Search

Introduction There are two main accepted reasons of Proximal junctional kyphosis (PJK) after Scheuermann's kyphosis treatment; overcorrection of initial curve and fusion that is too short proximally. The purpose of this study was to evaluate the incidence of PJK in patients who have been previously treated for Schuermann's kyphosis with a curve exceeding 70° and corrected under 40° according to proximal fusion level T2 or T3. Methods We retrospectively evaluated 30 patients treated for Schuermann's kyphosis with single stage posterior only procedure. We included patients that we achieved at least 50% correction of the initial curve. The surgeries were performed at the same institution by a single senior spinal surgeon. Patients were divided into two groups according to proximal fusion level T2 (16 patients) or T3 (14 patients) and evaluated for PJK, follow-ups ended three years after surgery. Results Mean age was 22.7 in T2 and 21.6 years in T3 group. Mean preoperative Cobb angle was 78° in T2 and 78.7° in T3 group. The mean postoperative Cobb angle was 33.2° in T2 and 35° in T3 group. None of the patients showed neurologic complications. Four patients had PJK in T3 group and one needed revision. Conclusions Selecting T2 as the proximal fusion level in Schuermann's kyphosis may decrease the incidence of PKJ. Studies with a larger number of patients needed to verify our results.

Objective Distraction-based systems are the most common systems used in the treatment of early-onset scoliosis. In addition to its corrective and deformity progression preventive properties, its vertebral growth stimulation effect has been proved. Recently popularized magnetically controlled growing rods (MCGRs) showed superior results in terms of outcomes and decreased complication rate. Its vertebral growth stimulation effect has not been studied. The aim of the study is to evaluate the vertebral growth stimulation effect in patients treated with MCGR. Methods Patients with progressive scoliosis treated by dual MCGR, who had no obvious lumbar vertebral deformity and had a regular 3-month interval spinal lengthening for at least 30 months, were subdivided into 2 groups according to the inclusion of L3 vertebra within instrumentation segments. The L3 vertebral vertical and horizontal lengths were measured postoperatively and at the last follow-up, and their differences were analyzed statistically in both groups. Results Twenty-four patients were included; 18 of them had an L3 vertebra outside instrumentation segments, while the other 6 had spanned by MCGR. Uninstrumented L3 were followed up for an average of 36 months. The height difference between initial postoperative examination and the last follow-up was 3.55 mm ± 0.63 mm, and the width difference was 3.85 mm ± 0.75 mm. Conversely, patients with instrumented L3 were followed up for a mean of 38.9 months. Their initial postoperative examination and last follow-up differences in height and width were 6.91 mm ± 1.11 mm and 3.66 mm ± 0.92 mm, respectively. Conclusions Frequent distractions stimulate longitudinal vertebral growth in vertebrae spanned by MCGR.

STUDY DESIGN A prospective, a single-institution, nonrandomized study. OBJECTIVE The aim of this study was to evaluate the safety and effectivity of short-segment instrumentation in early-onset scoliosis (EOS) patients treated by magnetic-controlled growing rods (MCGRs). SUMMARY OF BACKGROUND DATA Despite the common use of conventional growing rods and the recent popularity of MCGR in the treatment of progressive EOS, distal instrumented vertebra and number of the spanned levels are not standardized. METHODS Patients with progressive EOS, characterized by the major thoracic curve and nonstructural compensatory curve, were a candidate to be treated by dual MCGR short segment spinal instrumentation spanning the major thoracic curve; such patients are followed up for a minimum period of 30 months. Radiological data were collected and analyzed in terms of Cobb angle of both primary and secondary curve, kyphosis angle, T1-T12, and T1-S1 distances, and T1-T12/T1-S1 ratio in preoperative, postoperative, and last follow-up. RESULTS Sixteen patients with different diagnoses of EOS, mean age at the operation was 7 years and 10 months (5 years and 6 months-9 years and 10 months), and mean period of follow-up was 37 (30-54) months. The Cobb angle of both major and compensatory curve are corrected by the mean value of 62° (44-85), 35° (22-45) preoperatively to 29° (12-49), 14° (9-24) postoperatively, and maintained at 28° (10-47), 10° (2-20) in the last follow-up, respectively. The T1-T12/T1-S1 ratio was 0.58 preoperatively, 0.6 postoperatively, and 0.62 at the last follow-up. The average yearly T1-T12 and T1-S1 length increase were calculated as 7 and 9 mm/year, respectively. CONCLUSION Selective fusion principals are applicable to EOS, in that short segment instrumentation with MGCR in thoracic curve EOS patients is an effective technique in correction of both structural and compensatory curve, and in maintaining the correction during subsequent nonsurgical spinal distraction. LEVEL OF EVIDENCE 4.

