Deniz Kargin

Vitamin-d measurement in patients with adolescent idiopathic scoliosis

Our retrospective study compared vitamin-D levels in 229 patients with adolescent idiopathic scoliosis (AIS) and 389 age-matched controls, and evaluated the correlation between vitamin-D levels and sex, Cobb’s angle, and serum levels of calcium (Ca), phosphorus, and alkaline phosphatase in the AIS group. Vitamin-D levels were lower in the AIS group, with no sex-specific effects, indicative of a possible vitamin-D resistance in AIS. Vitamin-D levels correlated positively with Ca levels and negatively with Cobb’s angle, indicative of a possible role of vitamin D in the etiopathogenesis of AIS. Patients with AIS should be monitored for vitamin-D deficiency/insufficiency.

Sacral agenesis: evaluation of accompanying pathologies in 38 cases, with analysis of long-term outcomes.

PurposeSacral agenesis (SA), or caudal regression syndrome, is a congenital malformation of the spine of varying degree of severity. The aim of our study was to identify associated impairments in structure and function of the orthopedic, neurological, cardiopulmonary, genitourinary, and gastrointestinal systems, and to evaluate their impact on function.MethodsThis was a retrospective case series analysis of 38 patients with SA. Patients were divided into two groups: SA with myelomeningocele (group 1) and without myelomeningocele (group 2). Between-group comparisons in terms of the features of the SA, impairments in associated systems, impact on gross motor function, need for surgery, and association with prenatal screening and maternal gestational diabetes were evaluated.ResultsThe majority of comorbidities were orthopedic and neurological in nature. Impairments in sphincter control and independent transferring were more prevalent in group 1, resulting in lower function. Scoliosis, kyphosis, and hip dislocation/subluxation were the most common orthopedic problems, with a higher prevalence of kyphosis in group 1. The requirement for neurosurgery was significantly higher in group 1.ConclusionsOrthopedic and neurological comorbidities are commonly associated with SA and are more prevalent in the presence of a myelomeningocele. As the impairments impact a child’s ability for maximum function, early identification and intervention is required to correct or ameliorate the impairment.Level of Evidence: Level IV.

Preoperative and Postoperative Photographs and Surgical Outcomes of Patients With Kyphosis.

Study Design. A retrospective clinical study was performed. Objective. The aim of the study was to show patients their pre- and postoperative body photographs, and determine the effect on postoperative patient satisfaction for thoracic and thoracolumbar sharp and round angular kyphosis. Summary of Background Data. Previous studies have reported the normative values of pelvic sagittal parameters and the classification of normal patterns of sagittal curvature, but no study has investigated and compared the clinical photographs of sharp and round kyphosis. Methods. In patients who underwent surgery for thoracic and thoracolumbar sharp and round angular kyphosis, whole spine anteroposterior and lateral radiographs, and clinical photographs were obtained preoperatively and at the final follow-up. Pelvic and spinal parameters were measured, and the pre- and postoperative photographs were shown to patients. The Scoliosis Research Society 22r (SRS22r) and Short Form 36 surveys were administered to all patients, and the scores were analyzed. Results. Thirty-eight patients diagnosed with kyphosis (mean age 19.6 yr, mean follow-up duration 26.4 mo) were divided into two groups: sharp (18 patients, mean age 20.1 yr) and round (20 patients, mean age 19.6 yr) kyphosis. There was no difference between values in the sharp and round groups in terms of age, follow-up duration, and Risser score (P > 0.05). In both groups, the subscores for pain, self-image, mental health, and satisfaction, except for the function/activity score, and the total score of the SRS22r survey were, however, significantly different between pre- and postoperative photographs. In addition, there was no significant difference between the two groups in any SRS22r domain and Short Form 36 scores. Conclusion. The surgical treatment of kyphosis was uniformly associated with improved quality of life, regardless of the kyphosis type. Thus, showing patients their pre- and postoperative photographs may enhance patient satisfaction, as measured by SRS22r scores. Level of Evidence: 4

Analysis of complications following posterior vertebral column resection for the treatment of severe angular kyphosis greater than 100

