Cenk Özkan

Morphometry of the thoracolumbar vertebrae in sickle cell disease

Patients with sickle cell disease (SCD) who have deformities and vertebral fractures due to osteoporosis may require surgery. Spinal surgeons must become familiar with the vertebral morphometry of patients with SCD and to that aim we have examined the morphometry of the thoracolumbar spine in these patients. A cohort of 100 patients with SCD was examined using plain thoraco lumbar anteroposterior/lateral radiographs and dual energy X-ray absorptiometry (DEXA). Vertebral morphometry (vertebral body diameters, pedicle, spinal canal and deformity) was assessed for different age groups. Results were compared to published studies of healthy subjects. The vertebral dimensions for the 16-20-year and the 21+-year-old groups were significantly smaller for females than males at most spinal levels, while measurements in the 6-10 years and 11-15 years age groups were similar across both sexes at most levels. No significant statistical difference was found between the diameters of the right and left pedicles. With the exception of the sagittal diameter, most of the dimensions of the vertebral bodies measured in SCD patients were less than those of healthy individuals; multiple deformities were also observed. Low bone density was noted in 32 patients. Our data highlight the differences in vertebral bone mineral density, anatomy and deformities in patients with SCD compared to healthy individuals. When considering surgical intervention for patients with SCD, it is important that pre-operative radiography and planning is undertaken, and that the surgeon is familiar with the geometry of the pedicles of the thoracolumbar vertebrae necessary for the safe insertion of pedicle screws. Osteoporosis must be considered when planning surgical interventions in these patients.

Angular shortening and delayed gradual distraction for the treatment of asymmetrical bone and soft tissue defects of tibia: a case series.

BACKGROUND Acute shortening is reported to be an effective method for the treatment of open fractures with bone and soft tissue defects. Little is known about primary skin closure with angulation to the side of the defect and distraction at the fracture site. METHODS We present a series of three cases treated for defective fractures of tibia by angular shortening and delayed gradual distraction with hinged circular external fixator. Two cases were type IIIB open fractures and one case was an infected nonunion. Bone and soft tissue defects were managed by adaptation of edges and primary skin closure with angulation to the side of the defect. Axial alignment was restored by gradual distraction after a 2 to 3 weeks interval. Residual limb length discrepancy was lengthened through a separate corticotomy in two cases. RESULTS Bone formation at both the fracture and corticotomy sites were sufficient to achieve union in all patients. Fixation time averaged 261 (182-392) days and average bone healing index was 42 days/cm. No further surgical intervention was necessary for soft tissue reconstruction after primary skin closure. Infection was eradicated in the case of infected nonunion. CONCLUSIONS Angular compression to the side of the defect is a safe and reliable method of treatment for asymmetrical bone or soft tissue defects of tibia. It eliminates the need for complex soft tissue reconstruction procedures. Unnecessary debridement of bone is prevented by angular adaptation of edges. Definitive treatment of complex injuries is possible with a circular external fixator.

Arthroscopy of the knee in pre-adolescent children

Introduction: Arthroscopic operations performed in the pediatric age group constitute less than 5% of all arthroscopies. Diagnostic accuracy is reported to be lower than the procedures in adult patients. The incidence of pathologies also varies in the literature. We aimed at assessing the diagnostic accuracy of arthroscopy and review the incidence of pathologies in pre-adolescent patients. Materials and methods: In the period April 1990–January 2002, 50 pre-adolescent patients underwent knee arthroscopy after clinical and radiological assessment. Average age was 10.24 (1–13) with a male-to-female ratio of 34:16. Results: Discoid lateral meniscus was found to be the most common pathology encountered in 17 cases followed by infection and synovitis in 8 cases each. Diagnostic accuracy of arthroscopy correlated with preoperative clinical and radiologic evaluation was 90%. Arthroscopy findings were negative in two cases. Two cases of plica syndrome and one case of chondral injury were mistaken for medial meniscal tear. Final diagnosis was familial Mediterranean fever in one case of synovitis and knee fusion was performed at follow-up due to progressive degenerative changes. No other patient required reoperation. Conclusion: Arthroscopy is a safe procedure with minor morbidity allowing treatment of various intraarticular knee disorders. Diagnostic accuracy of the procedure may increase with careful preoperative work-up.

