Publications by authors named "Gokhan Demirkiran"

51 Publications

Response to 'Letter to the editor regarding: In-brace alterations of pulmonary functions in adolescents wearing a brace for idiopathic scoliosis by Yagci et al.'

Prosthet Orthot Int 2021 Apr;45(2):103-104

Faculty of Health Sciences, Physiotherapy and Rehabilitation Department, Hasan Kalyoncu University, Gaziantep, Turkey.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/0309364620967508DOI Listing
April 2021

Evaluation of upper extremity function and its relation to curve pattern in female adolescents with idiopathic scoliosis: a pilot study.

Spine Deform 2020 Dec 30;8(6):1175-1183. Epub 2020 May 30.

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

Study Design: Cross-sectional and clinical measurement.

Objective: To evaluate upper extremity function and its relation to the curve pattern in idiopathic scoliosis. Postural alterations and trunk distortions-caused by three-dimensional deformity itself in idiopathic scoliosis-may lead to functional changes in the upper extremity of subjects.

Methods: Handgrip, pulp and lateral pinch strengths, hand dexterity, hand reaction time, coordination of upper extremity, upper extremity performance, throwing accuracy, and self-reported upper extremity disability were evaluated in 96 subjects. These subjects were divided into 3 groups: 47 with main thoracic curve pattern scoliosis (Lenke type 1), 31 with thoracolumbar/lumbar curve pattern scoliosis (Lenke type 5), and 18 unaffected (healthy control). Comparisons were performed between these three groups.

Results: The thoracic scoliosis group showed a significant decrease in concave lateral pinch strength, concave hand dexterity of turning, coordination of the upper extremities, and concave hand reaction time than the thoracolumbar/lumbar scoliosis group (p < 0.05). Bilateral handgrip strengths decreased in thoracic scoliosis group when compared to healthy controls. Healthy individuals demonstrated greater throwing accuracy than individuals with scoliosis.

Conclusions: Upper extremity function was found to be affected based on the curve pattern. Individuals with main thoracic curves are likely to have deteriorated upper extremity function, especially for hand-specific motor skills, on the concave side, when compared to lumbar curves and healthy controls.

Level Of Evidence: Level III.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s43390-020-00148-8DOI Listing
December 2020

Growing-rod Graduates With Idiopathic Early-onset Scoliosis Have Comparable Exercise Tolerance to Patients With Surgically Treated Adolescent Idiopathic Scoliosis.

J Pediatr Orthop 2020 Sep;40(8):e734-e739

Orthopaedics and Traumatology.

Background: Growing-rod (GR) treatment is the current standard for progressive idiopathic early-onset scoliosis (I-EOS) in young children. Despite good radiographic outcomes, the impact of scoliosis treatment on pulmonary functions is not well-defined in this patient population. The aim of this study was to evaluate pulmonary functions and exercise tolerance in I-EOS patients graduated from GR treatment and to compare them with age-matched, surgically treated adolescent idiopathic scoliosis (AIS) patients and healthy controls.

Methods: Eight GR graduates with I-EOS with pulmonary function tests and complete radiographic results were compared with a group of 9 thoracic AIS patients at least 2 years out from posterior fusion. Both groups were also compared with a set of 10 healthy individuals. All subjects underwent cardiopulmonary exercise testing and spirometry to evaluate pulmonary function.

Results: Age, sex, height, arm span, weight, residual deformity, and level of instrumentation in GR and AIS patients were similar. In the GR group, forced vital capacity % and forced expiratory volume in 1 second % values were reduced compared with the healthy controls and AIS group (P<0.001, <0.001 and 0.036, 0.046, respectively). Breathing reserve index at lactate threshold (BRILT) was higher in GR and AIS patients (P=0.001 and 0.002, respectively), and was similar between GR and AIS patients (P=0.916). Heart rate at lactate threshold was higher in GR and AIS groups compared with controls (P<0.001 and 0.001, respectively).

Conclusions: AIS and GR patients demonstrated reduced pulmonary reserve and exercise tolerance compared with their peers with no spinal deformity. However, exercise tolerance of I-EOS patients treated with the GR method was similar to that of operated AIS patients. These results suggest a positive impact of GR treatment in children with I-EOS.

Level Of Evidence: Level III-cross-sectional comparative study.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/BPO.0000000000001567DOI Listing
September 2020

Coupling of cell fate selection model enhances DNA damage response and may underlie BE phenomenon.

IET Syst Biol 2020 04;14(2):96-106

Electrical and Electronics Engineering, Yaşar University, Selçuk Yaşar Kampüsü, İzmir, Turkey.

Double-strand break-induced (DSB) cells send signal that induces DSBs in neighbour cells, resulting in the interaction among cells sharing the same medium. Since p53 network gives oscillatory response to DSBs, such interaction among cells could be modelled as an excitatory coupling of p53 network oscillators. This study proposes a plausible coupling model of three-mode two-dimensional oscillators, which models the p53-mediated cell fate selection in globally coupled DSB-induced cells. The coupled model consists of ATM and Wip1 proteins as variables. The coupling mechanism is realised through ATM variable via a mean-field modelling the bystander signal in the intercellular medium. Investigation of the model reveals that the coupling generates more sensitive DNA damage response by affecting cell fate selection. Additionally, the authors search for the cause-effect relationship between coupled p53 network oscillators and bystander effect (BE) endpoints. For this, they search for the possible values of uncertain parameters that may replicate BE experiments' results. At certain parametric regions, there is a correlation between the outcomes of cell fate and endpoints of BE, suggesting that the intercellular coupling of p53 network may manifest itself as the form of observed BEs.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1049/iet-syb.2019.0081DOI Listing
April 2020

Response to letter to editor regarding 'In-brace alteration of pulmonary functions in adolescents wearing a brace for idiopathic scoliosis' by Yagci et al. (2019).

Prosthet Orthot Int 2020 04 12;44(2):100-101. Epub 2020 Mar 12.

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

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/0309364620910928DOI Listing
April 2020

Team Approach: Contemporary Treatment of Congenital Scoliosis.