Objective The aim of this study was to evaluate the complications, efficacy and safety of posterior vertebral column resection (PVCR) in severe angular kyphosis (SAK) greater than 100°. Methods The medical records of 17 patients (mean age 17.9 (range, 9–27) years) with SAK who underwent PVCR, were reviewed. Mean follow-up period was 32.2 (range, 24–64) months. Diagnosis of the patients included congenital kyphosis in 11 patients, post-tuberculosis kyphosis in 3 patients and neurofibromatosis in 3 patients. The sagittal plane parameters (local kyphosis angle, lumbar lordosis, sagittal vertical axis, pelvic tilt, sacral slope and pelvic incidence) were measured in the preoperative and the early postoperative periods and during the last follow-up on the lateral radiographs. Results The mean preoperative localized kyphosis angle was 121.8° (range, 101°–149°). The mean local kyphosis angle (LKA) was 71.5° at postoperatively evaluation (p < 0.05). Complications were detected in 12 patients (70.6%) with spinal shock in 4 patients, hemothorax in 3 patients, postoperative infection in 2 patients, dural laceration in 2 patients, neurological deficit in 2 patients (1 paraplegia and 1 root injury), the shifted cage in 2 patients and rod fracture in 2 patients. Neurological events occurred in six patients (35%) with temporary neurological deficit in 5 patients and permanent neurological deficit in 1 patient. Conclusion PVCR is an efficient and a successful technique for the correction of SAK. However, it can lead to a large number of major complications in SAK greater than 100°. Level of evidence Level IV, therapeutic study.

A comparison of two techniques: Open and percutaneous biopsies of thoracolumbar vertebral body lesions.

Aim: The purpose of this article is to compare the similarity of initial radiological diagnosis and pathological diagnosis between thoracal and lumbar vertebral bodies and the adequacy and the reliability of open and percutaneous biopsies performed via transpedicular approach in the lesions located in vertebral bodies. Materials and Methods: Thirty-three patients who had undergone transpedicular biopsy for vertebral body lesions were retrospectively evaluated. Seventeen patients were diagnosed by percutaneous transpedicular biopsy (11 in the lumbar vertebrae, 6 in the thoracal vertebrae). Sixteen patients were diagnosed by open transpedicular biopsy (9 in the lumbar vertebrae, 7 in the thoracal vertebrae). Results: The similarity ratio between the initial radiological diagnosis and the final pathological diagnosis was 71.4% in the open biopsy and was 69.2% in the percutaneous biopsy (P > 0.05). The similarity ratio between the initial radiological diagnosis and the final pathological diagnosis was 66.7% in the lumbar region and was 77.8% in the thoracal region (P > 0.05). For percutaneous biopsy group, the similarity ratio was 72.7% in the lumbar region and was 66.7% in the thoracal region (P > 0.05). For open biopsy group, the similarity ratio was 62.5% in the lumbar region and 83.3% in the thoracal region (P > 0.05). No complication was observed. Conclusion: Specimen adequacy of open biopsy was higher than percutaneous biopsy. Particularly, the open thoracal biopsy has provided the highest similarity ratio between the initial radiological diagnosis and the final pathological diagnosis.

Piriformis syndrome: treatment of a rare cause of posterior hip pain with fluoroscopic-guided injection

Introduction Piriformis syndrome involves the irritation of the piriformis muscle due to various reasons that are primarily related to anatomical variation or sciatic nerve compression due to contraction caused by overuse. In this study, we aimed to define an injection method that is easy to apply, safe, simple and repeatable. Materials and Methods We administered percutaneous lidocaine and depomedrol injections into the hips of 28 patients (14 men and 14 women) under fluoroscopic control. Bipolar injections of the piriformis muscle were performed at the medial pole, the intersection of the sciatic notch and the sacroiliac joint, and at the lateral pole of the femoral insertion region. Each injection was 5 cc, and the contrast agent was observed after the dyeing process. Results Clinical examinations were performed before and 6 weeks after the injections. The average of Harris Hip Score increased from a pre-injection score of 44.5 to a post-injection score of 68.5, and the Visual Analog Scale scores decreased from 8.3 to 4.2 (p<0.05). Comments Our findings lead to the conclusion that fluoroscopy-guided percutaneous local anaesthetic and corticosteroid injection is a simple and effective piriformis syndrome treatment that can feasibly be effectively performed by orthopaedic surgeons.