Results of using Ilizarov distraction osteogenesis technique for the treatment of cubitus varus deformities in adults

IntroductionFive adult patients, with posttraumatic cubitus varus deformity underwent corrective surgery by the Ilizarov method of distraction osteogenesis.MethodA standard technique was applied in all patients. The average follow-up was 28 (range, 24–38) months. Preoperative carrying angle ranged from 12° to 22° of varus (average 16.6°) and postoperative carrying angle ranged from 10° to 14° of valgus (average, 11.6°) equalized to the contralateral side.ResultThe outcome was rated as excellent in all patients. No complication was observed, except a grade-2 pin-tract infection in two patients.ConclusionRigid fixation, early rehabilitation, precise correction, satisfactory cosmetic scars and functionally excellent results can be obtained with this method.

Clinical and pathological results of denosumab treatment for giant cell tumors of bone: Prospective study of 14 cases

Objective Giant cell tumor of bone (GCT) is a primary, osteolytic, benign tumor of the bone. Surgery is the commonly used treatment; however, recurrence remains a problem. Receptor activator of nuclear factor kappa B (RANKL) is responsible for the formation of osteoclastic cells. Discovery of RANKL and its human monoclonal antibody, denosumab, led to use of denosumab for treatment of GCT. The aim of this study was to evaluate clinical and pathological results of treatment of GCT with denosumab and to assess adverse effect profile and recurrence rate. Methods Thirteen patients with 14 lesions were enrolled in the study. Mean age was 38.3 years. Patients were given subcutaneous injections of denosumab (120 mg) every 4 weeks (with additional doses on days 0, 8 and 15 in cycle 1 only) and were radiologically evaluated for tumor response. Pain and functional status were measured using Visual Analog Score (VAS) and Musculoskeletal Tumor Society Score (MSTS). Adverse effects were analyzed after each cycle. Results Participants were 5 men and 8 women. Mean follow-up was 17 months. One lesion was Campanacci grade I, 8 were grade II, and 5 were grade III. Eight lesions were recurrent, and remaining were primary lesions. After average of 9 cycles (range: 4–17 cycles), all tumors underwent radiological regression. Ten lesions were removed surgically. More than 90% of giant cells were found to have regressed in all pathological specimens. On last follow-up, average VAS was 1 and MSTS was 87%. Fatigue and joint and muscle pain after injections was reported by 46% of patients, and mild hypocalcaemia was seen in 1 patient. Conclusion Denosumab has been shown to be a successful drug in treatment of GCT. Denosumab can be used as neoadjuvant for all recurrent lesions, grade II lesions with high surgical risk, grade III lesions, and metastatic cases of GCT. Level of evidence Level IV, Therapeutic study

Elastofibroma dorsi: Clinical evaluation of 61 cases and review of the literature

Objective Elastofibroma dorsi (ED) is a rare, benign, soft tissue tumor typically located between inferior corner of scapula and posterior chest wall causing mass, scapular snapping, and pain. When classic symptoms and localization are present, it is diagnosed without biopsy and treated with marginal resection. This study retrospectively analyzed patients operated on for ED to evaluate presenting symptoms, tumor size, complications, and clinical results, and to suggest optimal treatments. Methods This study included 51 patients who underwent surgery for ED in 2 different clinics between 2005 and 2015. Patient age, gender, profession, side affected, symptoms, average duration of symptoms, and tumor size were researched. Radiological examinations of patients were evaluated. Patients with lesions larger than 5 cm in size were operated on. Postoperative complications, recurrence, and functional results were evaluated using Constant score and compared to preoperative values. Results A total of 61 operated lesions of 51 patients clinically and radiologically diagnosed with ED were retrospectively evaluated. Average length of time patient experienced symptoms was 11.21 months. Lesions in 19 (37.2%) patients were bilateral, 10 of which were symptomatic and larger than 5 cm in size, meeting indication for surgery. Average lesion diameter was 8.7 cm. Average follow-up was 26.89 months. Average of preoperative Constant score of 67.28 subsequently increased to 92.88 (p < 0.05). Seroma and hematoma were observed in 11.5% of patients. Conclusion Generally, good clinical results can be obtained with marginal resection without requiring a biopsy, considering classic complaints and radiological appearance of ED. Level of evidence Level IV, Therapeutic study.

