Senol Bekmez

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.

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.

Long-Term Results of Reconstruction with Pelvic Allografts after Wide Resection of Pelvic Sarcomas

Reconstruction after the resection of a pelvic tumor is a challenging procedure in orthopedic oncology. The main advantage of allograft reconstruction is restoration of the bony architecture of the complex pelvic region. However, high complication rates such as infection and allograft resorption had been reported in the literature. In this study, we aimed to retrospectively review nine patients treated with pelvic resection and structural pelvic allograft reconstruction. Functional results, complications, and survival of the patients and the allografts were evaluated. At a mean follow-up of 79 months, three patients were dead. Major complications were detected in eight of the nine patients. Infection (four of the nine patients) and allograft resorption (three of the nine patients) were the most common causes of failure. The cumulative survival of the patients was 66.7 percent at 70 months. However, allograft survival was only 26.7 percent at 60 months. Mean MSTS score was 69. In conclusion, we suggest that other reconstruction options should be preferred after pelvic resections because of the high complication rates associated with massive allograft reconstruction.

Evaluation of vacuum-assisted closure in patients with wound complications following tumour surgery†

Covering the reconstructed area with a healthy soft‐tissue envelope is a major challenge after limb‐sparing surgery in patients with malignant bone and soft‐tissue tumours. Negative pressure wound therapy (NPWT) of open wounds hastens healing and minimises the requirement for complex reconstructive soft‐tissue surgery. The aim of this study was to investigate the effectiveness and safety of NPWT in bone and soft‐tissue malignant tumour patients with postoperative wound complications. Between January 2006 and November 2009, at a single institution, 13 patients with malignant bone and soft‐tissue tumours who had undergone wide resection were retrospectively analysed. NPWT was performed in all patients to temporarily close the soft‐tissue defects. After obtaining the culture negativity and normal infection markers, definitive soft‐tissue reconstruction was performed to close the wound with primary suturisation in two patients, split thickness grafts in four patients, full thickness grafts in two patients, rotational flaps in three patients and free flaps in two patients. Mean duration of hospitalisation was 20 (range 8–48) days and mean follow‐up period was 57·3 (range 50–74) months. There was no tumour recurrence or skip metastasis in the follow‐up period. In addition, there was no periprosthetic infection or complication associated with NPWT. In conclusion, NPWT therapy seems to be a safe and effective option in the management of local wound problems and secondary surgical site infections after musculoskeletal tumour surgery.

Advances in growing rods treatment for early onset scoliosis.

Purpose of review The goal of treatment in early onset scoliosis is to correct the deformity while allowing the thoracic growth for optimal cardiopulmonary functions. Growing rods treatment is a distraction-based, growth-friendly method that is commonly used in treatment of early onset scoliosis with its specific indications. Magnetically controlled growing rods (MCGR) method has been introduced to avoid morbidity of recurrent lengthening procedures. In this review, recent developments in traditional growing rods and MCGR are summarized. Recent findings As the experience with growing rods increased and favorable results were reported, its indications have expanded. Recent studies focused on patient outcomes and complications. Another area of interest is the effects of growing rods in the sagittal spinal alignment. Midterm results demonstrated that MCGR treatment is promising but not free of complications. In MCGR, there is no consensus on the frequency and amount of distraction per session. Rod contouring and behavior of the magnet under MRI are major issues. Summary Growing rods treatment successfully controls the deformity while preserving the growth of spine and thorax, despite high complication rates. Magnetically controlled systems are introduced to avoid repetitive surgical lengthening procedures. Although preliminary results are promising, there are still significant challenges and unknowns for MCGR.

Convex Hemiepiphysiodesis: Posterior/anterior in-situ Versus Posterior-only With Pedicle Screw Instrumentation: An Experimental Simulation in Immature Pigs.

Study Design: Experimental study. Background: Convex growth arrest (CGA) has been commonly used in the treatment of long-sweeping congenital deformities of the immature spine. As there are major drawbacks about the anterior procedure in the conventional CGA method, a new modification has been documented that using only posterior spinal approach with pedicle screw instrumentation. The aim of the study was to compare posterior-only CGA using pedicle screws with combined anterior/posterior in-situ CGA for the findings in histologic, radiologic, and manual palpation examinations in an immature pig model. Methods: Twelve 10-weeks old pigs were grouped into 2. In group 1, posterior-only, pedicle screw instrumented CGA was performed on the left side of L1-L4 vertebrae. In group 2, conventional combined posterior and anterior CGA was performed to the left side of L1-L4 vertebrae without instrumentation. All animals were killed twelve weeks after surgery. T11-L5 segments were en-bloc resected and radiologic, histologic, and manual palpation examinations were done. Results: Marked scoliotic (12.2±2.5 and 9.2±1.3 in group 1 and 2, respectively) and kyphotic (11.2±1.0 degrees for the group 1 and 12±5.2 degrees for the group 2, respectively) deformities were noted in both groups, which were caused by hemiepiphysiodesis effect. Anterior and posterior parts of group 2 and posterior part of group 1 demonstrated fusion in histologic and radiologic analyzes. In anterior part of the group 1, marked narrowing on the disk spaces and thinning of growth plates were noted in radiologicg examination, chondrocyte degeneration, and newly-formed bone trabeculae in disk-space were noted in histological examination. In manual palpation, no motion was detected in group 1 and motion was detected in only one segment of one animal in group 2. Conclusions: Anterior growth of the vertebrae can be controlled by application of posterior transpedicular screws and rod. Such an effect can eliminate the need for anterior surgical intervention in convex hemiepiphysiodesis procedures. Clinical Relevance: The instrumented CGA technique provides a satisfactory epiphysiodesis effect both anteriorly and posteriorly, as previously demonstrated by clinical studies.