STUDY DESIGN Prospective unicentral nonrandomized study. OBJECTIVE To evaluate the safety and effectivity profile of magnetic controlled growing rods (MCGR) in patients with early onset scoliosis (EOS). SUMMARY OF BACKGROUND DATA Conventional growing rods are the most commonly used growth sparring devices in the treatment of EOS, as this technique requires repeated surgical operations for lengthening; it is associated with high rate of complications and increased costs. MCGR in treatment of EOS is effective in correcting deformity whereas allowing continuous spinal growth as reported by a few studies. METHODS A total of 18 patients with progressive EOS were treated by MCGR, two of them had undergone final fusion operation. Patients were followed-up for a minimium time of 9 months from the time of initial surgery. Radiological data were analyzed in terms of Cobb angle, kyphosis angle, T1-T12, and T1-S1 distances in preoperative, postoperative, and last follow up. RESULTS The mean preoperative Cobb and kyphosis angle were 68° (44-116°) and 43° (98-24°), it was corrected to 35° (67-12°) and 29° (47-21°) immediately after initial operation and maintained at 34.5° (52-10°) and 33° (52-20°) at last follow up, respectively.The mean preoperative T1-T12 and T1-S1 distance were 171 mm (202-130 mm) and 289 mm (229-370 mm), it was increased to 197 mm (158-245 mm) and 330 mm (258-406mm) immediately after initial operation and further increased to 215 mm (170-260 mm) and 357 mm (277-430 mm) at last follow up, respectively.Two patients had undergone final fusion, they had overall mean Cobb angle correction of 66° (62-70°), and kyphosis angle change of 53° (26-80°). Total height gain in T1-T12 and T1-S1 of 80.5 mm (67-94 mm) and 119 mm (105-133 ), respectively. CONCLUSION MCGR is safe and effective technique in correction of EOS deformity and in maintaining the correction during nonsurgical distraction procedures. A further correction of the deformity and more spinal height gain can be achieved in the final fusion operation. LEVEL OF EVIDENCE 3.

Background Various surgical techniques and outcome results have been reported after primary total hip arthroplasty for the treatment of patients dysplastic hips. Low failure and complication rates have been reported when the acetabular component has been placed in the true acetabulum. The current study reports the results of primary total hip arthroplasty in patients with high and low dislocation for whom the acetabular component was placed in the true acetabulum without femoral or trochanteric osteotomy. Methods 26 primary total hip replacements were performed on 22 patients. The mean duration of follow-up was 8.9 years. There were 4 men and 18 women. 17 hips were classified as type B (low dislocation) and 9 as type C (high dislocation), according to the classification system of Hartofilakidis et al. Acetabular components were placed in the true acetabulum without osteotomy for all patients. Results At the time of final follow-up (mean 8.9 years) the average Harris Hip Score was 85 points. Femoral head autograft was used in 9 hips to supplement acetabular coverage. In 8 patient linear calcar fracture. 7 fixed with Dall-Mile cable and 1 fixed with a side plate. On radiologic evaluation, 2 incidents of asymptomatic osteolysis, 1 of acetabular loosening, 1 graft resorption, and 1 impingement (correlated with physical examination) were identified. 2 patients had neuropraxia and were treated medically. There were no early or late infections. Only 1 patient with acetabular loosening required revision surgery. Conclusions Although it is surgically difficult to place the acetabular component in the true acetabulum without femoral or trochanteric osteotomy, at the final follow-up we report favourable results. Long-term follow-up is needed to verify our results.

