Mehmet Ayvaz

Discoid Meniscus An Ultrastructural Study With Transmission Electron Microscopy

Background The ultrastructure of the normal menisci has been thoroughly investigated and found to correlate with meniscal tears. Although discoid menisci are accepted to have the same composition as their normal counterparts, to our knowledge, no study in the literature has investigated this issue. Purpose To investigate the ultrastructure of the discoid menisci and compare it with nondiscoid menisci. Study Design Descriptive laboratory study. Methods Meniscal biopsies were taken from 12 patients who were operated for meniscus tear and diagnosed with discoid meniscus and from 6 patients who were operated for meniscal tear and did not have a diagnosis of discoid meniscus. The samples were examined with transmission electron microscopy. Results The study group demonstrated a decrease in the number of collagen fibers compared with the control group. Also, the homogeneous course of the collagen fibers observed in the control group was replaced by a heterogeneous course in the study group. Conclusion The ultrastructure of the discoid meniscus is different from the normal menisci. Clinical Relevance This difference may contribute to the vulnerability of the discoid meniscus to tears.

Safety and efficacy of posterior instrumentation for patients with congenital scoliosis and spinal dysraphism.

Objective: Instrumentation and correction of severe congenital scoliosis, particularly in patients with spinal dysraphism, has been reported to cause a high potential rate of neurological compromise after instrumentation. The aim of this study was to evaluate the safety and efficacy of posterior instrumentation and correction of congenital scoliosis with accompanying spinal dysraphism. Level of Evidence: Level IV therapeutic studies. Methods: Retrospective x-ray measurements to analyze the efficacy and the evaluation of hospital charts to document the intraoperative and postoperative complications were performed for a consecutive patient series. Scoliosis Research Society-22 questionnaire was used to analyze the health-related quality of life. Results: Twenty-two patients (18 girls and 4 boys) formed the basis of the study. The average age was 12 years (range, 7-18 years) and the average follow-up period was 3.2 years (range, 2-10 years). The types of spinal dysraphism were diastematomyelia in 20 patients and syringomyelia with tethered cord in 2 patients. Twelve patients had previous surgery and 3 patients had simultaneous surgeries for spinal dysraphism. Posterior instrumentation with/without anterior release and fusion was performed in all patients. Major curve was corrected from an average of 71 degrees to 40 degrees (correction rate, 43.6%). The compensatory curve was corrected from an average of 47 degrees to 25 degrees (correction rate, 46.8%). The average loss of correction at final follow-up was 2.2 degrees for major curve and 3.5 degrees for the compensatory curve. The average scores for the 5 domains of Scoliosis Research Society-22 questionnaire were 3.5 for function, 3.9 for pain, 3.5 for self-image, 3.6 for mental health, 3.9 for satisfaction, and 3.6 for total. Neurological monitoring was conducted by using the wake-up test in all patients. The overall complication rate was 31%, including neurological compromise in 2 patients (9%). Conclusions: Spinal instrumentation was effective for the control of deformity with a relatively higher rate of complications. However, with respect to high complication rate, the ideal solution for managing the congenital cases is still to prevent the progression of the curve with early intervention by using the optimal surgical approach for that particular patient.

Serial derotational casting in congenital scoliosis as a time-buying strategy.

Background: Serial casting is an effective treatment modality in early-onset idiopathic scoliosis; however, the role of this method in congenital scoliosis is not well studied. Methods: A total of 11 patients with progressive congenital scoliosis were treated with serial cast application. Age at initial cast application, magnitudes of the congenital, compensatory and sagittal deformities, coronal balance, T1 to T12 height, number of casts and time-in cast per patient, subsequent surgical interventions, and complications were evaluated. Results: Mean age at the first cast application was 40 months, and the average number of cast changes was 6.2 per patient. There were no major complications. The average precasting curve magnitude was 70.7 degrees (range, 44 to 88 degrees) and was significantly reduced to 55.1 degrees (range, 16 to 78 degrees) at the latest follow-up (P=0.005). The average precasting compensatory curve was 55.8 degrees (range, 38 to 72 degrees) and was significantly reduced to 39.8 degrees (range, 23 to 62 degrees) at the latest follow-up (P=0.017). Average T1 to 12 height increased from 12.8 cm at post-first cast to a 14.6 cm at the latest follow-up (P=0.04). Average time in cast was 26.3 months (range, 13 to 49 mo). During the treatment period, none of the patients required surgery for curve progression. Conclusions: Serial derotational casting is a safe and effective time-buying strategy to delay the surgical interventions in congenital deformities in the short-term follow-up. Level of Evidence: Level IV, case series.