Surgical Treatment Approaches in Severe Spinal Deformities Associated with Intraspinal Pathologies

Objective: Scoliosis with associated intraspinal anomalies may be treated either before the correction of spinal deformities or during the same session. Our study elucidates the impact of the timing of single- or two-stage neurosurgical and deformity treatment of intraspinal pathologies with the outcomes of serious spinal deformities and discusses the preferable method.Methods: Patients who were operated either concurrently or in two stages, due to intraspinal anomalies associated with rigid spinal deformities, were radiologically and clinically examined. Patients’ ages during the neurosurgical treatment and at the time of deformity treatment, period between two surgeries, follow-up period, clinical and radiological results and encountered complications were recorded.Results: Nineteen patients (13 females, 6 males) underwent surgery for spinal deformities associated with intraspinal pathologies between 2007 and 2014. Fifteen (78.9%) patients underwent a two-stage surgery and four (21.1%) patients’ concurrent surgeries. Mean age of the patients at the time of intraspinal pathology surgery was 8.6 ± 6.9 years and at posterior spinal fusion (PSF) 13.4 ± 3.9 years. The period between the two surgeries was 54.2 ± 67.5 months on average and the mean follow-up period was 39.8 ± 22.2 months. The anteroposterior Cobb’s angle was measured as 68.2° ± 27.1° preoperatively and 29.1° ± 18.7° at final examination (p=0.00). Visual analog scale score was 8.1 ± 1 preoperatively and 1.1 ± 0.2 at the final follow-up (p=0.00).Conclusion: The etiology, extent of deformity, curve progression and patient’s age were indicative in the surgical treatment of intraspinal pathologies and spinal curves. Concurrent surgical interventions may be recommended to avoid additional complications and for quicker recovery.

EVALUATION OF RADIOLOGICAL AND FUNCTIONAL RESULTS OF PATIENTS WITH PERIPROSTHETIC FEMORAL FRACTURE DURING TOTAL HIP ARTHROPLASTY SURGERY

Amaç: Total kalça protezi son 30 yıl içinde fonksiyonel ve radyolojik olarak başarılı sonuçları bildirilen ortopedik cerrahilerindendir. Bu cerrahi sırasın da meydana gelen periprostetik femur kırıklarının ilerleyen dönemde hastada yarattığı fonksiyonel sonuçları incelemek çalışmamızın ana konusuydu. Yöntemler: 2005-2011 yılları arasında merkezimizde tedavi edilmiş ve periprostetik femur kırığı geçirmiş olan 91 hastanın 94 kalçası çalışmaya dahil edildi. Oluşan kırık tipleri Vancouver sınıflamasına göre sınıflandırıldı. Kırık tedavisinde kullanılan yöntemler kaydedildi ve yine açılım şekilleri, kırığın ameliyatın hangi basamağında (raspalama, oyma, stem çakma, redüksiyon sırasında) oluştuğu not edildi. Hastalar, kontrole çağrılarak pelvis AP ve opere olan taraf femur AP grafileri çekildi. Yine aynı zamanda son muayenelerin de WOMAC skorlaması yapıldı. Daha önceki kontrollerinde çekilmiş olan grafileri ile son kontrollerinde ki grafileri arasında femoral stemde çökme olup olmadığı incelendi. Bulgular: Kırıkların çoğu femoral stemin çakılma aşamasında oluştuğu gözlemlendi (Hastaların %81’i). Hastaların son kontrollerinde ki WOMAC skoru ortalama 27 (8-81) olarak belirlendi. Kalçalardan 12 sinde (%13) ilerleyen zamanlar da protezde çökme tespit edilmiş ve bu kalçalardan 6’sı revizyon cerrahisi geçirmişti. Çökme görülen hastaların kırık tipleri ile olan ilişkilerine bakıldığın da istatistiksel olarak anlamlı fark bulunamadı (p=0,2). Yine çökme görülen hastaların ortalama WOMAC skorları 57’ye yükseldi ve istatistiksel olarak anlamlı bulundu (p<0,0001). Sonuç: TKP sırasında oluşan intraoperatif femur kırıkları, hastalarda uzun dönemde femoral stemde çökmeye yol açarak implant yetmezliğine yol açabilmektedir. Bu çökmenin oluşan kırık tipi ilişkisi çalışmamızda ortaya konamamıştır. Çökme nedeniyle hastalarda fonksiyonel açıdan anlamlı olarak bozulma görülmektedir. Anahtar Sözcükler: İntraoperatif kırık, periprostetik, total kalça protezi ABSTRACT