There is no clinical study which has evaluated real effectiveness of ropivacaine when it is used in a subacromial pump in addition to its bolus injection in a mixture of agents. The aim of the study is to evaluate pain relieving effect of ropivacaine infusion by a pain pump after arthroscopic shoulder surgery. Thirty-six patients were randomly divided into three groups. Arthroscopic subacromial surgery was performed under general anesthesia. A subacromial catheter was placed in groups 1 and 2 patients. At the end of the operation, 15 ml of 0.5 % ropivacaine, 15 mg of ketolorac, and 4 mg morphine sulfate mixture was applied to all patients into the subacromial space. In addition to that, group 1 patients were applied with 0.5 % ropivacaine running through a pain pump at 4 cm3/h. Group 2 patients only received 100 cm3 saline (placebo) through the same pain pump, which was also running at 4 cm3/h. No additional intervention except subacromial mixture application was performed in group 3. Pain levels were evaluated by using the visual analogue scale. Twelve male and 19 female patients were included in this study. During the first postoperative hour, there was no difference between the groups in terms of pain scores. During the ongoing 24-h period, group 2 patients suffered less pain and had less analgesic need compared with the other two groups (p 0.05). In terms of pain relief, the mixture of morphine, ropivacaine, and ketolorac was found to be as effective as the 24-h pump infusion of ropivacaine following arthroscopic rotator cuff repair. It was observed that placebo-given patients suffered less pain because saline increased the long-term effect of ropivacaine. So if an appropriate analgesic agent is applied to the subacromial space, there is no need for a pump infusion postoperatively.

Study DesignMechanical study.PurposeTo compare the pullout strength of different screw designs and augmentation techniques in an osteoporotic bone model.Overview of LiteratureAdequate bone screw pullout strength is a common problem among osteoporotic patients. Various screw designs and augmentation techniques have been developed to improve the biomechanical characteristics of the bone–screw interface.MethodsPolyurethane blocks were used to mimic human osteoporotic cancellous bone, and six different screw designs were tested. Five standard and expandable screws without augmentation, eight expandable screws with polymethylmethacrylate (PMMA) or calcium phosphate augmentation, and distal cannulated screws with PMMA and calcium phosphate augmentation were tested. Mechanical tests were performed on 10 unused new screws of each group. Screws with or without augmentation were inserted in a block that was held in a fixture frame, and a longitudinal extraction force was applied to the screw head at a loading rate of 5 mm/min. Maximum load was recorded in a load displacement curve.ResultsThe peak pullout force of all tested screws with or without augmentation was significantly greater than that of the standard pedicle screw. The greatest pullout force was observed with 40-mm expandable pedicle screws with four fins and PMMA augmentation. Augmented distal cannulated screws did not have a greater peak pullout force than nonaugmented expandable screws. PMMA augmentation provided a greater peak pullout force than calcium phosphate augmentation.ConclusionsExpandable pedicle screws had greater peak pullout forces than standard pedicle screws and had the advantage of augmentation with either PMMA or calcium phosphate cement. Although calcium phosphate cement is biodegradable, osteoconductive, and nonexothermic, PMMA provided a significantly greater peak pullout force. PMMA-augmented expandable 40-mm four-fin pedicle screws had the greatest peak pullout force.

The aim of this experimental study was to evaluate the effect of expansive open-door laminoplasty with simple suture fixation on spinal canal diameter in a rabbit model.Twenty white New Zealand rabbits were operated on with C4-C7 Hirabayashi open-door laminoplasty. The spinal canal diameter was evaluated radiologically on preoperative day 1 and postoperative days 1 and 42.The mean spinal canal diameter was 6.42 mm preoperatively, 8.04 mm on postoperative day 1 and 8.02 mm at day 42. There was a significant difference between the mean preoperative and postoperative day 1 spinal canal diameter (p0.001). There was no significant difference between the mean spinal canal diameter at postoperative day 1 and 42 (p0.05).Our results suggest that the open-door laminoplasty with simple suture fixation is an effective method to expand the spinal canal diameter. No recurrent narrowing is expected in short term.

