Tolga Tolunay

A critical appraisal of the North American Spine Society guidelines with the Appraisal of Guidelines for Research and Evaluation II instrument.

BACKGROUND CONTEXT The North American Spine Society (NASS) publishes clinical guidelines that are taken into consideration worldwide by clinicians who have a special interest in spinal surgery. The Appraisal of Guidelines for Research and Evaluation (AGREE) II is the second version of the original AGREE instrument to assess the quality of guidelines in terms of development process. This appraisal aims to evaluate each individual NASS guideline using AGREE II tool to demonstrate its methodologic robust and weakness. PURPOSE To evaluate the quality of the clinical practice guidelines published by the NASS. STUDY DESIGN Four appraisers used the AGREE II guideline evaluation instrument to evaluate the NASS guidelines. METHODS All six guidelines available on the NASS web site as of July 1, 2014 were evaluated. Four reviewers independently assessed these guidelines using the AGREE II instrument. The instrument standardizes the quantitative assessment of quality for a guidelines development process across six domains that include: scope and purpose, stakeholder involvement, rigor of development, clarity and presentation, applicability, and editorial independence. Additionally, each reviewer rated the overall quality of the guidelines. RESULTS Overall results for the AGREE II domains across all six guidelines were: scope and purpose (median score, 94.4%), stakeholder involvement (median score, 56.9%), rigor of development (median score, 91.7%), clarity of presentation (median score, 94.4%), applicability (median score, 60.9%), and editorial independence (median score, 71.9%). CONCLUSIONS Our study showed that the quality of the NASS guidelines needs some improvement. There is a critical need for broader stakeholder involvement including patient representatives and health economists. Consideration of resource implications and monitoring process and standardization of how recommendations are implemented need to be improved. Studies analyzing facilitators and barriers would be helpful for future NASS guidelines.

Biomechanical Performance of Various Cement-Augmented Cannulated Pedicle Screw Designs for Osteoporotic Bones

INTRODUCTION Early-stage pullout is a common problem for surgeons during the fixation of osteoporotic bones. Poor bone quality limits the use of pedicle screws for patients with osteoporosis. In this study, the researchers investigated the effects of hole and gap position and type on the pullout strength of cannulated screws. METHODS Seven different designs were tested, including a control group. All cannula diameters were 2 mm and holes were drilled with a diameter of 1.5 mm. Gaps were milled with a 2-mm-diameter tool with 2-mm displacement proximally. All holes and gaps were drilled or opened unilaterally and bilaterally. Grade 40 and 10 polyurethane foam was used to simulate healthy and osteoporotic bones, respectively. For pullout tests, insertion depth was 30 mm and 2-mm-diameter pilot holes were drilled into blocks before screws were inserted. The cross-head speed was 2 mm/min. For torsion tests, 1 side of the screw was fixed and other was twisted clockwise. RESULTS For torsion tests, the maximum torque value exhibited by the control group (non-cannulated) was 14.94 Nm. The highest torsional strength among tested cannulated screws was 13.54 Nm for Single side two holes including design (S2H) (p < .0001). The minimum torsional strength was 9.45 Nm with a breaking angle of 39° (p < .005). Comparing results for samples pulled out from grade 40 polyurethane foam, single side slot including design (SS) samples exhibited the highest pullout strength with a maximum force of 3,104 N. CONCLUSIONS The unilateral, sequential, 3-radial hole, drilled, cannulated screw was the optimal alternative when considering pullout and torsional strength as criteria.

Pullout performance comparison of novel expandable pedicle screw with expandable poly-ether-ether-ketone shells and cement-augmented pedicle screws