JBJS Rev 2019 10;7(10):e5

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

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2106/JBJS.RVW.19.00001DOI Listing
October 2019

In-brace alterations of pulmonary functions in adolescents wearing a brace for idiopathic scoliosis.

Prosthet Orthot Int 2019 Aug 4;43(4):434-439. Epub 2019 Apr 4.

3 Department of Physical Therapy and Rehabilitation, Faculty of Health Sciences, Hasan Kalyoncu University, Gaziantep, Turkey.

Background: Despite the common use of braces to prevent curve progression in idiopathic scoliosis, their functional effects on respiratory mechanics have not been widely studied.

Objective: The objective was to determine the effects of bracing on pulmonary function in idiopathic scoliosis.

Methods: A total of 27 adolescents with a mean age of 14.5 ± 1.5 years and idiopathic scoliosis were included in the study. Pulmonary function evaluation included vital capacity, forced expiratory volume, forced vital capacity, maximum ventilator volume, peak expiratory flow, and respiratory muscle strengths, measured with a spirometer, and patient-reported degree of dyspnea. The tests were performed once prior to bracing and at 1 month after bracing (while the patients wore the brace).

Results: Compared with the unbraced condition, vital capacity, forced expiratory volume, forced vital capacity, maximum ventilator volume, and peak expiratory flow values decreased and dyspnea increased in the braced condition. Respiratory muscle strength was under the norm in both unbraced and braced conditions, while no significant difference was found for these parameters between the two conditions.

Conclusion: The spinal brace for idiopathic scoliosis tended to reduce pulmonary functions and increase dyspnea symptoms (when wearing a brace) in this study. Special attention should be paid in-brace effects on pulmonary functions in idiopathic scoliosis.

Clinical Relevance: Bracing seems to mimic restrictive pulmonary disease, although there is no actual disease when the brace is removed. This study suggests that bracing may result in a deterioration of pulmonary function when adolescents with idiopathic scoliosis are wearing a brace.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/0309364619839856DOI Listing
August 2019

Does Decreased Surgical Stress Really Improve the Psychosocial Health of Early-onset Scoliosis Patients?: A Comparison of Traditional Growing Rods and Magnetically-controlled Growing Rods Patients Reveals Disappointing Results.

Spine (Phila Pa 1976) 2019 Jun;44(11):E656-E663

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

Study Design: Cross-sectional case-control study.

Objective: Compare psychosocial profile of magnetically-controlled growing rod (MCGR) patients to traditional-growing rod (TGR) with an array of psychiatric tools, expecting improvement in MCGR due to decreased number of surgical procedures.

Summary Of Background Data: TGR treatment has had positive clinical and radiographic results; however, upward of 10 surgical sessions and high complication rates have called into question the quality of life of these children. Improvement with the introduction of the MCGR is expected.

Methods: GR patients with minimum of 2-years follow-up were recruited. None had neurological conditions. All underwent testing with the Wechsler Intelligence Scale for Children-Revised, and only those in the normal range were included. Patients filled out questionnaires with mental health professionals to measure psychosocial status. MCGR patients' results were compared to TGR patients.

Results: Twenty-seven patients met criteria (10 MCGR, 17 TGR): average age at enrollment 11.8 years (range 5.9-17). MCGR group was significantly younger (9.1 vs. 13.3 yr) and had significantly shorter follow-up (45.6 vs. 82.8 mo) (P < 0.05). TGR patients underwent an average of 16 surgical procedures, MCGR an average of 1.5 (including complications, P < 0.05). Age at index surgery (6 yr), preoperative and postoperative major curve magnitudes (60°, 40° respectively) were statistically similar.There was no difference in current psychiatric diagnoses between the groups. MCGR patients scored worse than TGR patients in general functionality domains. TGR patients showed increased functionality and prosocial scores with increased number of procedures. This effect was not observed in MCGR.

Conclusions: The expected improvement in psychosocial status with the MCGR was not observed at a 31.6-month-follow-up. It appears that provided the patient spends enough time in the treatment process to notice benefit and does not experience major complications, noninvasiveness of lengthening procedures does not show up as an advantage with the psychosocial tools utilized in this study.

Level Of Evidence: 3.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/BRS.0000000000002938DOI Listing
June 2019

Two-dimensional polynomial type canonical relaxation oscillator model for p53 dynamics.

IET Syst Biol 2018 Aug;12(4):138-147

Department of Electrical-Electronics Engineering, Yaşar University, Bornova, İzmir, 35100, Turkey.

p53 network, which is responsible for DNA damage response of cells, exhibits three distinct qualitative behaviours; low state, oscillation and high state, which are associated with normal cell cycle progression, cell cycle arrest and apoptosis, respectively. The experimental studies demonstrate that these dynamics of p53 are due to the ATM and Wip1 interaction. This paper proposes a simple two-dimensional canonical relaxation oscillator model based on the identified topological structure of ATM and Wip1 interaction underlying these qualitative behaviours of p53 network. The model includes only polynomial terms that have the interpretability of known ATM and Wip1 interaction. The introduced model is useful for understanding relaxation oscillations in gene regulatory networks. Through mathematical analysis, we investigate the roles of ATM and Wip1 in forming of these three essential behaviours, and show that ATM and Wip1 constitute the core mechanism of p53 dynamics. In agreement with biological findings, we show that Wip1 degradation term is a highly sensitive parameter, possibly related to mutations. By perturbing the corresponding parameters, our model characterizes some mutations such as ATM deficiency and Wip1 overexpression. Finally, we provide intervention strategies considering our observation that Wip1 seems to be an important target to conduct therapies for these mutations.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1049/iet-syb.2017.0077DOI Listing
August 2018

Revealing determinants of two-phase dynamics of P53 network under gamma irradiation based on a reduced 2D relaxation oscillator model.

IET Syst Biol 2018 Feb;12(1):26-38

Department of Electrical-Electronics Engineering, Yaşar University, Bornova, İzmir 35100, Turkey.