Study Design In this prospective randomized study, the results of treating unstable thoracolumbar burst fractures by pedicle instrumentation with and without fracture level screw combination were given. Objective Our aim was to evaluate the efficacy of fracture level screw combination in achieving and maintaining correction in the treatment of unstable thoracolumbar burst fractures. Summary of Background Data Most authors reported that intraoperative correction of sagittal deformity is important for the maintenance of fracture reduction and is one of the most consistent predictor of satisfactory functional outcome. Methods Seventy-two patients with unstable thoracolumbar burst fractures were randomized into 4 groups with equal number of patients. In group 1, patients were treated by segmental posterior instrumentation with 2 levels above and 2 levels below the fracture level fixation, in group 2 they were treated as in group 1 with fracture level screw incorporation. In group 3, patients were treated by short-segment posterior instrumentation with 1 level above and 1 level below, in group 4 they were treated by short-segment posterior instrumentation with fracture level screw incorporation. Clinical and radiologic parameters were evaluated before surgery, after surgery, and at follow-up. Results The average follow-up was 50 months. Fracture level screw combination provided better intraoperative correction and maintenance in the treatment of unstable thoracolumbar burst fractures, which was more prevalent in short-segment fixation group. Conclusions Reinforcement with fracture level screw combination can help to provide better kyphosis correction and offers immediate spinal stability in patients with thoracolumbar burst fracture.

The combination of the reconstruction of the coracoclavicular ligaments with the resection arthroplasty of the distal end of the clavicle is a commonly used technique in acromioclavicular separations. The purpose of the current study was to quantify the reduction parameters using 3-D CT and to analyze their effects on clinical outcomes. Case series. The patients with chronic symptoms after acromioclavicular dislocation (type III) were treated with reconstruction of the coracoclavicular ligaments. The average follow-up was 69.5 months. The patient group consisted of 21 men and 8 women. The initial treatment at the time of injury was nonoperative in 26 of 29 patients. CT was used to document anteroposterior (APD), craniocaudal (CCD) and mediolateral (MLD) acromioclavicular reduction parameters. Constant Shoulder scoring system was used. The mean preoperative Constant score was 56.62 ± 18.63 points while the postoperative score was 89.93 ± 10.79 points. The mean APD was 9.2 mm, the mean CCD was 1.1 mm and the mean MLD was 8.4 mm. There was no correlation between the APD, MLD and the Constant Scores. However, an inverse correlation between the CCD and the postoperative Constant Scores was found. CCD plays an important role on the postoperative function. If the CCD is larger, the Constant score is lower. The reduction loss is a distinctive parameter of the functional outcome, even when the reconstructed coracoclavicular ligament is intact. Secure fixation may be achieved with techniques preserving CCD.

Objective Although the transpedicular decancellation osteotomy is a salvage technique for reconstruction of complex spinal deformities, it is not a procedure used exclusively for patients with kyphosis occurring as a sequel of treated tuberculosis. In this study, 16 adult patients with kyphosis underwent transpedicular decancellation osteotomy between 1993 and 1999. Pain, kyphosis angle, sagittal balance, and functional and neurologic status were the main parameters used for the clinical and radiologic assessment. Methods Sixteen patients with angular kyphotic deformity underwent transpedicular decancellation osteotomy between 1993 and 1999 with at least 5 years of follow-up. There were 6 male and 10 female patients with a mean age of 51.0. The radiologic involvement included the angle of kyphosis and plumb line on the anteroposterior and lateral radiographs. The preoperative and postoperative clinical assessment was performed by the using Oswestry Disability Index. All patients were asked to rate their preoperative and postoperative pain measurement using a pain visual analog scale. Fusion was evaluated on flexion-extension lateral radiographs. Results There were significant corrections in the kyphosis angle and the sagittal balance whereas no radiologic correction loss was observed in any of the patients during follow-ups. When the preoperative and the last follow-up pain visual analog scale and Oswestry Disability Index scores were compared, decrease was documented in both of them. Bony fusion was achieved in all patients and no neurologic complications were detected. Conclusions The transpedicular decancellation osteotomy effectively corrected the sagittal balance and improved pain and functional status. It was a safe and reliable technique in the treatment of posttuberculosis kyphosis.

