Publications by authors named "Muharrem Yazıcı"

123 Publications

Posterior Instrumentation and Fusion in Multiple-segment Adolescent Congenital Scoliosis: When are Posterior Column and Concave Rib Osteotomies Needed?

J Pediatr Orthop 2021 Apr 23. Epub 2021 Apr 23.

Department of Orthopaedics and Traumatology, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey Department of Orthopaedics and Traumatology, Hacettepe University School of Medicine, Ankara, Turkey Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA Division of Orthopaedic Surgery, University of Toronto, Toronto, ON, Canada.

Background: No clear guidelines exist for appropriate surgical treatment of congenital scoliosis. The spectrum varies from isolated posterior instrumentation and fusion (PIF-only) to vertebral column resections. Multiple posterior column osteotomies (PCOs) with and without concave rib osteotomies have previously been suggested as an alternative to invasive 3-column osteotomies. The aim of the study is to analyze outcomes of spinal surgery in congenital scoliosis patients for a new treatment algorithm based on a traction radiograph under general anesthesia (TruGA).

Methods: Surgical intervention was determined according to flexibility with TruGA: patients with >40% correction underwent PIF-only; patients with <40% of correction underwent PCO. Patients, who had <30% of correction in TruGA and/or more than 5 vertebral levels with failure of segmentation, underwent additional concave rib osteotomies. The radiologic and clinical results were compared.

Results: Forty-three patients met inclusion criteria (14M). The mean age was 13.8 (10 to 17) years, average follow-up 67 (24 to 107) months. Fourteen patients were in the PIF-only group, 29 in the PCO group. PCO patients were significantly older (14.5 vs. 12.3, P=0.001). Mean operative time and blood loss of PCO group were significantly greater than those of PIF-only group. Nine patients required concave rib osteotomies. While the curve magnitude of patients in the PIF-only and PCO groups did not differ significantly (54.6 vs. 63 degrees, P=0.067), curve rigidity was significantly higher in the patients of PCO group (51.2% vs. 32%, P=0.001). Despite this, postoperative correction rates for 2 groups were similar (51.1% vs. 47.8%, P=0.545).

Conclusions: The number of anomalous segments and the curve flexibility on TruGA play important roles in the decision-making process in congenital scoliosis and <40% flexibility of the major curve could be an important indicator of the need for PCO. Curves with more than 5 anomalous vertebral segments might be more likely to need additional concave rib osteotomies for adequate correction.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1097/BPO.0000000000001841DOI Listing
April 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

Professor Yücel Tümer, MD; a legend, mentor in children's orthopaedics in Turkey.

Acta Orthop Traumatol Turc 2021 Mar;55(2):85-86

Past President of Turkish Society of Children's Orthopaedics (2008-2010).

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http://dx.doi.org/10.5152/j.aott.2021.21120DOI Listing
March 2021

Sagittal spinal alignment after total hip arthroplasty for neglected high hip dysplasia: does changing the distorted mechanics of the hip normalize spinal alignment?

Spine Deform 2021 Jan 14;9(1):221-229. Epub 2020 Sep 14.

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

Purpose: The false acetabulum lies more laterally and posteriorly compared with the true acetabulum. Spatial orientation of the pelvis is significantly altered in patients with neglected high hip dysplasia. There has been no study to investigate how pelvic or sagittal spinal alignment change after true acetabulum gains function with hip arthroplasty. The aim of this study was to investigate the effect of total hip arthroplasty with femoral shortening on spinopelvic parameters in patients with neglected high hip dysplasia.

Methods: Twenty patients with Crowe type 3 or 4 hip dysplasia, who underwent total hip arthroplasty with femoral shortening in our institution were evaluated preoperatively after completion of rehabilitation and return to their normal daily life. Sagittal alignment (sacral slope, pelvic incidence, global tilt, segmental lordosis, segmental kyphosis, GAP score) and coronal alignment angles (coronal tilt, Cobb angle) of patients were measured by two independent observers.

Results: Twenty patients underwent hip arthroplasty with femoral shortening followed up for a minimum of 12 months. We found higher preoperative global lordosis (68.7 ± 9.7) and sacral slope (52.1 ± 8.8) angles, but the pelvic incidences (57.9 ± 10.1) were in the normal range. No statistically significant difference in any sagittal spinopelvic parameters between pre- and postoperative measurements was detected. GAP scores also did not change significantly (p = 0.231). Coronal plane parameters (Cobb angle, coronal pelvic tilt) were the only parameters in which a statistical change was observed (p = 0.02, p = 0.05, respectively).