A New Radiological Sign for Severe Angular Kyphosis: “The Baltalimani Sign”

Study Design Retrospective diagnostic study. Purpose To define a new radiological sign, “Baltalimani sign,” in severe angular kyphosis (SAK) and to report its relationship with the risk of neurological deficits and deformity severity. Overview of Literature Baltalimani sign was previously undefined in the literature. Methods We propose Baltalimani sign as the axial orientation of the vertebrae that are located above or below the apex of angular kyphosis on anteroposterior radiographs. Patients with SAK of various etiologies with kyphotic angles ≥90° were selected and evaluated for the presence of Baltalimani sign. Demographic data of the patients including age, gender, etiology, neurological status, local kyphosis angles, and the location of the kyphosis apex were recorded. Sensitivity, specificity, positive predictive value (PPV), and negative predictive values (NPV) of Baltalimani sign for the risk of the neurological deficits were evaluated by the IBM SPSS ver. 20.0. A p-values of <0.05 were considered statistically significant. Cohens kappa was used for analysis of interrater agreement. Results The mean local kyphosis angle in all patients was 124.2° (range, 90°–169°), and 15 of 40 (37.5%) patients had neurological deficits. Baltalimani sign was seen in 13 of 15 patients with neurological deficits (p=0.001). Baltalimani sign showed a sensitivity and specificity PPV and NPV of 61.9%, 86.7%, 89.5%, and 68.8% for the risk of the neurological deficits in SAK patients, respectively. Cohens kappa value was moderate (κ=0.506). Conclusions The detection of Baltalimani sign in SAK may indicate severity of deformity and the risk of neurological deficits.

Comparative Analysis of Shoulder Balance through Growth Guidance Techniques in the Surgical Treatment of Early-onset Scoliosis

Objective: The purpose of this study was to compare the efficacy of growth guidance techniques (single and dual growing rods, Vertical Expandable Prosthetic Titanium Rod-VEPTR) on shoulder balance, in the surgical treatment of early-onset scoliosis. Methods: Thirty six patients with early-onset scoliosis (EOS) due to various etiologies who were operated on in two different institutions were included in the study and they were divided in 3 groups. Group 1 consisted of 11 patients (mean age 7.5 years) who were treated with a single growing rod, Group 2 had 13 patients (mean age 8.1 years) who were treated with dual growing rods, and Group 3 consisted of 12 patients (mean age 4.1 years) who were treated with VEPTR technique. The coracoid height difference (CHD), clavicular tilt angle difference (CTAD) and clavicula-rib cage intersection difference (CRID) were measured on standing anteroposterior X-ray images in the preoperative, early postoperative and the last follow-up periods. Data obtained from these measurements were subject to statistical analysis. Results: The average postoperative follow up period was 3.04 (range: 2.3 to 4.8) years for Group 1, 2.23 (range: 1 to 3.1) years for Group 2 and 2.18 (range: 1 to 3.2) years for Group 3. Clinical improvement in shoulder balance was obtained for Group 1 and Group 2 post-operatively, but there was no significance in the comparison among the three groups. Conclusion: The effect of growth guidance techniques on shoulder balance remains unpredictable in the surgical treatment of early-onset scoliosis.