Hakan Senaran

The risk of progression of scoliosis in cerebral palsy patients after intrathecal baclofen therapy.

Study Design. Retrospective radiographic and medical chart review with matched control group. Objective. To identify the effect of intrathecal baclofen on the incidence of scoliosis, rate of curve progression, and pelvic obliquity compared with a matched cohort. Summary of Background Data. Although intrathecal baclofen therapy (ITB) has been shown to be effective in decreasing spasticity, case reports have described some children receiving ITB in whom progressive scoliosis was noted; other authors have described no effect on the spinal column. A controlled study has not been performed. Methods. All patients with spastic CP treated with ITB between 1997 and 2003 at a single institution were reviewed. A total of 107 patients undergoing ITB for a minimum of 2 years were identified, of which 26 patients subsequently developed or had progression of scoliosis. Twenty-five age, gender, and gross motor function classification system (GMFCS) score-matched quadriplegic CP patients with scoliosis who did not receive ITB constituted the control group used to compare the rate of curve progression and pelvic obliquity. Results. The average curve progression for the baclofen group after pump implantation was 16.3° per year; and for the control group was 16.1° per year. Both groups’ curves progressed over time during growth (P = 0.001), but baclofen did not have an independent effect on curve progression (P = 0.181). Average pelvic obliquity for the 2 groups increased over time (P = 0.001), but there was no difference between the groups (P = 0.536). Twelve of 57 patients (21%) developed scoliosis after pump implantation during a mean of 3.6 years of follow-up. Thirty of 92 matched control patients (32%) not treated with ITB within the same time interval had scoliosis by maturity. Conclusion. This study demonstrates that ITB has no significant effect on curve progression, pelvic obliquity, or the incidence of scoliosis when compared with an age, gender, and GMFCS score-matched control group of patients with spastic CP without ITB.

Difficult thoracic pedicle screw placement in adolescent idiopathic scoliosis.

Study Design Retrospective radiographic and clinical consecutive case series. Objective The objective of this study was to identify patients treated with posterior spinal fusion and pedicle screw instrumentation for adolescent idiopathic scoliosis (AIS) in whom it was not possible to place a planned pedicle screw, and describe the possible difficulties in screw placement. Summary of Background Data Despite the knowledge of anatomic characteristics of upper thoracic spine pedicles and considerable experience in thoracic pedicle screw placement, inserting pedicle screws in some patients with AIS may be difficult. Methods We reviewed 96 patients with AIS in whom the intent was to use an all-screw construct in 2004. Placement of the pedicle screws was usually by the freehand method, with intraoperative fluoroscopy used as needed. If a screw could not be safely placed after multiple attempts, a down-going supralaminar or transverse process hook was placed. Medical records were reviewed and radiographs were measured by one of the authors. Results We identified 17 cases (18%) in which a hook had been placed. All cases had a major thoracic curve (Lenke 1, 2, and 3) and the single hook had always been placed at the most cephalad level of the construct on the patients right side. The most common levels for hook placement were T3 and T4; these pedicles were noted to be sclerotic, narrow, and have a moderate amount of rotation on the preoperative posterior-anterior and side bending radiographs. Conclusions Care should be exercised during pedicle screw instrumentation in the apical region of the proximal thoracic curve, whether structural or nonstructural, especially in the concavity. The preoperative radiographs may give helpful clues to intraoperative challenges of pedicle screw insertion at the uppermost level of instrumentation. Hook fixation was satisfactory in this scenario.