Conclusion: Lumbar lordosis and sacral slope values are outside standard ranges in patients with neglected dysplasia of the hip. The reconstruction of the distorted mechanics of the hip joint does not normalize sagittal pelvic and spine anatomy however improvements in coronal alignment were observed. Disease specific values of sagittal spinal alignment should be used in the treatment of lumbar degenerative problems in patients with neglected high hip dysplasia.

Level Of Evidence: IV.
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http://dx.doi.org/10.1007/s43390-020-00204-3DOI Listing
January 2021

Improving Safety and Efficacy in the Surgical Management of Low-tone Neuromuscular Scoliosis: Integrated Approach With a 2-attending Surgeon Operative Team and Modified Anesthesia Protocol.

J Pediatr Orthop 2021 Jan;41(1):e1-e6

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

Background: Substantially increased operative time and amount of bleeding may complicate the course of surgical treatment in neuromuscular scoliosis. A well-organized team approach is required to reduce morbidity. The aim of this study is to review our early, short-term surgical outcomes with our new integrated approach that includes a 2-attending surgeon team and modifications in the anesthesia protocol in low-tone neuromuscular scoliosis and compare with a matched cohort of our historic patients.

Methods: We retrospectively reviewed our patients with (1) neuromuscular scoliosis with collapsing spine deformity, (2) low-tone neuromuscular etiology, (3) multilevel posterior column osteotomies with posterior all pedicle screw spinal fusion, and (4) more than 1-year follow-up. Patients were grouped into 2: group 1 consisted of patients managed with the integrated surgical team approach, group 2 included the matched historic patients.

Results: There were 16 patients in group 1 and 17 patients in group 2. There was no significant difference between the groups regarding age, sex, body mass index, number of levels fused, major coronal deformity magnitude, pelvic obliquity, number of posterior column osteotomies, or amount of deformity correction. However, significantly shorter operative time (241 vs. 297 min, P=0.006), less intraoperative bleeding (1082 vs. 1852 mL, P=0.001), less intraoperative blood transfusion (2.1 vs. 3.1 U, P=0.028), less postoperative intensive care unit admission (23% vs. 100%, P=0.001), and shorter hospital stay (4.7 vs. 5.9 d, P=0.013) were observed in group 1.

Conclusions: Our results indicate that spinal deformity surgery in patients with underlying low-tone neuromuscular disease may not be as intimidating as previously thought. Our surgical team approach integrating a 2-attending surgeon operative team, a new anesthetic protocol that includes a modification of perioperative blood management is effective in reducing operative times, blood loss, transfusion rates, intensive care unit admission, and length of hospital stay.

Levels Of Evidence: Level III-retrospective comparative study.
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http://dx.doi.org/10.1097/BPO.0000000000001658DOI Listing
January 2021

Early Results of a Management Algorithm for Collapsing Spine Deformity in Young Children (Below 10-Year Old) With Spinal Muscular Atrophy Type II.

J Pediatr Orthop 2020 Jul;40(6):e413-e419

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

Background: Progressive C-shaped scoliosis with marked pelvic obliquity is common to spinal muscular atrophy (SMA). Reducing the number of procedures with effective deformity control is critical to minimize the risk of pulmonary complications. This study reports the preliminary results of magnetically controlled growing rods (MCGR) in SMA-related collapsing spine deformity.

Methods: Inclusion criteria for this retrospective review were: (1) SMA type 2 patients, (2) early onset scoliosis (below 10 y), (3) collapsing spine deformity with pelvic obliquity, (4) growth-friendly scoliosis treatment with MCGR, (5) in between 2014 and 2017. Extracted data included demographic and clinical information, radiologic parameters, surgical details, and final status of the patients.

