was to evaluate the outcome of percutaneous treatment in patients with unstable pelvic fractures.

Methods: Twenty patients (11 females, 9 males; mean age, 32 years, range, 11-66 years) who had unstable pelvic fractures and were treated percutaneously were enrolled in the study. Short Form-36 (SF-36) scores, Majeed scores, Iowa Pelvic Scores, and Pelvic Outcome Scores were determined for the outcome assessment.

Results: The minimum duration of follow-up was 2 years, (range, 24-48 months). The mean Injury Severity Score (ISS) was 31 (range, 16-50). The average SF-36 scores were comparable with the general population in terms of bodily pain, general health and social function. The mean Majeed functional pelvic score was 93.3 (range, 72-100; 19 excellent and 1 good clinical grades) and the mean Iowa Pelvic Score was 86 (range, 82-90). The mean Pelvic Outcome Score was 33 (range, 24-37; maximum score, 40).

Conclusion: We have demonstrated better outcomes in patients with pelvic fractures treated with percutaneous fixation. The technique may be advantageous as it avoids the use of extensive approaches, bleeding, wound complications, and prolonged surgeries.
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May 2011

Periscapular abscess: unusual cause of shoulder pain in children.

J Pediatr Orthop B 2012 Jul;21(4):310-2

Department of Orthopedics, Thomas Jefferson University, Alfred I. duPont Hospital for Children, Wilmington, Delaware, USA.

Periscapular abcess is an extremely rare clinical condition. Diagnosis and treatment can be delayed because the clinical picture often resembles septic arthritis of the shoulder. Early diagnosis and prompt surgical treatment are mandatory, as delayed treatment can be fatal due to sepsis. Previously, four cases of periscapular abcess were described in English literature. We describe two pediatric patients with periscapular abcess, who were treated surgically and healed without any complication.
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http://dx.doi.org/10.1097/BPB.0b013e328349139aDOI Listing
July 2012