Nusret Köse

The Effect of Opening Wedge Thoracostomy on Thoracic Insufficiency Syndrome Associated with Fused Ribs and Congenital Scoliosis

BACKGROUND Thoracic insufficiency syndrome is the inability of the thorax to support normal respiration or lung growth and is seen in patients who have severe congenital scoliosis with fused ribs. Traditional spinal surgery does not directly address this syndrome. METHODS Twenty-seven patients with congenital scoliosis associated with fused ribs of the concave hemithorax had an opening wedge thoracostomy with primary longitudinal lengthening with use of a chest-wall distractor known as a vertical, expandable prosthetic titanium rib. Repeat lengthenings of the prosthesis were performed at intervals of four to six months. Radiographs were analyzed with respect to correction of the spinal deformity, as indicated by a change in the Cobb angle, and lateral deviation of the spine, as indicated by the interpedicular line ratio. Spinal growth was assessed by measuring the change in the length of the spine. Correction of the thoracic deformity and thoracic growth were assessed on the basis of the increase in the height of the concave hemithorax compared with the height of the convex hemithorax (the space available for the lung), the increase in the thoracic spinal height, and the increase in the thoracic depth and width. The thoracic deformity in the transverse plane was measured with computed tomography, and the scans were analyzed for spinal rotation, thoracic rotation, and the posterior hemithoracic symmetry ratio. Clinically, the patients were assessed on the basis of the relative heights of the shoulders and of head and thorax compensation. Pulmonary status was evaluated on the basis of the respiratory rate, capillary blood gas levels, and pulmonary function studies. RESULTS The mean age at the time of the surgery was 3.2 years (range, 0.6 to 12.5 years), and the mean duration of follow-up was 5.7 years. All patients had progressive congenital scoliosis, with a mean increase of 15 degrees /yr before the operation. The scoliosis decreased from a mean of 74 degrees preoperatively to a mean of 49 degrees at the time of the last follow-up. Both the mean interpedicular line ratio and the space available for the lung ratio improved significantly. The height of the thoracic spine increased by a mean of 0.71 cm/yr. At the time of the last follow-up, the mean percentage of the predicted normal vital capacity was 58% for patients younger than two years of age at the time of the surgery, 44% for those older than two years of age (p < 0.001), and 36% for those older than two years of age who had had prior spine surgery. In a group of patients who had sequential testing, all increases in the volume of vital capacity were significant (p < 0.0001), but the changes in the percentages of the predicted normal vital capacity were not. There was a total of fifty-two complications in twenty-two patients, with the most common being asymptomatic proximal migration of the device through the ribs in seven patients. CONCLUSIONS Opening wedge thoracostomy with use of a chest-wall distractor directly treats segmental hypoplasia of the hemithorax resulting from fused ribs associated with congenital scoliosis. The operation addresses thoracic insufficiency syndrome by lengthening and expanding the constricted hemithorax and allowing growth of the thoracic spine and the rib cage. The procedure corrects most components of chest-wall deformity and indirectly corrects congenital scoliosis, without the need for spine fusion. The technique requires special training and should be performed by a multispecialty team.

Normal Range of Motion of the Joints of the Upper Extremity in Male Subjects, with Special Reference to Side*

We measured, with a universal full-circle manual goniometer, the active and passive arcs of motion of the shoulder, elbow, forearm, and wrist in 1000 healthy male subjects who were right-hand dominant and who ranged in age from eighteen to twenty-two years. The ranges of motion on the right side were significantly smaller than those on the left. We concluded that the contralateral, normal side may not always be a reliable control in the evaluation of restriction of motion of a joint.

Rotational profile of the lower extremity and foot progression angle: computerized tomographic examination of 50 male adults.

Abstract Acetabular, femoral and tibial torsion of 50 normal adult male subjects were measured by computerized tomography and the relationship between these angles and foot-progression angle was examined. The mean acetabular anteversion was 15.6° on the right and 15.8° on the left, (range 3°–30°). The mean femoral torsion was 6.5° on the right and 5.8°on the left (range 14°–28°). The mean tibiofibular torsion was 30.9° on the right and 29.1° on the left (range 16°–50°). Although the normal range of torsional measurements of the lower extremity was very broad, subjects usually had out-toeing with a mean foot-progression angle of 13.7° on the right and 13.0° on the left (range 6°–21°). No correlation was detected on the rotation between different levels of the lower limb. No difference was detected in the lower extremity rotational profile between right and left sides.