Results: A total of 11 patients (7 boys, 4 girls) were included. The average age at index surgery was 8.2 (6 to 10) years. Dual MCGR was implanted in 8 patients. In 3 patients, because of curve rigidity and inability of apex to be brought into the stable zone, apical fusion with gliding connectors (convexity) and a single MCGR (concavity) was preferred. Instrumentation included the pelvis in 9 and stopped at the lumbar spine (L3) in 2 patients at the index procedure. Average preoperative deformity of 81.8 degrees (66 to 115) decreased to 29 degrees (11 to 57) postoperatively and was 26 degrees at average 35 months (16 to 59). Pelvic obliquity of 20.9 degrees (11 to 30) decreased to 4.9 degrees (2 to 8) after index surgery and was 6.5 degrees (2 to 16) at the last follow-up. T1-S1 height of 329 mm (280 to 376) after index surgery increased to 356 mm (312 to 390) after 9.2 (4 to 20) outpatient lengthening. No neurologic, infectious, or implant-related complication was recorded. Distal adding-on deformity occurred in 2 patients without initial pelvic fixation.One patient deceased secondary to pneumonia at 16 months after surgery.

Conclusions: Short-term results indicate that MCGR may be a good option in SMA-associated collapsing spine deformity to reduce the burden of repetitive lengthening procedures. The authors recommend apical deformity control in the convex side in case of curve rigidity. In addition, including the pelvis in the instrumentation at index surgery is critical to prevent distal adding-on.

Level Of Evidence: Level IV-retrospective case series.
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http://dx.doi.org/10.1097/BPO.0000000000001489DOI Listing
July 2020

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

Technical aspects of surgical correction of spinal deformities in cerebral palsy.

J Child Orthop 2020 Feb;14(1):30-40

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

Purpose: Cerebral palsy (CP) is a disorder arising from a non-progressive lesion in the developing immature brain with an encephalopathy, that results in various levels of motor and sensory dysfunction. Motor disability of these children can be assessed by the Gross Motor Function Classification System in five levels, and depending on their motor functional capability, the most severely affected children fall into levels IV and V. Children in groups IV and V present a full spectrum of musculoskeletal deformities, among which, scoliosis is the most frequently found spinal deformity that most often requires surgical treatment. However, these are procedures that are usually technically demanding, requiring experienced surgical teams and a multidisciplinary approach.

Methods: In order to overcome some of the technical pitfalls that may complicate these complex surgical procedures, the authors have gathered together different tips and tricks that may help surgeons performing surgical correction of spinal deformities in CP children.

Conclusion: Although for these children surgery is a major undertaking, with the multidisciplinary approach and advances of technology, anaesthesia and optimization of pre- and postoperative care, complications are manageable in most cases, improving not only the outcome of surgery but also the patient's quality of life and satisfaction of parents and caretakers.
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http://dx.doi.org/10.1302/1863-2548.14.190167DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7043119PMC
February 2020

Restoring sagittal and frontal balance following posterior instrumented fusion.

Ann Transl Med 2020 Jan;8(2):30

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

Correction techniques for adolescent idiopathic scoliosis have evolved over the years as the understanding of the disease and the implant technology advanced. Utilization of the modern implant systems, along with the appropriate corrective maneuvers and selection of the appropriate levels of instrumentation, improves the outcomes after surgical treatment of adolescent idiopathic scoliosis. Coronal and sagittal balance are important predictors for successful posterior spine fusion. Many corrective methods have been developed to address the multiple facets of the spinal deformity and curve types. Treating surgeons should familiarize themselves with all of the techniques, their utility, and appropriate usage in different deformity settings. A literature review is provided with the best evidence available to achieve optimal deformity correction to help guide treating physicians.
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http://dx.doi.org/10.21037/atm.2019.12.68DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6995917PMC
January 2020

Results of growth-friendly management of early-onset scoliosis in children with and without skeletal dysplasias: a matched comparison.

Bone Joint J 2019 12;101-B(12):1563-1569

Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland, USA.

Aims: The aim of this study was to compare the surgical and quality-of-life outcomes of children with skeletal dysplasia to those in children with idiopathic early-onset scoliosis (EOS) undergoing growth-friendly management.

Patients And Methods: A retrospective review of two prospective multicentre EOS databases identified 33 children with skeletal dysplasia and EOS (major curve ≥ 30°) who were treated with growth-friendly instrumentation at younger than ten years of age, had a minimum two years of postoperative follow-up, and had undergone three or more lengthening procedures. From the same registries, 33 matched controls with idiopathic EOS were identified. A total of 20 children in both groups were treated with growing rods and 13 children were treated with vertical expandable prosthetic titanium rib (VEPTR) instrumentation.