Is it necessary to operate all split cord malformations before corrective surgery for patients with congenital spinal deformities

Study Design. Retrospective case series. Objectives. To evaluate the necessity of neurosurgical interventions for split cord malformations (SCMs) before correction and instrumentation for patients with congenital spinal deformity(CSD)s. Summary of Background Data. SCMs are commonly associated with CSD. As pathology of SCMs understood well, the common belief of all SCM must be operated before any orthopedic intervention is needed to be revised. Materials and Methods. Sixty-one consecutive patients with CSD and spinal dysraphism treated by correction and posterior instrumentation between 1994 and 2005 were retrospectively evaluated. Inclusion criteria were patients with CSD and SCM, who were treated with long segment instrumentation (more than 6 functional units) with at least 2 years of follow-up. Thirty-two patients (8 male and 24 female) with an age average of 11 years +8 months (4–18 years) fulfilled the criteria. While all patients with Type I SCM were managed with neurosurgical intervention (spur excision and dural reconstruction) before corrective surgery, Type II SCM cases were treated by instrumented fusion without neurologic intervention. Results. There were 18 patients with Type I and 14 patients with Type II SCM. The average follow-up was 52 (24–144) months. The correction rate of deformity was 44% in type I and 47% in Type II SCM. Two patients with Type II SCM had transient neurologic deterioration while there were no neurologic events in patients with Type II SCM. Conclusion. Due to high incidence of SCMs, all patients with CSDs must be evaluated with MRI, before surgery. Neurosurgical interventions are recommended even for neurologically asymptomatic Type I SCM before spinal deformity surgery; however, patients with Type II SCM can be treated safely without a need of neurosurgical intervention.

The Effect of Pedicle Screw Insertion at a Young Age on Pedicle and Canal Development

Study Design. A longitudinal case study. Objective. To determine whether pedicle screws placed in an immature spine exert effect on the continued growth of the vertebral body. Summary of Background Data. Pedicle screws have revolutionized surgical treatment of spinal deformities by allowing a mode of secure fixation that provides consistently better correction rates in adults and adolescents. In the young child, however, the trajectory of pedicle screws takes them through an open physis: the neurocentral cartilage. There exists little information regarding the possible effect of pedicle screws inserted at a young age on further development of the spine and the spinal canal. Methods. Patients undergoing pedicle screw instrumentation of at least 2 levels before the age of 5 years (60 mo) for the first time for any diagnosis and who had been followed for at least 24 months were included. Measurements were performed in instrumented and adjacent noninstrumented levels without visible deformity in pre- and postoperative cross-sectional images and compared using statistical methods. Results. Ninety segments in 15 patients met the inclusion criteria (average age at instrumentation 46.3 mo [range, 29–60 mo]). Forty segments had no screws and 50 had at least 1 screw. Pedicle length and vertebral body diameter had significantly increased in both groups, whereas spinal canal parameters did not change significantly. No significant difference was observed between the growth rates in levels with or without screws in pedicle length, vertebral body diameter, or spinal canal parameters (anterior-posterior and interpedicular diameters, and area). Conclusion. Pedicle screw instrumentation performed before the age of 5 years does not cause a negative effect on the growth of pedicles, the transverse plane of the vertebral body, or the spinal canal. It can be safely performed in the treatment of deformity in this age group.

Intraneural hemangioma of digital nerve diagnosed with MR imaging

Hemangioma may occur at any location. Although the imaging findings of hemangioma are well known, it may be difficult to differentiate this entity from other soft-tissue tumors. Intraneural hemangiomas are extremely rare. We present a girl with a painful swelling in the fourth web space of her right hand. Since it was painful, the referring clinician considered the possibility of a glomus tumor. However, demonstration of dilated feeding or draining vessels suggested the diagnosis of hemangioma. At surgery a hemangioma of the ulnar digital nerve of the ring finger was resected marginally.

Safety and efficacy of instrumented convex growth arrest in treatment of congenital scoliosis.