Compartment syndrome after intraosseous infusion: An experimental study in dogs

An experimental study was designed to investigate the development of compartment syndrome with the use of an intraosseous line in dogs. We used an open technique for insertion of a 20-gauge spinal needle to the tibia. The needle was secured to the tibia with bone cement. Throughout the intraosseous infusion of saline with radio-opaque dye (rate, 480 mL/h), serial radiographic examination and pressure monitoring of the anterolateral compartment of the leg was performed. Although there was no change up to approximately 350 mL of fluid infusion, the radio-opaque dye was detected in the soft tissues and compartment pressure increased to more than 35 mm Hg. Compartment pressure continued to increase in direct proportion to the amount of dye infused. In the present study, the possible technical errors, which may cause compartment syndrome, have been eliminated. However, compartment syndrome developed because of the failure of microvasculature within a muscle adjacent to bone. We suggest that there is a need for a dose-and time-dependent scale for safe intraosseous infusion.

Oxidant status increased during fracture healing in rats

We evaluated oxidant status during bone healing in 50 rats. In 40 rats, the right tibia was fractured and fixed intramedullarly (study leg) and the left tibia was pinned but not fractured (control leg). Rats were killed on days 1, 3, 7, 14, 28 and malondialdehyde (MDA) levels were determined in tibial bone tissue. The MDA levels of study and control legs were compared with basal MDA levels in bone in 10 rats. There was no apparent difference between the basal level and control legs, but the study legs showed a statistically significant increase in MDA levels on days 7 and 14. We conclude that no oxidative stress injury occurs during the ischemic period of fracture healing, but it may be significant during inflammation and the formation of callus.

The relationship of heel pad elasticity and plantar heel pain

Loss of heel pad elasticity has been suggested as one of the possible explanations of plantar heel pain. This hypothesis is evaluated by this blinded observer prospective study, using an age and weight matched control population. Hindfoot lateral radiographs of 73 patients with plantar heel pain, 29 of whom had bilateral involvement (102 feet), and who ranged in age from 20 to 60 years, were studied and compared with 120 healthy subjects (240 feet). Heel pad thickness and heel pad compressibility index were not significantly different in patients with plantar heel pain than in healthy subjects matched for age and weight. In patients with unilateral heel pain, heel pad thickness and heel pad compressibility index on the painful side were not significantly different from the opposite painless side. The contribution of the heel pad elasticity measured as a visual compressibility index for plantar heel pain is a matter of debate.

Treatment of severe residual clubfoot deformity by trans-midtarsal osteotomy.

This study reviews the preliminary results of transmidtarsal osteotomy performed on 11 patients (12 feet) who previously underwent surgery for resistant clubfoot and needed further surgery for severe residual deformities. Opening wedge medial cuneiform osteotomy, closing wedge cuboid osteotomy, and truncated wedge middle and lateral cuneiform osteotomy were performed. The procedure was performed initially on normal cadaver feet. The average improvement of anteroposterior talo-first metatarsal angle was 20 degrees and lateral calcaneo-first metatarsal angle was 16 degrees. The authors conclude that with this simple procedure, angular and rotational correction in three planes can be obtained simultaneously in severe residual clubfoot deformity without the need for extensive soft tissue release.

Prevention of heterotopic ossification after total hip replacement: a prospective comparison of indomethacin and salmon calcitonin in 60 patients.

We did a prospective consecutive study of prophylaxis for heterotopic ossification (HO) comparing indomethacin (100 mg/day) and salmon calcitonin (3 MRC-U/kg/day) for 14 days. Each group consisted of 30 patients. 19 patients in the indomethacin group and 2 in the calcitonin group developed HO. We conclude that use of calcitonin in the prophylaxis of HO after total hip replacement is more effective than indomethacin.

PATELLECTOMY WITH VASTUS MEDIALIS OBLIQUUS ADVANCEMENT FOR COMMINUTED PATELLAR FRACTURES: A PROSPECTIVE RANDOMISED TRIAL

We have compared the results of simple patellectomy (group A, n = 16) and patellectomy with advancement of the vastus medialis obliquus (group B, n = 12) in a prospective, randomised trial, with a minimum follow-up of three years. The results in group B were significantly better (p

Spontaneous bilateral hip fractures in a patient with steroid- induced osteoporosis-a case report

A 44-year-old man was referred to us because of pain in both hips for 3 preceding months. He had received daily doses of fluocortolone (ULTRALAN ORAL ®, Schering Turkey equivalent oral dose 5 mg) 100 mg for 3 days, 80 mg for 3 days, 60 mg for 3 days, 40 mg for 3 days and 20 mg for 18 days-1200 mg in 30 days-after a cataract operation, because of cystic macular edema 9 months before. 6 months after steroid therapy, he felt pain in his left hip which was aggravated by weight bearing and sometimes kept him awake at night. Radiographs of the hips 1 month later were reported to be normal. The patient had to use walking aids and 1 month later he developed pain in the right hip too and was referred to us.