Results: Mean preoperative major curves were 76° (34° to 115°) in the skeletal dysplasia group and 75° (51° to 113°) in the idiopathic group (p = 0.55), which were corrected at final follow-up to 49° (13° to 113°) and 46° (12° to 112°; p = 0.68), respectively. T1-S1 height increased by a mean of 36 mm (0 to 105) in the skeletal dysplasia group and 38 mm (7 to 104) in the idiopathic group at the index surgery (p = 0.40), and by 21 mm (1 to 68) and 46 mm (7 to 157), respectively, during the distraction period (p = 0.0085). The skeletal dysplasia group had significantly worse scores in the physical function, daily living, financial impact, and parent satisfaction preoperatively, as well as on financial impact and child satisfaction at final follow-up, than the idiopathic group (all p < 0.05). The domains of the 24-Item Early-Onset Scoliosis Questionnaire (EOSQ24) remained at the same level from preoperative to final follow-up in the skeletal dysplasia group (all p > 0.10).

Conclusion: Children with skeletal dysplasia gained significantly less spinal growth during growth-friendly management of their EOS and their health-related quality of life was significantly lower both preoperatively and at final follow-up than in children with idiopathic EOS. Cite this article: 2019;101-B:1563-1569.
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http://dx.doi.org/10.1302/0301-620X.101B12.BJJ-2019-0735.R1DOI Listing
December 2019

Spinal Instrumentation in Growing Children Retards the Natural Development of Pelvic Incidence.

J Pediatr Orthop 2019 Mar;39(3):141-145

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

Background: Pelvic incidence increases gradually throughout growth until skeletal maturity. Growing rod instrumentation has been suggested to have a stabilizing effect on the development of the normal sagittal spinal alignment. The purpose of this study is to determine the effect of fixed sagittal plane caused by dual growing rod instrumentation on the natural progression of sagittal spinopelvic parameters in children with idiopathic or idiopathic-like early onset scoliosis.

Methods: Hospital records of children with growing rod instrumentation from 4 separate institutions were reviewed retrospectively. Inclusion criteria were idiopathic or idiopathic-like early onset scoliosis, treatment with dual growing rods with lower instrumented vertebra L4 or upper and more than 2 years of follow-up. Instrumentation levels, magnitudes of major curve, thoracic kyphosis (T2-T12), lumbar lordosis (L1-S1) and pelvic incidence were recorded from preoperative and postoperative standing whole-spine radiographs. Estimated pelvic incidence was also calculated for each patient as if their spines had not been instrumented using the previous normative data.

Results: A total of 37 patients satisfied the inclusion criteria. Average age at initial surgery was 7.4±1.8 years (range, 4 to 12 y). Mean follow-up time was 71±26 months (range, 27 to 120 mo). Mean preoperative Cobb angle of 59±13.5 (range, 30 to 86) degrees was reduced to 35.1±17.5 (range, 11 to 78) degrees at the last follow-up. Mean preoperative T2-T12 kyphosis angle was 46.2±14.9 degrees (range, 22 to 84 degrees). At the latest follow-up, it was 44.8±16.2 degrees (range, 11 to 84 degrees) (P=0.93). Mean L1-S1 lordosis angle was 50.5±10.7 degrees (range, 30 to 72 degrees) preoperatively. At the latest follow-up, mean L1-S1 lordosis angle was 48.8±12.7 degrees (range, 26 to 74 degrees) (P=0.29). Mean preoperative pelvic incidence was 45.7±7.9 degrees (range, 30 to 68 degrees). At the latest follow-up, it was 46.7±8.4 degrees (range, 34 to 72 degrees) (P=0.303). The estimated average pelvic incidence was 49.5 degrees (P=0.012).

Conclusions: Previously reported developmental changes of the sagittal spinal parameters were not observed in children who underwent posterior spinal instrumentation. Our findings suggest that spinal instrumentation impedes the natural development of the sagittal spinal profile.

Level Of Evidence: Level IV-this is a retrospective case-series.
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http://dx.doi.org/10.1097/BPO.0000000000000882DOI Listing
March 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.
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http://dx.doi.org/10.1097/BRS.0000000000002938DOI Listing
June 2019

Surgical and Health-related Quality-of-Life Outcomes of Growing Rod "Graduates" With Severe versus Moderate Early-onset Scoliosis.