Utilizing the "Stable-to-be Vertebra" Saves Motion Segments in Growing Rods Treatment for Early-Onset Scoliosis.

Background: There is no consensus on the selection of distal instrumentation levels in growing rod surgery. Many surgeons utilize the stable zone of Harrington, but there is not overwhelming evidence to support this preference. The aim of this study was to determine the value of bending/traction radiographs in selection of distal instrumentation levels of a growing rod construct in children with idiopathic or idiopathic-like early-onset scoliosis (EOS). Methods: Twenty-three consecutive patients with idiopathic or idiopathic-like EOS who underwent growing rod surgery at 2 separate institutions between 2006 and 2011 were included. Lengthening procedures were performed periodically at 6-month intervals. Analyses were performed retrospectively for age at index surgery, follow-up period, and radiographic measurements. Lower instrumented levels, neutral vertebra, stable vertebrae (SV), and stable-to-be vertebrae (StbV) were identified on the preoperative radiographs. Coronal Cobb angles, tilt of lower instrumented vertebra (LIV) and LIV+1, and disk wedging under the LIV and LIV+1 were measured on the early postoperative and latest follow-up radiographs. Results: Average age at index surgery was 83.6 months. Mean follow-up period was 68.1 months. Initial analysis showed that the relationship of LIV to the StbV was a better predictive of LIV+1 tilt than the SV at the final follow-up. Therefore, the patients were grouped according to the relationship of the LIV to the StbV. LIV was the StbV in 9 patients, proximal to the StbV in 8 patients, and distal to the StbV in 6 patients. At the latest follow-up, tilt of LIV+1 exceeded 10 degrees in 7 of the 8 patients where LIV was proximal to the StbV, whereas only in 1 of 9 patients where LIV was StbV, and in none of the 6 patients where LIV was distal to the StbV. The data indicate that selection of the StbV as the LIV could spare an average of 1.8 vertebral segments when compared with the SV, as StbV is never distal but almost always proximal to the SV. Conclusions: Choosing the StbV as the LIV saves motion segments and prevents distal adding on, while providing satisfactory deformity correction in idiopathic and idiopathic-like EOS. Level of Evidence: Level III—retrospective comparative study.

Surgical Management of Progressive Thoracolumbar Kyphosis in Mucopolysaccharidosis: Is a Posterior-only Approach Safe and Effective?

Background: According to the current literature, the recommended surgical treatment is circumferential spinal fusion, including both anterior and posterior procedures, for progressive thoracolumbar kyphosis in mucopolysaccharidosis (MPS). The purpose of this study was to report our experience with the posterior-only approach and instrumented fusion for MPS kyphosis. Methods: Six consecutive patients with MPS and thoracolumbar junctional kyphosis managed with the posterior-only approach were included. Demographic data, the type of MPS, medical comorbidities, and accompanying clinical manifestations were recorded. Measurements recorded on radiographs for the study included the presence of any coronal-plane deformity, fusion levels, changes in the local kyphosis angle (LKA), proximal and distal junctional kyphosis angles, and the apical vertebral wedge angle. Results: The average age at the time of surgery was 6.6 (range, 4 to 12) years. The average follow-up duration was 52.6 (range, 44 to 64) months. The mean preoperative LKA of 63.1±15.8 (range, 48 to 92) degrees decreased to a mean of 16.6±8.4 (range, 5 to 30) degrees immediately after surgery. At the latest follow-up, the mean LKA was 19.6±8.8 (range, 8 to 34) degrees. Apical vertebral listhesis was reduced in all patients with surgical correction. The average apical vertebral wedge angle of 15 (range, 11 to 19) degrees at the early postoperative period decreased to 4.6 (range, 2 to 7) degrees at the latest follow-up. Adjacent-segment problems occurred in 2 patients. There were no neurological complications or implant failures in any of the patients. Conclusions: Posterior-only corrective techniques and instrumented fusion with pedicle screws for progressive thoracolumbar junctional kyphosis in MPS patients are safe and effective methods. Its results are comparable to those achieved with conventional circumferential fusion. However, patients should be monitored closely for adjacent-segment problems. Level of Evidence: Level IV—retrospective case series.

Transverse sacral fractures and concomitant late-diagnosed cauda equina syndrome.

Transverse sacral fractures in young patients occur with high-energy mechanisms. Because of the drawbacks in radiographic and neurologic evaluations of the sacral area in polytrauma patients, misdiagnosis is quite common. In this study, we aimed to report our clinical results in three patients with displaced transverse sacral fractures compromising the sacral canal and concomitant late-diagnosed (at least 48 hours) cauda equina syndrome. Bilateral lumbopelvic fixation, followed by sacral laminectomy and decompression, was performed in all patients. Despite the late- diagnosed cauda equina syndrome, we observed that surgical decompression and lumbopelvic fixation had positive effects on neurologic recovery, pain relief and early unsupported mobilization.

Hemiepiphysiodesis for the Treatment of Congenital Scoliosis

In long, sweeping curves seen in congenital scoliosis, definitive fusion should be avoided as it may limit growth of the thoracic spine and lungs. In such cases, the treatment goal should be to correct the deformity and maintain spinal alignment while preserving growth. The convex growth arrest (CGA) procedure intends to modulate growth with inhibition on the convex side while allowing growth on the concave side of the deformity. The traditional technique with the combined anterior and posterior approaches does not allow immediate deformity correction and has been shown to have unpredictable results. The traditional CGA technique has been modified by performing the hemiepiphysiodesis on the convex side with pedicle screws and a rod in a posterior-only fashion and adding a growing rod construct to the concave side. In this chapter, we present a 3.5-year-old female patient with a long, sweeping congenital scoliotic curve that was managed with convex instrumented CGA and concave distraction technique.