Aim of this study is to assess the pullout performance of various pedicle screws in different test materials. Polyurethane foams (Grade 10 and Grade 40) produced in laboratory and bovine vertebrae were instrumented with normal, cannulated (cemented), novel expandable and normal (cemented) pedicle screws. Test samples were prepared according to the ASTM F543 standard testing protocols and surgical guidelines. To examine the screw placement and cement distribution, anteriosuperior and oblique radiographs were taken from each sample after insertion process was completed. Pullout tests were performed in an Instron 3369 testing device. Load versus displacement graphs were recorded and the ultimate pullout force was defined as the maximum load (pullout strength) sustained before failure of screw. Student’s t-test was performed on each group whether the differences between pullout strength of pedicle screws were significant or not. While normal pedicle screws have the lowest pullout strength in all test materials, normal pedicle screws cemented with polymethylmethacrylate exhibit significantly higher pullout performance than others. For all test materials, there is a significant improvement in pullout strength of normal screws by augmentation. While novel expandable pedicle screws with expandable poly-ether-ether-ketone shells exhibited lower pullout performance than normal screws cemented with polymethylmethacrylate, their pullout performances in all groups were higher than the ones of normal and cannulated pedicle screws. For all test materials, although cannulated pedicle screws exhibit higher pullout strength than normal pedicle screws, there are no significant differences between the two groups. The novel expandable pedicle screws with expandable poly-ether-ether-ketone shells may be used instead of normal and cannulated pedicle screws cemented with polymethylmethacrylate due to their good performances.

Pullout performance comparison of pedicle screws based on cement application and design parameters

Pedicle screws are the main fixation devices for certain surgeries. Pedicle screw loosening is a common problem especially for osteoporotic incidents. Cannulated screws with cement augmentation are widely used for that kind of cases. Dual lead dual cored pedicle screw has already given promising pullout values without augmentation. This study concentrates on the usage of dual lead dual core with cement augmentation as an alternative to cannulated and standard pedicle screws with cement augmentation. Five groups (dual lead dual core, normal pedicle screw and cannulated pedicle screw with augmentation, normal pedicle screw, dual lead dual cored pedicle screw) were designed for this study. Healthy bovine vertebrae and synthetic polyurethane foams (grade 20) were used as embedding test medium. Test samples were prepared in accordance with surgical guidelines and ASTM F543 standard testing protocols. Pullout tests were conducted with Instron 3300 testing frame. Load versus displacement values were recorded and maximum pullout loads were stated. The dual lead dual cored pedicle screw with poly-methyl methacrylate augmentation exhibited the highest pullout values, while dual lead dual cored pedicle screw demonstrated similar pullout strength as cannulated pedicle screw and normal pedicle screw with poly-methyl methacrylate augmentation. The dual lead dual cored pedicle screw with poly-methyl methacrylate augmentation can be used for osteoporotic and/or severe osteoporotic patients according to its promising results on animal cadaver and synthetic foams.

Biomechanical properties of osteoporotic rat femurs after different hormonal treatments: genistein, estradiol, and estradiol/progesterone

Introduction: The purpose of the study is to compare the effects of genistein, estradiol, estradiol/progesterone combination on the bone mineral density and biomechanical properties of ovariectomized rats’ bone. Methods: 50 female adult Sprague-Dawley rats were divided into five groups. Bilaterally ovaeriectomy were performed in all groups except the sham-operated group. Groups were a sham-operated group and a control group (water was given), estradiol treated group (17-β estradiol 0.015 mg/kg per day), genistein treated group (genistein 10 mg/kg per day), and an estradiol/progesterone combination group (17-β estradiol 0.015 mg/kg plus drosperinone 0.028 mg/kg per day). The water or hormones were implemented in relevant groups for eight weeks by orogasthric catheter. The bone mineral density and biomechanical properties of the femur were analyzed. Results: Genistein, estradiol, and estradiol/progesterone groups increased bone mineral density significantly compared to the control group. In diaphysis and metaphysis bending test, all groups had higher peak load values than the control group. There were statistically significant differences between the estrogen/progesterone group and control group in diaphysis bending with regard to peak load. There were statistically significant differences between the estradiol and control groups in metaphysis bending with regard to peak load. In axial rotation test, all groups had higher peak torque values than the control groups. Conclusions: Genistein, estradiol and estrogen/progesterone combination improved the biomechanical properties of the ovariectomized rat bone. Genistein which has less side effects may be considered as an alternative in the treatment of postmenopausal osteoporosis.