This study proposes a two-dimensional (2D) oscillator model of p53 network, which is derived via reducing the multidimensional two-phase dynamics model into a model of ataxia telangiectasia mutated (ATM) and Wip1 variables, and studies the impact of p53-regulators on cell fate decision. First, the authors identify a 6D core oscillator module, then reduce this module into a 2D oscillator model while preserving the qualitative behaviours. The introduced 2D model is shown to be an excitable relaxation oscillator. This oscillator provides a mechanism that leads diverse modes underpinning cell fate, each corresponding to a cell state. To investigate the effects of p53 inhibitors and the intrinsic time delay of Wip1 on the characteristics of oscillations, they introduce also a delay differential equation version of the 2D oscillator. They observe that the suppression of p53 inhibitors decreases the amplitudes of p53 oscillation, though the suppression increases the sustained level of p53. They identify Wip1 and P53DINP1 as possible targets for cancer therapies considering their impact on the oscillator, supported by biological findings. They model some mutations as critical changes of the phase space characteristics. Possible cancer therapeutic strategies are then proposed for preventing these mutations' effects using the phase space approach.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1049/iet-syb.2017.0041DOI Listing
February 2018

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

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

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

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

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

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

Conclusions: Both GR and MCGR applications significantly release titanium and possibly aluminum. MCGR further releases vanadium. MCGR possibly releases more titanium than traditional GR. Time-dependent alterations of serum ion levels, structural properties of the MCGR device, and exposure caused by magnetic distraction processes warrant investigation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jspd.2017.06.005DOI Listing
January 2018

Paper #3: Can TGR change the natural history of pulmonary functions in EOS? Is Radiological Straightness Correlated with Normal Lung Development?

Spine Deform 2017 Nov;5(6):441

Even though traditional growing rod (TGR) patients score lower in exercise tolerance and spirometry compared to age-matched controls, their pulmonary functions are similar to those of instrumented adolescent idiopathic scoliosis (AIS) patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jspd.2017.09.006DOI Listing
November 2017

Paper #44: Pull-Out of the Upper Thoracic Pedicle Screws Can Cause Spinal Canal Encroachment in Growing Rod Treatment.

Spine Deform 2017 Nov;5(6):463-464

The aim of this study is to report the prevalence of spinal canal encroachment of pedicle screw in proximal anchor of GR construct and determine risk factors using a single-center cohort.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jspd.2017.09.047DOI Listing
November 2017

Graduation Protocol After Growing-Rod Treatment: Removal of Implants without New Instrumentation Is Not a Realistic Approach.

J Bone Joint Surg Am 2017 Sep;99(18):1554-1564

1Department of Orthopaedics and Traumatology, Hacettepe University School of Medicine, Ankara, Turkey 2University Orthopaedics, Hawthorne, New York.

Background: The growing rod remains an effective option in the treatment of early-onset scoliosis, and has previously been likened to an internal brace. While details of growing-rod treatment have been largely agreed on, the appropriate end point remains a matter of controversy. A decision was made in 2004, at the beginning of growing-rod treatment at our institution, to remove longitudinal instrumentation when the period of lengthening concluded and, similar to discontinuing a brace, leave the spine free.

Methods: From 2004, patients managed with a growing rod who were ≤10 years old at the time of the index surgery and had no previous surgery were enrolled in the prospective treatment pathway. For this report, the inclusion criteria were complete records and radiographs; regular lengthenings; no complications defined as SV (severity grade) IIA, IIB, III, or IV; and a minimum follow-up of 2 years after reaching the age of 14 years. At the age of 14 years, the patients were reevaluated and 1 of 3 treatments was undertaken. In Group 1, which included patients with adequate correction and no requirement for extension of fusion, the growing rods were removed. In Group 2, which included patients with inadequate correction and/or interval changes, the growing rods were removed and instrumented fusion was performed. In Group 3, which included patients with a Risser sign of 0 or who were otherwise immature, lengthening was continued.

Results: Twenty-six patients met the inclusion criteria. The mean age at the time of the index operation was 82.6 months. There were 10 patients in Group 1, 9 patients in Group 2, and 7 patients in Group 3. Of the 10 patients whose rods were removed without additional instrumentation, 9 had clinically important worsening of the deformity and required reimplantation with fusion.

Conclusions: Despite the initial intention to remove the implants, allow the spine to regain motion, and observe patients when they turned 14, the results of this report reveal that only 10 of the initially included 26 patients met the criteria to do so. In 9 of these patients, the deformity worsened after removal, confirming that prolonged growing-rod treatment does not necessarily result in spontaneous, reliable fusion. Removal of spinal implants without new instrumentation is not a realistic graduation protocol following growing-rod treatment, and implants should be retained, or if extension is required, another procedure should be undertaken.

Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2106/JBJS.17.00031DOI Listing
September 2017

Psychological Profile of Children Who Require Repetitive Surgical Procedures for Early Onset Scoliosis: Is a Poorer Quality of Life the Cost of a Straighter Spine?

Spine Deform 2017 09;5(5):334-341

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

Study Design: Cross-sectional study.

Objective: Assess the psychosocial status of children with early-onset scoliosis (EOS) undergoing multiple procedures and evaluate associations with other variables.

Summary Of Background Data: EOS may require repetitive surgical procedures to control deformity and preserve growth. These procedures impact patients' psychosocial status because of the repetitive surgeries.

Methods: EOS patients 6-18 years, undergoing traditional growing rod treatment with more than 5 surgical procedures, and neurologically/mentally intact were included. Patients were screened for psychiatric disorders before inclusion. The Quality of Life Scale for Children (PedsQL), Strengths and Difficulties Questionnaire (SDQ) self-report form, Beck Depression Inventory, Children Depression Inventory (CDI), Beck Anxiety Inventory (BAI), and the Self-Report for Childhood Anxiety Related Disorders (SCARED) were completed by the children. PedsQL Parental Form and SDQ Parent Form were completed by their parents.

Results: Twenty-one patients (9 male, 12 female) met the inclusion criteria. Average age was 6.4 years (4-10.5) at index surgery, and 13.5 years (8-17) at final follow-up. The mean number of procedures was 13 (6-18). Mean follow-up was 83.9 months (36-122). Depression was observed in 23.8% of patients, and generalized anxiety disorder in 42.8%. Patients in the study group were more likely than the general population to have a psychiatric diagnosis. Number of procedures undergone was found to correlate negatively with BAI, SCARED, and the behavioral difficulties domain of SDQ parent form score and positively with emotional functioning, psychosocial health summary score, PedsQL total score, and increased social and physical functioning. Nonidiopathic etiology was found to be related to increased behavioral difficulties and lower functioning.