Avascular necrosis rate in early reduction after failed pavlik harness treatment of developmental dysplasia of the hip

Our hypothesis is that hips with developmental dysplasia (DDH), which fail Pavlik harness treatment and are reduced within 3 months of age, have a low rate of avascular necrosis (AVN). Inclusion criteria are as follows: diagnosis of DDH within 2 months of birth, failure of reduction or stabilization by Pavlik harness treatment, surgical reduction of the hip advised to be performed within 3 months of age, and follow-up for Salter criteria of AVN. Twenty-one consecutive cases (35 hips) met the inclusion criteria. Nineteen cases (31 hips) were initially reduced within 3 months of age, and none of these cases developed AVN. After Pavlik harness failure, initial closed reduction was achieved in 33 (94%) of 35 hips, and open reduction required in 2 (6%) of 35 hips. At latest follow-up, one (3%) of 35 hips had AVN. At the time of reporting, 1 (3%) of the 35 hips has required an additional procedure (Pemberton osteotomy) for residual dysplasia. There were 2 outlier cases (4 hips) in which the parents delayed the reduction and 1 case developed unilateral AVN, which was reduced after the proximal femoral ossification center developed at 7 months of age. The data presented in the current study support our hypothesis.

The associated effects of untreated unilateral hip dislocation in cerebral palsy scoliosis.

Introduction: The presence of a unilateral hip dislocation in children with cerebral palsy (CP) may cause problems with sitting imbalance, pressure ulcers, and hip pain. There is a dynamic interplay between hip dislocation, pelvic obliquity (PO), and scoliosis. The effect of an untreated unilateral hip dislocation on the rate of curve progression of CP scoliosis has not been defined in the literature. The purpose of this study is to investigate the effect of unilateral hip dislocation on PO and the rate of curve progression in children with spastic quadriplegic CP. Methods: Patients with spastic quadriplegic CP who had spine radiographs at the time of initial presentation with scoliosis and at the latest follow-up were evaluated. Twenty-three children with spastic CP who had an untreated unilateral hip dislocation and scoliosis constituted the study group. The control group consisted of 83 quadriplegic CP patients with scoliosis and well-located hips. The rate of curve progression, incidence of PO, and the rate of PO progression at follow-up were compared between the 2 groups. Results: The mean ages of patients with a unilateral dislocation and with well-located hips at initial radiograph were 10.4 and 10.5 years, respectively. The mean follow-up was 3.5 years. The mean rate of scoliosis curve progression in patients with a unilateral hip dislocation was 12.9 degrees per year. In the control group, the mean progression rate was 12.2 degrees per year. The incidence of PO at follow-up was 74% in scoliotic patients with a dislocation and 63% in scoliotic patients with normal hips. Using repeated-measures analysis of variance, unilateral hip dislocation was found to have no significant effect on scoliosis progression; however, progression of PO was significantly increased in the hip dislocation group (P < 0.05). Pelvic obliquity was corrected after posterior spinal fusion to the sacrum with pelvic fixation, without reducing the hip(s) at the same surgery. Conclusion: Unilateral hip dislocation causes a significant increase of PO but does not affect the rate of scoliosis curve progression.

Short-term functional outcomes of first metatarsophalangeal total joint replacement for hallux rigidus.

Background: Although metatarsophalangeal (MTP) arthrodesis has been advocated by many authors, implant arthroplasty appears to be successful option in advanced hallux rigidus (HR). The aim of our study was to evaluate the early results of the ToeFit-Plus prosthesis for the treatment of HR. Methods: Between December 2007 and January 2011, a total of 26 toes of 24 patients with MTP arthritis of the great toe were treated with ToeFit-Plus implant. The average follow-up time was 29.9 (range: 25 to 62) months. All patients were evaluated clinically and radiographically. Postoperative satisfaction and function were scored according to the American Orthopaedic Foot and Ankle Society (AOFAS) score. Pain was assessed with the use of a visual analogue scale. Results: Mean preoperative AOFAS score improved from 42.7 (range: 36 to 59) to 88.5 (range: 59 to 98) at the final follow-up (P < .01). Preoperative average visual analogue scale pain scores improved from 7.4 preoperatively to 1.9 at the final follow-up (P < .01). The average MTP joint range of motion improved from 25.9 degrees preoperatively to 53.8 degrees at the final follow-up. No radiologic loosening was found, but radiolucency was observed in 2 patients with this implant. No revision was required for any of the patients during the follow-up period. Conclusions: This total first MTP joint prosthesis yielded good functional outcome and high patient satisfaction level with low early complication rate. Preservation of joint movement and good pain relief with early mobilization were the advantages of this procedure. Salvage arthrodesis remains an option if future revisions are indicated. Level of Evidence: Level IV, retrospective case series.