Background: Anterior and posterior convex hemiepiphysiodesis is a widely used surgical alternative in the treatment of congenital scoliosis. This procedure has the disadvantage of the need for both anterior and posterior approaches. Furthermore, outcomes may be unpredictable. Posterior convex growth arrest (CGA) with pedicle screws at each segment on the convex side may obviate the need for anterior surgery and provides more predictable outcomes. This study retrospectively evaluates the safety and efficacy of instrumented posterior CGA in congenital scoliosis. Methods: Patients who had posterior CGA with convex pedicle screw instrumentation for congenital scoliosis were evaluated retrospectively. Thirteen patients (6 male, 7 female) were included in the study. Preoperative, early postoperative, and last follow-up standing posteroanterior and lateral x-rays were evaluated. Cobb angles were recorded for the instrumented segment (main curve). Global thoracic kyphosis was measured between T2 and T12 on sagittal plane. These values were compared preoperatively, postoperatively, and at last follow-up. The T1-S1 vertical height and the height between the concave side pedicles of the upper and lower end vertebra of the main curve was also determined and recorded as the concave height. Results: The average follow-up was 56.1±10 months (range, 36 to 74 mo) and the average age of the patients at the time of operation was 64.5±30.1 months (range, 15 to 108 mo). All patients were Risser zero at the time of surgery. The average curve magnitude was 49±10.9 degrees (range, 34 to 68 degrees) preoperatively, 38.3±9.7 degrees (range, 28 to 58 degrees) early postoperatively, and 33.5±12.4 degrees (16 to 52 degrees) at last follow-up. There was a significant difference between the preoperative and early postoperative main curve Cobb angle measurements (P=0.001). The average concave height was 94.2±20.2 mm in the early postoperative period and 104.7±21.7 mm at last follow-up (P=0.003). The average T1-S1 height was 292.1±67.1 mm in the early postoperative period and 363.9±94.5 mm at last follow-up (P=0.005). There was at least ≥5 degrees improvement in 9 of the 12 patients in the follow-up period after the index procedure. In 3 patients, the curve did not change and the correction was maintained. Curve progression was observed in 1 patient due to a technical error. There were no wound infections or instrumentation failures during follow-up. Conclusions: Instrumented CGA can safely be used in long sweeping curves of immature spines. Using this technique; thoracotomy, anterior procedure, and 2-stage surgery can be avoided. Moreover, it guarantees some degree of correction in all patients because of the instrumentation effect, eliminating the unpredictable nature of classic CGA. Level of Evidence: Therapeutic level IV study.

Treatment of complicated pediatric femoral fractures with titanium elastic nail.

Nonunion and major complications are not very common in pediatric fractures. No commonly accepted methods exist for the treatment of these fractures. In this study, treatment of complicated pediatric femoral fractures with titanium elastic nails was evaluated. Five girls and four boys with nine femoral fractures constituted the group. The mean age of the patients was 8.7 (5–11) years and the mean follow-up was 46.6 (24–84) months. Five of them had implant failure and nonunion, two of them had loss of position in the external fixator, one of them had incomplete union and loss of position in the external fixator and the other had femoral fracture in the lengthening segment of the femur and had loss of position and incomplete union in the spica cast. All the patients were treated with a closed or open reduction of the fracture, debridement if treated with open method and fixation of the fracture with titanium elastic nails. Complete union was achieved in all the patients within the 6–9 months. No neurovascular injury or infection was reported in the group. The result of the treatment showed that fixation of complicated pediatric femoral fractures with intramedullary titanium elastic nails is a good option.

Intralesional curettage and cementation for low-grade chondrosarcoma of long bones: retrospective study and literature review

BackgroundVarious treatment strategies for low-grade chondrosarcomas with variable outcomes have been reported in the literature. The aim of this study was to assess the oncological and functional outcomes associated with intralesional curettage followed by adjuvant therapy comprising high-speed burring, thermal cauterization, and bone cementation with polymethylmethacrylate.MethodsWe performed a retrospective review of 21 consecutive patients with intramedullary low-grade chondrosarcoma of long bones treated by intralesional curettage and adjuvant therapy comprising high-speed burring, thermal cauterization, and cementation at our institution from 2007 to 2012.ResultsThe average age of the patients was 48.7 (range, 18–71) years. There were 7 male and 14 female patients. The mean follow-up period was 58.4 (range, 26–85) months after surgery. The treated lesions were located in the proximal humerus (n =10), proximal tibia (n =6), and distal femur (n =5). At the average follow-up time point of 58.4 (range, 26–85) months, no patient had developed local recurrence and no distant metastases were observed. The average Musculoskeletal Tumor Society score among all 21 patients was 95% (84–100).ConclusionsThe combination of intralesional curettage, application of high-speed burring, thermal cauterization, and cementation is an effective treatment strategy for low-grade intramedullary chondrosarcoma of long bones. Excellent oncological and functional results can be obtained.

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

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.