Conclusion: A higher prevalence of depressive and anxiety symptoms was observed in patients with EOS along with dysfunctional areas of daily life. Other comorbidities may also contribute to dysfunction and difficulties. Determination of the aspects of EOS treatment that have a negative impact on psychosocial functioning may allow for more competent help for these patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jspd.2017.03.007DOI Listing
September 2017

Anterior and Posterior Vertebral Column Resection Versus Posterior-only Technique: A Comparison of Clinical Outcomes and Complications in Congenital Kyphoscoliosis.

Clin Spine Surg 2017 Aug;30(7):285-290

*Hacettepe University Hospitals, Hacettepe University Medical School, Ankara, Turkey †Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA.

Study Design: Retrospective cohort.

Objective: The purpose of this study is to compare the anterior-posterior surgery to posterior-only vertebra resection for congenital kyphoscoliosis in pediatric patients.

Summary Of Background Data: Vertebral column resection is a very powerful correction technique mainly used in the treatment of severe and rigid spinal deformities. The technique can be applied with combined anterior and posterior vertebral column resection (APVCR) or posterior-only vertebral column resection (PVCR) approaches. PVCR has gained popularity recently due to several apparent advantages, but APVCR is still believed by some to be a viable alternative, despite the use of an anterior exposure.

Materials And Methods: A retrospective chart and radiographic review was performed including the patients with congenital kyphoscoliosis up to 16 years of age who were operated on by a single senior surgeon in our department after 2005. The data included surgical time, estimated blood loss, duration of hospital and postoperative intensive care unit stay, intraoperative and postoperative complications. Preoperative, postoperative, and follow-up radiographs were evaluated for scoliosis, kyphosis, and spinal balance.

Results: Twenty-six patients (20 girls, 6 boys) met the inclusion criteria. APVCR was performed on 17 (median age, 13.2 y) and PVCR on 9 (median age, 10.7 y). Scoliosis correction at the time of last follow-up was 54.3% and 52.6% for APVCR and PVCR, respectively, whereas the average kyphosis correction was 25.4 degrees in APVCR and 30.1 degrees in PVCR group. Surgical time, hospital stay, and estimated blood loss were all significantly higher in the APVCR group, whereas the complication rates were similar. No neurological or vascular complications were encountered.

Conclusions: This study showed that although the operative time and surgical blood loss were higher with APVCR, there were no major complications and the radiologic outcomes were similar between APVCR and PVCR. APVCR should be considered as an acceptable technique especially in deformities where PVCR would be technically difficult or at the beginning of the spine surgeon's learning curve.

Level Of Evidence: Level III.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/BSD.0000000000000348DOI Listing
August 2017

Congenital unilateral absence of the upper extremity may give rise to a specific kind of thoracolumbar curve.

J Pediatr Orthop B 2018 Mar;27(2):180-183

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

There is an increased incidence of scoliosis in patients with congenital malformations of the upper extremity even in the absence of overt vertebral abnormalities. In this case series, we summarize the curve characteristics of four patients presenting to two spine surgery clinics with unilateral amelia or phocomelia and a progressive scoliotic curve with the apex on the side of deficiency. All patients required orthopedic intervention for their curves. Amelia and phocomelia are severe congenital malformations of the upper limb affecting trunk balance and, conceivably, causing scoliosis with the absence of counterbalancing weight on the affected side. The combination of upper limb absence and same-sided scoliosis in these patients may provide a clue of the mechanical factors causing scoliosis in other disorders. In this article, we attempt to define this exceptional deformity, theorize on its etiology, and draw attention to this particular combination of problems.

Level Of Evidence: Case series; Level IV.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/BPB.0000000000000478DOI Listing
March 2018

Unplanned Reoperations in Magnetically Controlled Growing Rod Surgery for Early Onset Scoliosis With a Minimum of Two-Year Follow-Up.

Spine (Phila Pa 1976) 2017 Dec;42(24):E1410-E1414

Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong.

Study Design: A retrospective review of prospectively collected clinical and radiologic data of patients with magnetically controlled growing rods (MCGRs) from a multi-centered study with a minimum of 2-year follow-up.

Objective: The aim of this study was to describe the incidence and causes of unplanned reoperations and to report the outcomes of patients treated with MCGR for early-onset scoliosis (EOS).

Summary Of Background Data: Published clinical studies have demonstrated that MCGR is safe and effective for curvature control of EOS, and can avoid repeated surgeries for distractions. However, there have been no reports on the unplanned reoperations and complications of MCGR for EOS with a large series of patients.

Methods: Between 2009 and 2012, 30 patients with EOS underwent MCGR implantation in six institutions. A retrospective review of prospectively collected clinical and radiologic data with a minimum of 2-year follow-up was conducted. Demographic data, radiologic measurements, unplanned reoperations, and other complications were noted. Risk factors for unplanned reoperations were analyzed.

Results: Patients underwent MCGR implantation at the mean age of 7.2 years. The mean follow-up period was 37 months. Fourteen patients (46.7%) underwent an unplanned reoperation within the follow-up period, with a mean time to reoperation of 23 months after initial surgery (range, 5-48 months). Causes of unplanned reoperation were failure of rod distractions, proximal foundation failure, rod breakage, and infection. More frequent distractions (between 1 week and 2 months) were associated with a higher rate of reoperation than distraction frequencies between 3 and 6 months (71% vs. 25%).

Conclusion: This is the largest series with the longest follow-up to date that examines the need for additional unplanned surgery after the initial procedure. It highlights that MCGR surgery can be associated with unplanned reoperations, and more frequent distractions may be a risk factor. Long-term comparative studies with traditional growing rod are required to evaluate the effectiveness of this implant.

Level Of Evidence: 4.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/BRS.0000000000002297DOI Listing
December 2017

Health-Related Quality of Life in Early-Onset Scoliosis Patients Treated Surgically: EOSQ Scores in Traditional Growing Rod Versus Magnetically Controlled Growing Rods.