Spine (Phila Pa 1976) 2019 May;44(10):698-706

Department of Orthopaedic Surgery, University of California-San Diego, San Diego, CA.

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

Objective: The aim of this study was to compare surgical and quality-of-life outcomes at the end of growing rod treatment in patients with severe versus moderate early-onset scoliosis (EOS).

Summary Of Background Data: Knowledge of the outcomes of severe EOS after growth-friendly treatment is limited because this condition is uncommon.

Methods: We identified 40 children with severe EOS (major curve ≥90°) treated with growing rods before age 10 with minimum 2-year follow-up after last lengthening or final fusion. From the same registry, we matched 40 patients with moderate EOS (major curve < 90°). Twenty-seven patients in the severe group and 12 in the moderate group underwent final fusion (P < 0.001).

Results: Mean preoperative curves were 102° (range, 90°-139°) in the severe group and 63° (range, 33°-88°) in the moderate group (P < 0.001). At final follow-up, mean curves were 56° (range, 10°-91°) and 36° (range, 12°-89°), respectively (P < 0.001). Fourteen (35%) children in the severe group and 32 (80%) in the moderate group had scoliosis of < 45° at final follow-up [risk ratio (RR), 0.44; 95% confidence interval (95% CI), 0.20-0.57]. At final follow-up, 30 (75%) children in the severe group and 35 (88%) in the moderate group had achieved T1-T12 length of ≥18 cm (RR, 0.86; 95% CI, 0.70-1.09). Thirty-five children in the severe group and 26 in the moderate group had at least one complication (RR, 1.35; 95% CI, 1.05-1.73). Mean 24-Item Early-Onset Scoliosis Questionnaire scores were similar between groups at final follow-up.

Conclusion: Delaying surgery until the major curve has progressed beyond 90° is associated with larger residual deformity and more complications than treating at a lesser curve magnitude. Quality-of-life outcomes were similar between those with severe and moderate EOS.

Level Of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000002922DOI Listing
May 2019

Is Magnetically Controlled Growing Rod the Game Changer in Early-onset Scoliosis? A Preliminary Report.

J Pediatr Orthop 2019 Mar;39(3):e195-e200

Departments of Orthopaedics and Traumatology.

Background: Magnetically controlled growing rod (MCGR) concept was introduced with the premise of minimizing the repetitive lengthening surgeries, which is default in traditional growing rod (TGR) treatment for early-onset scoliosis (EOS). Despite good radiographic outcomes, previous studies did not compare identical patient groups in terms of etiology and deformity characteristics; therefore, a true comparison of the MCGR and TGR is essential. This study was designed to compare 2 techniques in terms of clinical, radiologic, and health-related quality of life (HRQoL) outcomes.

Methods: Patients with long sweeping congenital curves who underwent convex growth arrest and concave distraction (with TGR or MCGR) were retrospectively reviewed. Instrumented all-posterior convex growth arrest and concave distraction with growing rod technique were performed. Demographic parameters, follow-up time, number of lengthening procedures, radiographic parameters, number of unplanned surgeries, and complications were recorded. The Early-Onset Scoliosis Questionnaire (EOSQ-24) was used to evaluate HRQoL outcomes.

Results: A total of 20 patients were included (10 MCGR, 10 TGR). No significant differences were found with regard to average age, follow-up time, radiographic parameters, or complications. Overall surgery per patient including index surgery, and planned and unplanned procedures were significantly lower in the MCGR group (8.8 vs. 1.3) (P=0.01). No patient in either group had graduated from growing rod treatment. HRQoL analysis revealed no significant difference between the 2 groups in any specific domain or in the overall score of the EOSQ-24.

Conclusions: Although equally effective in controlling the deformity and superior in reducing the number of surgeries with comparable complication rates, MCGR does not offer any significant improvement in HRQoL outcomes or the overall complication rate. Despite the obvious advantages, according to this preliminary report, the current technology and technique of MCGR may not be sufficient to be the long-awaited "game changer" in the treatment of EOS.
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http://dx.doi.org/10.1097/BPO.0000000000001268DOI Listing
March 2019

A comparison of growth among growth-friendly systems for scoliosis: a systematic review.

Spine J 2019 05 2;19(5):789-799. Epub 2018 Oct 2.