Rhythm and orthopedics: The effect of music therapy in cast room procedures, a prospective clinical trial

INTRODUCTION Cast room procedures generally cause anxiety in patients. Anxiety complicates the procedure as well as increases the risk of a complication. Listening to music was found to be the safest and most common non-drug treatment method. The aim of this study is to evaluate the effect of listening to music on adult patients in cast room procedures. This study points out the relation between anxiety and anxiety relevant cardiac arrhythmia. MATERIALS AND METHODS The study was performed on 199 patients with stable general condition, aged above 18. The patients were divided into two groups. Randomization method used in the study was coin flip. The first group (Group 1) listened to music during cast room procedures whereby the second group (Group 2) did not listen to music. Length of the procedure, complication, blood pressure and heart rate evaluations before and after the procedure, Visual Analogue Scale (VAS scores for pain), State-Trait Anxiety Inventory (STAI) anxiety score, patient satisfaction, willingness of the patient to repeat the procedure, P wave dispersion (Pd) and corrected QT interval dispersion (QTcd) as electrocardiographic arrhythmia predictors were evaluated. The Clinical Research Ethics Committee approval was obtained for this study. RESULTS Significant difference was shown between the two groups for the following criteria: VAS scores (p = 0.005), anxiety scores (p = 0.032), processing time (p = 0.027), and QTcd values (p = 0.031). Patient satisfaction (p < 0.001) and willingness to repeat the procedure (p < 0.001) were higher for the group who listened to music. No significant difference in Pd values, blood pressure and heart rate was reported within the groups. CONCLUSION Music therapy is a non-invasive, safe, nonpharmacologic, anxiolytic, and analgesic treatment. Music therapy should become standard protocol in cast room procedures. One of the most important achievements of this study was the fact that music decreases anxiety and anxiety-related cardiac arrhythmia. Therefore, conducting further prospective studies including high cardiac risk patients especially with arrhythmia is crucial.

İzole Ulna Cisim Kırıklarında Konservatif ve Cerrahi Tedavi Yöntemlerinin Karşılaştırılması

Amac: Izole ulna cisim kiriklarinin tedavisinde hem konservatif hem de cerrahi metodlar onerilmistir. Calismanin amaci izole ulna cisim kiriklarinin optimal tedavisini ve kirik iyilesmesini etkileyen faktorleri arastirmaktir. Gerec ve Yontemler: Calismaya 2013-2016 yillari arasinda hastanemize basvurmus izole ulna cisim kirikli 43 hasta alindi. Hastalar konservatif tedavi edilen ve cerrahi olarak tedavi edilen olmak uzere 2 grupta incelendi. Sonuclarin degerlendirilmesinde eklem hareket acikligi, kavrama gucu, fonksiyonel ve radyolojik sonuclar kullanildi. Agri vizuel analog skala (VAS) ile degerlendirildi. Kavrama gucune ise el dinamometresiyle hasta otururken ve dirsek 90 derece fleksiyonda bakildi. Fonksiyonel sonuclara kol, omuz el sorunlari skorlamasi (DASH Skoru) ile bakildi. Bulgular: Konservatif tedavi edilen grupta 23 hasta, cerrahi tedavi edilen grupta 20 hasta bulunmaktaydi. Her 2 grup arasinda yas, cinsiyet dagilimi, kirik paterni, yaralanma mekanizmasi ve kirik lokasyonu acisindan fark saptanmadi. Her 2 grup arasinda VAS skoru, kavrama gucu, DASH skoru ve kaynama acisindan da fark saptanmadi. Konservatif tedavi edilen grupta kaynama suresi ortalama 12±1,04 haftayken cerrahi olarak tedavi edilen grupta kaynama suresi ortalama 17±1,16 haftaydi (p=0,586). Her 2 grup arasinda dirsek ve el bilegi eklem hareket acikligi ve komplikasyonlar acisindan da fark saptanmadi. Sonuc: Calismamizda cerrahi olarak tedavi edilen hastalarin konservatif olarak tedavi edilen hastalardan fonksiyonel ve klinik olarak daha iyi sonuclara sahip olmadigi ve konservatif tedavi yontemlerinin sonuclarinin basarili oldugunu saptandi. Izole ulna cisim kiriklari tedavi yonteminin belirlenmesinde prospektif, cok merkezli ve daha genis hasta serilerini kapsayan calismalara ihtiyac vardir.