Spine (Phila Pa 1976) 2018 Jan;43(2):148-153

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

Study Design: Cross-sectional study.

Objective: To compare quality of life and caregiver burden in traditional growing rod (TGR) and magnetic controlled growing rods (MCGR) patients.

Summary Of Background Data: MCGR decrease surgical sessions associated with treatment of early onset scoliosis (EOS), hoping to minimize the burdens seen with repetitive invasive surgeries in TGR treatment. Although the clinical indications for these treatments have largely been agreed upon, there is a lack of understanding of their impact on patients' and families' quality of life.

Methods: Inclusion criteria: ≤10 years of age at index procedure, major curve ≥30°, no previous spine surgery, minimum 1-year postoperative follow-up. The previously validated 24-item early onset scoliosis questionnaire (EOSQ-24) was utilized to assess quality of life. Statistic methods were applied to compare domain scores between TGR and MCGR patients.

Results: Forty-four children with EOS were enrolled; 25 TGR and 19 MCGR. Groups were similar in sex and age at index surgery. Age at time of questionnaire and mean length of follow-up were significantly different; patients were older (14.0 vs. 8.8 yr) and had longer follow-up (101.3 vs. 34.3 mo) in TGR (P < 0.01). Deformity correction and complication rates were similar between groups. At the time of questionnaire, scores of economic burden and overall satisfaction in MCGR were significantly superior to those in TGR by univariate analysis. When controlled for duration of follow-up, some domain scores trended towards statistical significance, some remained stable, and others regressed to non-significance.

Conclusion: Health related quality of life data reveal superior outcomes in overall satisfaction and financial burden domains in the MCGR group. However, the positive effects of MCGR decrease when controlled for length of follow up, indicating that the MCGR is not yet a magic fix-all, and that the TGR remains an option in the treatment of EOS.

Level Of Evidence: 3.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/BRS.0000000000002274DOI Listing
January 2018

Magnetic Resonance Imaging Safety of Magnetically Controlled Growing Rods in an In Vivo Animal Model.

Spine (Phila Pa 1976) 2017 May;42(9):E504-E508

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

Study Design: Experimental animal study.

Objective: To investigate the interaction between magnetically controlled growing rods (MCGRs) and magnetic resonance imaging (MRI).

Summary Of Background Data: Growing rod treatment through serial operations results in adverse effects on the patient and high treatment costs. MCGRs can be lengthened noninvasively in an outpatient setting and with lower treatment costs. When MRI investigation is required, the interaction between MCGRs and MRI is an issue of concern in patients with MCGRs. This study investigated MRI compatibility of MCGRs in an in vivo setting.

Methods: The study was conducted on three sheep. A standard posterior approach was used. One polyaxial pedicle screw at the ends was placed. Two sheep were instrumented unilaterally and one bilaterally with MCGRs. Temperature change was measured using MR-compatible sensors. Thoracic and lumbar MRIs were obtained using a 0.3 T MRI unit. MRI waves were applied for 45 minutes and temperature changes were recorded every 3 minutes. The lengths of the MCGRs were measured and anteroposterior and lateral spine radiographs were obtained pre- and postoperatively.

Results: No displacement in the positions of the MCGRs occurred. The lengths of the MCGRs did not change compared with the preoperative length. The ability of the MCGRs to elongate was not impaired after MRI scanning. There was a mean increase in the temperature of the MCGRs by 1.45°C (0.5-2.4°C). The MCGRs had a strong scattering effect on MRI of the related segments.

Conclusion: This study indicated that lower magnet MRI is safe in an animal model with MCGRs, with no displacement of the rods and no changes in their length, no significant heating, and no adverse effects on the lengthening mechanism but with a significant scattering effect on visualization of the surrounding tissues. Further investigations are needed to clarify the exact distance where an MRI investigation of distant organs may be done without scattering.

Level Of Evidence: N/A.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/BRS.0000000000001880DOI Listing
May 2017

Implant Complications After Magnetically Controlled Growing Rods for Early Onset Scoliosis: A Multicenter Retrospective Review.

J Pediatr Orthop 2017 Dec;37(8):e588-e592

*Department of Orthopedics, San Diego Spine Foundation †Department of Orthopedics, Rady Children's Hospital, San Diego, CA ‡Department of Orthopedics, Florence Nightingale Hospital, İstanbul §Department of Orthopedics, Dokuz Eylul University, Mimarsinan Konak Izmir ¶Department of Orthopedics, Hacettepe University Hospital §§Department of Orthopedics, Ankara Gazi University Hospital, Gazi Üniversitesi Rektörlüğü, Ankara, Turkey ∥Department of Orthopedics, The Duchess of Kent Children's Hospital, Pokfulam, Hong Kong #Department of Orthopedics, Starship Children's Hospital, Auckland, New Zealand **Department of Orthopedics, Rizzoli Orthopaedic Institute, Bologna ‡‡Department of Orthopedics, Bambino Gesu Ospedale Pediatrico, Fiumicino, Province of Rome, Italy ††Department of Orthopedics, Turku University Hospital, Turku, Finland.

Background: Traditional growing rods have a reported wound and implant complication rate as high as 58%. It is unclear whether the use of magnetically controlled growing rods (MCGR) will affect this rate. This study was performed to characterize surgical complications following MCGR in early onset scoliosis.

Methods: A multicenter retrospective review of MCGR cases was performed. Inclusion criteria were: (1) diagnosis of early onset scoliosis of any etiology; (2) 10 years and younger at time of index surgery; (3) preoperative major curve size >30 degrees; (4) preoperative thoracic spine height <22 cm. Complications were categorized as wound related and instrumentation related. Complications were also classified as early (<6 mo from index surgery) versus late (>6 mo). Distraction technique and interval of distraction was surgeon preference without standardization across sites.