Department of Orthopaedic Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands.

Background Context: The optimal method for surgical treatment of early onset scoliosis is currently unknown. Although the aim of growth-friendly systems is to reduce the curve and maintain growth, there is no consensus on how to measure spinal growth during and after the treatment. Different measurements of different segments (T1-S1, T1-T12, instrumented length) are used for different time points to evaluate growth. The aim of this review is to assess what measurements are used and to compare the growth-friendly systems based on spinal growth during treatment.

Methods: The electronic MEDLINE, EMBASE, and Cochrane databases were systematically searched for original articles that reported growth for traditional growing rods (TGR), vertical expandable prosthetic titanium rib expansion technique (VEPTR), Shilla, magnetically controlled growing rods (MCGR), and Luque-trolley systems. All measurements were recorded, and weighted averages calculated in centimeter per year were compared.

Results: We included 52 studies (26 TGR, 12 MCGR, 6 VEPTR, 4 Luque trolley, 1 Shilla, and 3 mixed). Often only one segment was reported (T1-S1 length in 22 studies, T1-T12 length in two studies, and instrumented length in five studies). The remaining 22 studies reported T1-S1 length in combination with T1-T12 length (15 studies) or instrumented length (eight studies). Spinalgrowth achieved by initial correction only was a considerable 3.9 cm (based on 34 studies) as well as the spinal growth achieved by the final fusion surgery (2.3 cm in four studies). To specifically assess growth achieved with the system, length gain after initial surgery and before final fusion in growth system graduates was considered. Only four TGR studies reported on this "true" spinal growth with 0.6 and 0.3 cm/y in the T1-S1 and T1-T12 segment, respectively.

Conclusions: Reporting on spinal growth is currently inadequate and does not allow a good comparison of different techniques. However, all systems often report growth similar to Dimeglio's T1-S1 spinal growth of 1 cm/y. It should be recognized though that a considerable portion of the reported spinal growth is the result of the initial and final surgical correction and not due to the growth-friendly implant.
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http://dx.doi.org/10.1016/j.spinee.2018.08.017DOI Listing
May 2019

Pull-out of Upper Thoracic Pedicle Screws Can Cause Spinal Canal Encroachment in Growing Rod Treatment.

J Pediatr Orthop 2018 Aug;38(7):e399-e403

Orthopaedics and Traumatology, Hacettepe University, Ankara, Turkey.

Background: Proximal foundation failure is a common complication of growing rod (GR) treatment for early-onset scoliosis. Spinal canal encroachment due to pull-out of pedicle screw used as proximal foundation has been anecdotally reported in GR patients. The aim of this study is to report the prevalence of spinal canal encroachment of pedicle screws in GR treatment and determine risk factors using a single-center cohort.

Methods: Inclusion criteria were: (1) GR for early-onset scoliosis and (2) pull-out of at least 1 proximal anchor pedicle screw. Patients were divided into 2 groups according to the presence of medial screw migration. Medial migration of the screw was confirmed by computed tomography. The extracted data included demographic, clinical, and radiographic information.

Results: A total of 21 patients (of 96) met inclusion criteria (21.8%). None of the screws appeared malpositioned on early postoperative x-ray. Average follow-up until screw failure was 50.4 months (64 to 85 mo) and average number of lengthenings 8.1 (4 to 13). Computed tomography revealed canal encroachment in 11 patients (group 1), and no encroachment in 10 (group 2). There was no significant difference between groups for age, follow-up or number of lengthenings. At the time of screw pull-out, coronal plane deformity was increased compared with early postoperative x-ray in all; however, this increase was significantly higher in group 1 (45.7 vs. 35 degrees, P=0.002). Proximal junctional angle (PJA) was increased in both groups at the time of pull-out. While not statistically significant, PJA increased linearly in group 1 but spiked in group 2 at the time of pull-out. There was no neurological event preoperatively, intraoperatively or postoperatively. Failed screws were safely revised in either planned/unplanned surgeries.

Conclusions: In patients with proximal anchor failure of GR, especially if there is increase of coronal deformity and/or PJA, possible spinal encroachment should be kept in mind.

Level Of Evidence: Level IV-retrospective case series.
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http://dx.doi.org/10.1097/BPO.0000000000001196DOI Listing
August 2018

Pedicle Subtraction Osteotomy Versus Multiple Posterior Column Osteotomies in Severe and Rigid Neuromuscular Scoliosis.