Minimally invasive treatment of simple bone cysts with percutaneous autogenous bone marrow injection.

Percutaneous autogeneic bone marrow injection is an effective method for managing simple bone cysts, and it might be considered before the application of more extensive procedures.

Value of limited hip abduction in developmental dysplasia of the hip

Abstract Background : Developmental dysplasia of the hip (DDH) continues to be missed by routine physical examination in up to 50% of cases. Ultrasound (US) supplementation is the best method of screening for DDH, but the resources required should not be underestimated. Limited abduction of the hip (LHA) in an infant triggers suspicion, and often an urge to treat, in most orthopaedic surgeons and pediatricians alike. This study aimed to document the value of unilateral LHA in the diagnosis and decision making of DDH, and the correlation between LHA and US.

The effect of platelet-rich plasma on osteochondral defects treated with mosaicplasty.

PurposeThis study investigated the efficacy of platelet-rich plasma (PRP) on articular surfaces on which the mosaicplasty technique was performed. Our hypothesis was that PRP can accelerate the osseointegration process and enhance the quality of articular integrity after the mosaicplasty procedure.MethodsStandard defects were created in the femoral groove of both patellofemoral joints of 12 New Zealand rabbits. PRP solution was placed inside the defect before fixation of the osteochondral autografts and injected inside the involved joint after capsular closure of the tested knees. The contralateral knees served as the control sides. The animals were euthanized three or six weeks after mosaicplasty, and both limbs were assessed according to Pineda’s histological grading scale. Significance level was set at p ≤ 0.05 a priori, and the Mann–Whitney U test was used for statistical analysis.ResultsHistologic findings at the interface between the transferred autograft and the original cartilage revealed better integration of the adjacent surfaces in the mosaicplasty with PRP group three weeks after the procedure; the difference was significant (p < 0.05). However, no significant difference in the transition zone was observed between the groups six weeks after the experiment (p = 0.59).ConclusionsOur animal model showed that adjunctive use of PRP produced a better healing response and resulted in superior histological scores after three weeks compared with the mosaicplasty-only procedure. Interpretation of our results is important in terms of rapid return to previous activity levels. Thus, application of PRP can represent a valid therapeutic option for improving the efficacy of mosaicplasty by stimulating the local healing response.

Center of the femoral head: a magnetic resonance imaging study.

Abstract: Determination of the center of the femoral head (CFH) may be difficult because of incomplete epiphyseal ossification of the femoral head in children younger than 8 years. The purpose of this study is to find a practical method for determining the center of the femoral head in normal hips of children younger than 8 years. Twenty-seven children who had magnetic resonance imaging (MRI) examinations of their hips (N = 54) were reviewed retrospectively. The average age of the subjects was 4.7 years (range, 1.2-8 years). Measurements were performed on the closest section to the midcoronal plane of the femoral head (the widest spherical femoral head seen on the MRI section). The CFH on the MRI section was found using a constructed circular frame by using a computer program. The medial and lateral edges of the proximal femoral ossific nucleus were marked, and the midpoint of the ossific nucleus adjacent to the growth plate (MPON) was determined. The distance between the MPON and the CFH was calculated. The average distance was 1.5 mm (range, 0-5 mm). The distance between these 2 points was less than or equal to 2 mm in 40 hips (74%). In conclusion, this study shows that the MPON can be used as a landmark to determine the center of the femoral head in normal hips of children younger than 8 years and can be used to measure the lower extremity mechanical axis.

Intracortical epidermoid cyst of the tibia.

Epidermoid cyst in a long bone is an extremely rare condition. The authors describe such a tumor located in the cortex of the tibia in a 21-year-old woman. She was successfully treated with curettage and autogenous bone grafting.