Results: Fifty-four MCGR patients met inclusion criteria. There were 30 primary and 24 conversion procedures. Mean age at initial surgery was 7.3 years (range, 2.4 to 11 y), and mean duration of follow-up 19.4 months. Twenty-one (38.8%) of 54 patients had at least 1 complication. Fifteen (27.8%) had at least 1 revision surgery. Six (11.1%) had broken rods (2 to 4.5 and 4 to 5.5 mm rods); two 5.5 mm rods failed early (4 mo) and 4 late (mean=14.5 mo). Six (11.1%) patients experienced 1 episode of lack or loss of lengthening, of which 4 patients subsequently lengthened. Seven patients (13.0%) had either proximal or distal fixation-related complication at average of 8.4 months. Two patients (3.7%) had infections requiring incision and drainage; 1 early (2 wk) with wound drainage and 1 late (8 mo). The late case required removal of one of the dual rods.

Conclusions: This study shows that compared with traditional growing rods, MCGR has a lower infection rate (3.7% vs. 11.1%). MCGR does not appear to prevent common implant-related complications such as rod or foundation failure. The long-term implication remains to be determined.

Level Of Evidence: Level IV.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/BPO.0000000000000803DOI Listing
December 2017

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

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

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

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

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

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

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

Download full-text PDF

Source
http://dx.doi.org/10.1186/s13014-016-0649-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4880816PMC
May 2016

Adult Spinal Deformity Correction with Multi-level Anterior Column Releases: Description of a New Surgical Technique and Literature Review.

Clin Spine Surg 2016 May;29(4):141-9

*Department of Orthopaedics and Traumatology, Hacettepe University, Hacettepe Hastaneleri, Ankara, Turkey Departments of †Orthopaedic Surgery ‡Neurologic Surgery, University of California - San Francisco, San Francisco, CA.

Study Design: Case series.

Objective: To evaluate radiographic and clinical outcomes of adults with spinal deformity treated with multilevel anterior column releases (ACR).

Summary Of Background Data: Pedicle subtraction osteotomy can be used effectively to correct spinal deformity; however, it is not without complications. ACR is an attractive alternative minimally invasive technique for spinal deformity correction, although few clinical reports on its clinical effectiveness exist.

Methods: Adults with spinal deformity who underwent multilevel ACRs (≥2) followed by open posterior instrumentation with a minimum 1-year follow-up were retrospectively reviewed. Deformity radiographic data and clinical outcomes, including the Oswestry Disability Index (ODI) and the EuroQol-5D were analyzed.

Results: Eight patients [7 female, 1 male; mean age 65 y (49-79 y)] met inclusion criteria. The mean follow-up was 18.4 months (12-28 mo). The average number of levels treated with an ACR per patient was 2.4 (2-3). There were no anterior approach-related complications. The average number of levels instrumented posteriorly was 8.1 (3-15). Six patients underwent Schwab type 1 posterior osteotomies (partial facetectomies). After the first anterior stage, there was a significant increase in the lumbar lordosis and significant decreases in the sagittal vertical axis, pelvic tilt, and lumbopelvic mismatch (P<0.05). After the second stage there was no significant change in the sagittal vertical axis, lumbar lordosis, pelvic tilt, or lumbopelvic mismatch relative to the values obtained after ACR. There was significantly less disability postoperatively [ODI: 15 (0-30)] compared with preoperatively [ODI: 46 (16-80)] (P<0.01). There was significant improvement in general health after operation, as assessed by the EuroQol-5D utility scores [preop: 0.44 (0.21-0.82) vs. postop: 0.71 (0.60-0.80)] (P=0.01). Back and leg visual analog scale pain scores improved significantly postoperatively.

Conclusions: A staged approach using multilevel ACRs with open posterior instrumentation has an acceptable complication profile and provides excellent restoration of sagittal and coronal balance and pelvic parameters in adults with spinal deformity.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/BSD.0000000000000377DOI Listing
May 2016

Magnetically controlled Growing Rods for Early-onset Scoliosis: A Multicenter Study of 23 Cases With Minimum 2 years Follow-up.

Spine (Phila Pa 1976) 2016 Sep;41(18):1456-1462

San Diego Spine Foundation, San Diego, CA.

Study Design: Retrospective study.

Objective: To report 2-year clinical and radiographic results of patients treated with magnetically controlled growing rods (MCGR).

Summary Of Background Data: MCGR for early-onset scoliosis has been reported to provide adequate spinal growth and curve correction by eliminating surgical lengthening procedures. This study was designed to report the results of MCGR patients with 2-year follow-up.

Methods: A retrospective study of MCGR patients with the following inclusion criteria: (i) major curve size ≥30°, (ii) T1-T12 height <22 cm, (iii) <11-years old; all at the time of index surgery was performed. Of 54 patients enrolled, 23 had 2-year follow-up. Both primary and conversion patients were evaluated at baseline 6, 12, and 24 months.

Results: Mean preoperative age in the primary group was 6.6 ± 2.6 years versus 8.3 ± 2.2 years for the conversion group. A total of 41 adverse events occurred in 11 patients, of which 14 events were implant related. Major coronal curve magnitude improved from 61.3° to 34.3° from baseline to postoperation in primary cases and from 49.4° to 43.8° in conversion cases. Curve correction was maintained for 2 years in both groups. T1-S1 height improved from 252.7 to 288.9 mm in primary cases and was maintained for 2 years. However, conversion cases had some decline in T1- S1 height (270.3 at baseline to 294.4 mm post-MCGR and 290.2 mm at 2-year follow-up; mean loss of 4.2 mm (1.5%) from postoperation to 2 years, P > 0.05).

Conclusion: This study showed satisfactory curve correction and growth is achieved among primary cases. T1-S1 height in conversion cases had a slight decline in 2 years. However, this decline was not statistically significant.

Level Of Evidence: 3.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/BRS.0000000000001561DOI Listing
September 2016

Integrity of Damage Control Posterior Spinal Fusion Constructs for Patients With Polytrauma: A Biomechanical Investigation.

Spine (Phila Pa 1976) 2015 Dec;40(23):E1219-25

*Department of Orthopaedic Surgery, University of California-San Francisco (UCSF)/San Francisco General Hospital, San Francisco, CA †Department of Orthopaedics and Traumatology, Hacettepe University, Hacettepe Hastaneleri, Sihhiye, Ankara, Turkey ‡Department of Neurologic Surgery, UCSF, San Francisco, CA.

Study Design: Biomechanical.