Investigation of toggling effect on pullout performance of pedicle screws

Objective of this study is to assess the pullout performance of various pedicle screws in different test materials after toggling tests comparatively. Solid core, cannulated (cemented), novel expandable and solid-core (cemented) pedicle screws were instrumented to the polyurethane foams (Grade 10 and Grade 40) produced in laboratory and bovine vertebra. ASTM F543 standard was used for preparation process of samples. Toggling tests were carried out. After toggling test procedures, pullout tests were performed. Load versus displacement graph was recorded, and the ultimate pullout force was defined as the maximum load (pullout strength) sustained before failure of screw. Anteriosuperior and oblique radiographs were taken from each sample after instrumentation in order to examine screw placement and cement distribution. The pullout strength of pedicle screws decreased after toggling tests with respect to the initial condition. While the cemented solid-core pedicle screws had the highest pullout strength in all test materials, they had the highest strength differences. The cemented solid-core pedicle screws had decrement rates of 27% and 16% in Grade 10 and Grade 40, respectively. There are almost same decrement rate (between 5.5% and 6.5%) for all types of pedicle screws instrumented to the samples of bovine vertebra. The pullout strengths of novel expandable pedicle screws in both of early period and after toggling conditions were almost similar, in other words, the decrement rates of it were lower than other types. According to the data collected from this study, polymethylmethacrylate augmentation significantly decreases pullout strength following the toggling loads. Higher brittleness of cured polymethylmethacrylate has adverse effect on the pullout strength. Although augmentation is an important process for enhancing pullout strength in early period, it has some disadvantages for preserving stabilization in a long time. Expandable pedicle screw with polyetheretherketone shell may be good alternative to polymethylmethacrylate augmentation on both primer stabilization and long-term loading application with toggling.

Akut Aşil tendon yırtıklarının Lynn yöntemi ile tamiri

Objectives: Efficiency assessment of Lynn method on open primary repair of acute Achilles tendon ruptures. Methods: Data were evaluated from 19 patients who treated with the Lynne method due to acute Achilles tendon rupture. Average follow-up length was 12.3 months (range 8-15 months). Dominant side was the right side by all patients and all patients were males. Plantaris tendon augmentation was applied after end-to-end repair by modified Kessler suture technique. Results: The mean postoperative AOFAS score (The American Orthopaedic Foot and Ankle Society hindfoot clinical outcome scores) was 93.5 (range 82-100). The average of Achilles tendon postoperative assessment score, as developed by Thermann and colleagues, was 93.3. Both assessment scores were between 90-100 and were evaluated as very good. None of the patients developed post-operative wound infection. The Thompson test was negative on all patients and bilateral motor strength was 5/5. Conclusion: Lynn method, especially in young and active patients with acute Achilles tendon rupture is a method that should be considered in treatment protocols.Amac: Akut Asil tendon yirtiklarinin acik primer tamirinde Lynn yonteminin etkinliginin degerlendirilmesi. Yontemler: Akut Asil tendon yirtigi nedeniyle Lynn yontemi ile tedavi edilen 19 hastanin verileri degerlendirildi. Hastalarin ortalama takip sureleri 12,3 ay (8 – 15 ay) idi. Tum hastalarin dominant taraflari sag taraf olup, calismaya katilan butun hastalar erkekti. Tum hastalara modifiye Kessler dikis teknigi kullanilarak uc-uca tamir yapildiktan sonra plantaris tendonu ile guclendirme uygulandi. Bulgular: Postoperatif AOFAS skoru (The American Orthopaedic Foot and Ankle Society hindfoot clinical outcome scores) ortalama 93,5 (dagilim 82-100) olarak hesaplandi. Thermann ve arkadaslarinin gelistirdigi Asil tendon cerrahi sonrasi degerlendirme skorunda ortalama puan 93,3 olarak saptandi. Her iki degerlendirme 90-100 puan arasinda cikmis olup sonuclar cok iyi olarak degerlendirildi. Operasyon sonrasinda hicbir hastada yara yeri enfeksiyonu gelismedi. Yapilan son kontrollerinde tum hastalarin Thompson testi negatif olup, bilateral motor kuvvet 5/5 olarak saptandi. Sonuc: Lynn yontemi, ozellikle aktif ve genc yastaki akut Asil tendon yirtigi olan hastalarin tedavi protokolleri arasinda goz onunde bulundurulmasi gereken bir yontemdir.