Displacement Analysis of Robotic Frames for Reliable and Versatile Use as External Fixator

External fixators are widely used in the area of orthopedics to manage deformities and fractures. The historical trend in obtaining a mechanical infrastructure has shifted from simple devices like pins, rods, and hinges to more sophisticated frames involving parallel manipulators. Despite advantages of such robotic frames especially in removing stiffness issues, there are still problems associated with the reliable deployment of these modern devices. Problems like singularity, possibilities of guiding fragments along many different trajectories have been handled in this paper. A method has been shown how to detect singularity in displaced, aligned, and intermediate positions of the fragments. How the robotic system could be actuated according to different functions have been investigated, in addition to their effects on trajectories of distal fragment end. These considerations have been demonstrated on numerical examples.

Definitive Surgery for Open Fractures of the Long Bones with External Fixatıon

Reconstruction Methods for Fractures with Bone Defects, Vascular Injury, and Salvage Procedures

Computer-Assisted Fixators for Deformity Surgery

Extremity discrepancies, short stature, pseudoarthrosis, infections such as chronic osteomyelitis, acute trauma with bone loss, and deformities either in the bones or joints are routine problems dealt with in daily practice. In the majority of these problems, an Ilizarov external fixator (EF) is used, often as the first choice or for revision of previously unsuccessful surgery (as reported by Ilizarov (Clin Orthop Relat Res 280: 7–10, 1992)). The Ilizarov EF is highly modular, which increases the chance of success, but also entails a long learning curve. Especially in multiplanar deformities, because of the hinge positioning difficulties, lengthening and translations are made with different apparatus thus the system requires frequent revision (as reported by Mutlu (J Eng Math 54:119, 2006)). This situation creates anxiety in the patient and is time-consuming for the physician. Therefore, the use of circular Ilizarov external fixator is gradually being replaced by computer-assisted fixators.

Treatment of post-traumatic elbow deformities in children with the Ilizarov distraction osteogenesis technique

Objective The present study assessed functional and radiographic outcomes of distraction osteogenesis treatment of post-traumatic elbow deformities in children. Methods Eight children were treated between 2008 and 2013 for post-traumatic elbow deformities using distraction osteogenesis. Mean age at time of operation was 10.9 years. Six patients had varus and 2 had valgus deformity. Magnitude of correction, fixator index, complications, carrying angle, and elbow range of motion were assessed. Functional results were graded according to protocol of Bellemore et al. Results Mean follow-up was 43 months. Mean preoperative varus deformity in 6 patients was 29.2° and valgus deformity in 2 patients was 28.5°. Preoperative flexion and extension of elbow were 123.8° and −10.6°, respectively. Mean carrying angle was 9° valgus at last follow-up. Mean flexion and extension were 134.4° and −6.0°, respectively. Change in carrying angle was statistically significant (p = 0.002). There were 2 grade 1 pin tract infections and 1 diaphyseal fracture of humerus. Functional outcome was rated excellent in 7 patients and good in 1 patient. Conclusion Ilizarov distraction osteogenesis is a valuable alternative in treatment of elbow deformities in children. The surgical technique is simple and correction is adjustable. Gradual correction prevents possible neurovascular complications and minimally invasive surgery produces less scarring. Compliance of patient and family is key factor in the success of the outcome. Level of evidence Level IV, therapeutic study