Objective: Evaluate spinal stability achieved with different levels of posterior percutaneous fixation (postPerc) for thoracolumbar fractures in cadavers subjected to ICU activities.

Summary Of Background Data: "Spine damage control" involves postPerc performed within 24 hours of injury and staged, elective, definitive stabilization. Amount of instrumentation needed to initially achieve adequate spinal stability, minimize morbidity, and accommodate ICU care needs between stages are not defined.

Methods: In full-unembalmed cadavers motion-tracking sensors were placed at T11 and L1. A T12 corpectomy with PLC injury was stabilized with 1, 2, and 3 levels of PostPerc above/below the injury. Motions between T11 and L1 were measured during Log-Roll and Sit-Up on an ICU bed. After in situ testing, anatomic spinal motion ranges were determined under pure moment loads.

Results: 5 cadavers were evaluated. For Log-Roll, 2 and 3 levels above/below restored stability to intact, whereas 1 level above/below did not for axial rotation. For translation, all instrumentation restored stability to intact. During Sit-Up, a linear increase in flexion was observed. At 45° Sit-Up, 2 and 3 levels above/below were similar to intact for flexion; 1 level above/below had significantly more flexion. All instrumentations restored translation to intact for Sit-Up; significantly more axial collapse occurred for instrumentation compared with intact. During ex situ testing, 2 and 3 levels above/below were similar; 1 level above/below had significantly greater laxity in flexion, extension, and axial rotation.

Conclusion: Posterior instrumentation 2 or 3 levels above/below a severe thoracolumbar fracture model can restore spinal stability back to its intact condition. 2 levels of fixation above/below this "worst-case scenario" is minimum fixation sufficient to provide absolute spinal stability in the ICU setting as a "Damage Control" technique in patients with polytrauma. In less severe injury models, 1 level of fixation above/below may provide adequate spinal stability; although this should be confirmed in future investigations.

Level Of Evidence: N/A.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/BRS.0000000000001058DOI Listing
December 2015

The validity and reliability of "Spinal Mouse" assessment of spinal curvatures in the frontal plane in pediatric adolescent idiopathic thoraco-lumbar curves.

Eur Spine J 2016 Feb 22;25(2):476-82. Epub 2015 Apr 22.

Department of Physiotherapy and Rehabilitation, Faculty of Health Science, Hacettepe University, 06100, Sıhhiye, Ankara, Turkey.

Purpose: Radiological measurement has been accepted as the gold standard for evaluating scoliosis for many years. However, exposure of children to X-ray constitutes a major limitation of the radiological methods. Spinal Mouse (SM) is a safe, practical and easy to perform measurement of curvature in scoliosis, but its validity and reliability have not been investigated. The aim of this study was to investigate the validity and reliability of Cobb angle and SM measurements in children with adolescent idiopathic scoliosis (AIS).

Methods: Fifty-one patients with AIS who were followed up conservatively were included in the study. The mean age of the patients was 14.4 years (9-18 years). Frontal plane curvatures were evaluated with SM by 2 physiotherapists and the results were compared with radiological measurements. Radiological measurements were performed by 2 orthopedists.

Results: All the measurements were of the thoraco-lumbar curve and the mean value was 35.08° according to Cobb angle measurement. There was no difference between the interobserver measurements of SM (p = 0.256) while the Cobb degrees measured by the 2 orthopedists was different (p = 0.0001). We did not find a statistically significant difference between Cobb measurements and the SM measurements of observer 1 and 2 (p = 0.505). The interobserver and intraobserver agreement of the Cobb and SM measurements was excellent (ICC = 0.872-0.962). When the differences between the evaluations were compared, the interobserver SM differences were seen to be lower than the interobserver Cobb angle differences (p = 0.003). The agreement between the Cobb and SM measurements was higher for curves over 40°. We found a strong or very strong relationship between measurements made with the Cobb and SM methods (p < 0.0001).

Conclusions: We conclude that SM can be used for research and patient follow-up in the clinic as a safe, reliable, quick, and easy to use method with no side effects although it cannot be the only factor to consider when determining the treatment plan of AIS patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00586-015-3945-7DOI Listing
February 2016

Utilizing the "Stable-to-be Vertebra" Saves Motion Segments in Growing Rods Treatment for Early-Onset Scoliosis.

J Pediatr Orthop 2016 Jun;36(4):336-42

*Department of Orthopaedic Surgery, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA †Department of Orthopaedics, Hacettepe University Faculty of Medicine ‡Department of Orthopaedics, Dr Sami Ulus Children's Hospital, Ankara, Turkey §Department of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.

Background: There is no consensus on the selection of distal instrumentation levels in growing rod surgery. Many surgeons utilize the stable zone of Harrington, but there is not overwhelming evidence to support this preference. The aim of this study was to determine the value of bending/traction radiographs in selection of distal instrumentation levels of a growing rod construct in children with idiopathic or idiopathic-like early-onset scoliosis (EOS).

Methods: Twenty-three consecutive patients with idiopathic or idiopathic-like EOS who underwent growing rod surgery at 2 separate institutions between 2006 and 2011 were included. Lengthening procedures were performed periodically at 6-month intervals. Analyses were performed retrospectively for age at index surgery, follow-up period, and radiographic measurements. Lower instrumented levels, neutral vertebra, stable vertebrae (SV), and stable-to-be vertebrae (StbV) were identified on the preoperative radiographs. Coronal Cobb angles, tilt of lower instrumented vertebra (LIV) and LIV+1, and disk wedging under the LIV and LIV+1 were measured on the early postoperative and latest follow-up radiographs.

Results: Average age at index surgery was 83.6 months. Mean follow-up period was 68.1 months. Initial analysis showed that the relationship of LIV to the StbV was a better predictive of LIV+1 tilt than the SV at the final follow-up. Therefore, the patients were grouped according to the relationship of the LIV to the StbV. LIV was the StbV in 9 patients, proximal to the StbV in 8 patients, and distal to the StbV in 6 patients. At the latest follow-up, tilt of LIV+1 exceeded 10 degrees in 7 of the 8 patients where LIV was proximal to the StbV, whereas only in 1 of 9 patients where LIV was StbV, and in none of the 6 patients where LIV was distal to the StbV. The data indicate that selection of the StbV as the LIV could spare an average of 1.8 vertebral segments when compared with the SV, as StbV is never distal but almost always proximal to the SV.