Spine (Phila Pa 1976) 2018 08;43(15):E905-E910

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

Study Design: Retrospective analysis.

Objective: The aim of this study is to compare the safety and efficacy of the apical pedicle subtraction osteotomy (PSO) technique with multiple posterior column osteotomies (PCOs) in nonambulatory patients with severe, rigid neuromuscular scoliosis.

Summary Of Background Data: Neuromuscular scoliosis frequently causes intolerance to sitting due to pelvic obliquity, trunk decompensation, and associated back and rib impingement pain which diminish the patient's functional capacity. In the case of rigid curves, spinal osteotomy techniques are occasionally required for effective correction.

Methods: We retrospectively reviewed our patients with severe and rigid neuromuscular scoliosis with associated pelvic obliquity who were treated with posterior instrumented fusion extending to pelvis with more than 1-year postoperative follow-up. We compared radiological and clinical results of PSO and multiple PCO techniques in severe rigid neuromuscular scoliosis with pelvic obliquity of more than 15° in traction radiograph under general anesthesia. Hospital records were also reviewed for operative time, intraoperative blood loss, amount of blood transfusion, duration of hospital stay, and complications.

Results: There were 12 patients in the PSO group and 10 patients in the PCO group. There was no significant difference between groups in terms of major curve magnitude, sagittal parameters or pelvic obliquity. Although not statistically significant, PSO technique did trend toward better scoliosis correction (post-op Cobb angle 56.1° vs. 66.7° [P = 0.415]). PSO technique provided a significantly better correction in pelvic obliquity (59% vs. 84%) (P = 0.001). There was no significant difference in average intraoperative blood loss, transfusion, and operative times including anesthesia time, hospital stay, or complications.

Conclusion: PSO may be an option in correction of severe and rigid neuromuscular scoliosis. It provides better correction of pelvic obliquity without increasing operative time, need for transfusion, or duration of hospitalization as compared to multiple apical PCO technique. Traction radiograph under general anesthesia is a valuable tool in surgical decision making.

Level Of Evidence: 4.
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http://dx.doi.org/10.1097/BRS.0000000000002538DOI Listing
August 2018

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

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

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

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

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

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

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

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

Thoracic Spine Growth Revisited: How Accurate Is the Dimeglio Data?

Spine (Phila Pa 1976) 2017 Jun;42(12):917-920

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

Study Design: Cross-sectional descriptive study.

Objective: To describe the normal rate pattern of thoracic spine growth in children without any spinal deformity.

Summary Of Background Data: The knowledge of thoracic spine growth and height is important for growing spine treatment and the decision of final fusion. Currently, pediatric spinal deformity is approached as early onset and late onset with an understanding of the fast growth during the first 5 years of life. The growth data that support this classification is often cited but has not been reconfirmed with follow-up studies.

Methods: Sagittal computed tomography (CT) reformations of thoracic vertebrae were examined in children without spinal deformity. The sagittal CT cut at the widest canal diameter was identified and the measurements were performed on this image. The length of the thoracic spine was measured from the posterosuperior corner of T1 to the posteroinferior corner of the T12.

Results: One hundred forty-four thoracic CT scans satisfied the inclusion criteria. The analysis of the data identified two break points in the growth velocity; one at the end of the 4th year of life and the other at the beginning of the 12th year. Specifically, growth rate between 1 and 4 years was 1.71 cm/yr, between 4 and 8 years was 0.55 cm/yr, between 8 and 10 was 0.74 cm/yr, between 10 and 12 was 0.69 cm/yr, and between 12 and 16 was 1.61 cm/yr.

Conclusion: The results show that in growing children the thoracic spine demonstrates two major growth spurts. The initial growth spurt is between the birth to the end of the fourth year of life and the second is between the 12 and 16 years of age. Between 4 and 12 years there is a steady but slower increase in thoracic height. The findings show that the fastest growth velocity may be limited to a younger age group than previously believed. This data will help guide growth friendly management strategies.

Level Of Evidence: 2.
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http://dx.doi.org/10.1097/BRS.0000000000002104DOI Listing
June 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.
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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.
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http://dx.doi.org/10.1097/BRS.0000000000001880DOI Listing
May 2017