Conclusions: Choosing the StbV as the LIV saves motion segments and prevents distal adding on, while providing satisfactory deformity correction in idiopathic and idiopathic-like EOS.

Level Of Evidence: Level III-retrospective comparative study.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/BPO.0000000000000467DOI Listing
June 2016

Convex Instrumented Hemiepiphysiodesis With Concave Distraction: A Treatment Option for Long Sweeping Congenital Curves.

J Pediatr Orthop 2016 Apr-May;36(3):226-31

*Hacettepe University Hospitals, Hacettepe University Medical School, Ankara ‡Department of Orthopaedics and Traumatology, Acibadem University School of Medicine, Istanbul, Turkey †Department of Orthopaedic Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA.

Background: Convex hemiepiphysiodesis has been reported to have mixed results in the treatment of congenital spine deformities. Multiple modifications of the original technique were suggested to improve the results. The purpose of this study is to report the results and complications of an instrumented convex growth arrest procedure modified with concave distraction.

Methods: The records of 11 patients with long sweeping congenital curves (involving multiple anomalous vertebrae) who underwent convex instrumented hemiepiphysiodesis with concave distraction were evaluated. Mean age at index operation was 58 months (range, 29 to 101 mo). Lengthening of the concave distraction rod was done every 6 months. The magnitude of coronal/sagittal deformity and T1-T12 height were measured on the preoperative, postoperative, and latest follow-up radiographs. Average follow-up was 44.9 months (range, 24 to 89 mo).

Results: In the coronal plane, the convex hemiepiphysiodesis segment was corrected from an average of 60.5 to 40.4 degrees postoperatively and further improved to 35.5 degrees at the latest follow-up. The distracted segment was corrected from 33.4 to 15.2 degrees postoperatively and to 12.7 degrees at the latest follow-up. Sagittal plane alignment was minimally affected. The average T1-T12 height was 157.1 mm in the early postoperative period and 181.1 mm at last follow-up. During follow-up, we identified partial pull-out of screws on the distraction side in 5 of the 11 patients and rod breakages in 3 patients. These were revised during planned lengthenings. There were no unplanned surgeries, deep wound infections, nor neurological complications.

Conclusions: Convex instrumented hemiepiphysiodesis with concave distraction resulted in good curve correction while maintaining the growth of thorax. The correction of the anomalous segment improved over time, proving the effectiveness of the hemiepiphysiodesis. Addition of a concave distraction construct appears to enhance spinal growth, thereby augmenting the hemiepiphysiodesis effect.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/BPO.0000000000000441DOI Listing
November 2016

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

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

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

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

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

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

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

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

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

Level Of Evidence: 2.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/BRS.0000000000000884DOI Listing
July 2015

Safety and Efficacy of Apical Resection Following Growth-friendly Instrumentation in Myelomeningocele Patients With Gibbus: Growing Rod Versus Luque Trolley.

J Pediatr Orthop 2015 Dec;35(8):e98-103

*Hacettepe University Hospitals, Hacettepe University Medical School, Ankara, Turkey †Johns Hopkins Bloomberg Children's Center, Baltimore, MD ‡Department of Orthopaedic Trauma, Hospital for Special Surgery, New York, NY.

Introduction: Thoracolumbar/lumbar kyphosis in myelomeningocele patients is a common and severely debilitating condition, amenable only to surgical correction. Several surgical techniques have been proposed. Growth-friendly techniques should be preferred in this patient population due to an already compromised trunk height. The growing rod (GR) and Luque trolley (LT) with Galveston instrumentation are well-known growth-friendly techniques. We compared results and complications in 2 groups of patients who have undergone kyphectomy and fixation, either with the GR (group 1) or the LT with Galveston pelvic fixation (group 2).

Methods: Ten patients undergoing GR fixation and 5 patients undergoing LT with Fackler fixation following kyphectomy (vertebral column resection or multiple eggshell) were included. GRs were lengthened every 6 months. Unplanned surgery in group 1 was defined as an unscheduled operation due to complication; all subsequent operations in group 2 were considered unplanned. Thoracic and local kyphosis and T1-S1 and T1-12 heights were measured preoperatively, postoperatively, and at final follow-up.

Results: Mean age at initial surgery was 6 years and 6.5 years for groups 1 and 2, respectively. Mean age at the last follow-up was 12.5 years for group 1 and 13.1 years for group 2. Mean follow-up was 72.7 months for group 1 and 68.6 months for group 2. Preoperative, postoperative, and final follow-up kyphosis angles in that order for group 1 were 72.3 degrees (10 to 110 degrees), 16.9 degrees (-50 to +55 degrees), and 21.6 degrees (-41 to +97 degrees), and for group 2 106.6 degrees (81 to 132 degrees), 15.6 degrees (-37 to +50 degrees), and 19.2 degrees (-42 to +38 degrees), respectively. Postoperative and final follow-up in that order for mean T1-T12 and T1-S1 heights for group 1 were 14 (11.2 to 18.7) cm, 20.4 (19.3 to 25.7) cm and 21 (17.2 to 23.2) cm, 31.6 (23.6 to 41.5) cm. Postoperative and final follow-up in that order for mean T1-T12 and T1-S1 heights for group 2 were 15.9 (14.3 to 19.7) cm, 20.1 (15.5 to 24.6) cm and 24.4 (17.7 to 27.8) cm, 29.5 (25.3 to 31.3) cm. Growth per year was 1.05 and 0.84 cm for groups 1 and 2, respectively (P=0.297). Fourteen versus 4 unplanned surgeries were performed in groups 1 and 2, respectively, and an additional 4 implant revisions were performed in group 1 during planned lengthenings.

Conclusions: Both the LT and the GR system are reasonable alternatives of fixation postkyphectomy, both of which preserve growth to differing degrees. In this patient population with an already severely stunted trunk height, the surgeon must choose whether the amount of extra growth achieved by the GR is worth the risk of an increased number of surgeries.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/BPO.0000000000000419DOI Listing
December 2015