Tuberculosis spondylitis of the lumbosacral region has rarely been documented in the literature. We present an 87-month follow-up study of 7 of 62 patients with tuberculous spondylitis of the lumbosacral region treated by chemotherapy, transpedicular drainage, posterior instrumentation, and fusion. The purpose was to prove the hypothesis that chemotherapy with transpedicular drainage and single-stage posterior instrumentation-fusion is enough for the prevention of lumbar kyphosis and sagittal offset in selected cases.There were four men and three women, with average age of 53 years. All patients underwent transpedicular debridement, posterior fusion, and instrumentation. We studied the following data for consideration in these patients: most involved vertebra, vertebral body loss, progress of kyphosis, and sagittal offset.The fourth lumbar vertebra was the most commonly involved vertebral segment. The average preoperative kyphosis was 17.5 degrees and decreased to 5.4 degrees postoperatively. Mean preoperative and postoperative sagittal offset was 0.34 mm and -5 mm, respectively. The average postoperative sagittal offset was increased from -5 to -2 mm at the third month and henceforth remained unchanged. There was no recurrent infection.We consider that transpedicular drainage, posterior instrumentation, and fusion constitute a less demanding operative technique for lumbosacral tuberculous spondylitis for the prevention of lumbar kyphosis and sagittal offset in patients without neurologic deficit and major vertebral body loss. This is the only lumbosacral tuberculous spondylitis series in which the patients were operated on with single-stage posterior surgery and merits a brief report in the light of the larger series.

Objective Fractures of the distal third of the clavicle with coracoclavicular ligament disruption have been associated with delayed union or nonunion. A combined surgical technique for the fracture fixation and ligament repair for acute fractures was developed. The technique includes K-wire fixation and suture anchor placement with Ethibond suture to the coracoid process. The results of this combined technique were evaluated. Design Prospective, consecutive case series. Setting Surgical treatment was performed at the Department of Orthopedics and Traumatology. Patients Ten patients with acute fractures of the distal third of the clavicle were enrolled with a mean follow-up period of 24.1 (range, 12-36) months. Intervention A single suture anchor was placed on the coracoid process in a vertical position. The Ethibond suture attached to the anchor was used to depress the elevated proximal part of the clavicle by pulling it down to the coracoid process where the anchor was placed. The suture was pulled over the proximal clavicle and tied. The distal fragment was fixed to the proximal clavicle by an intramedullary K-wire. The torn coracoclavicular ligaments were approximated using absorbable suture. Main outcome measurements The patients were evaluated by the Constant scores and Modified Shoulder Rating Scale. Results The mean Constant score was 96.6 points in the last follow-up. Nine patients had excellent results, and 1 patient had a good result, using the Modified Shoulder Rating Scale. Conclusions This is a reliable technique with encouraging results for treating displaced distal third clavicle fractures with coracoclavicular ligament disruption.

To increase the stability of sternotomy and so decrease the complications because of instability.Tests were performed on 20 fresh sheep sterna which were isolated from the sterno-costal joints of the ribs. Median straight and interlocking sternotomies were performed on 10 sterna each, set as groups 1 and 2, respectively. Both sternotomies were performed with an oscillating saw and closed at three points with a No. 5 straight stainless-steel wiring. Fatigue testing was performed in cranio-caudal, anterio-posterior (AP) and lateral directions by a computerized materials-testing machine cycling between loads of 0 to 400 N per 5 s (0.2 Hz). The amount of displacement in AP, lateral and cranio-caudal directions were measured and also the opposing bone surface at the osteotomy areas were calculated at the two halves of sternum.The mean displacement in cranio-caudal direction was 9.66 ± 3.34 mm for median sternotomy and was 1.26 ± 0.97 mm for interlocking sternotomy, P0.001. The mean displacement in AP direction was 9.12 ± 2.74 mm for median sternotomy and was 1.20 ± 0.55 mm for interlocking sternotomy, P0.001. The mean displacement in lateral direction was 8.95 ± 3.86 mm for median sternotomy and was 7.24 ± 2.43 mm for interlocking sternotomy, P0.001. The mean surface area was 10.40 ± 0.49 cm² for median sternotomy and was 16.8 ± 0.78 cm² for interlocking sternotomy, P0.001. The displacement in AP and cranio-caudal directions is less in group 2 and it is statistically significant. Displacement in lateral direction in group 2 is less but it is statistically not significant. Surface area in group 2 is significantly wider than group 1.Our test results demonstrated improved primary stability and wider opposing bone surfaces in interlocking sternotomy compared to median sternotomy. This method may provide better healing and less complication rates in clinical setting, further studies are necessary for its clinical implications.

Background: Valgus foot is a common foot deformity in spina bifida. The most popular operation for the valgus deformity has been the Grice talocalcaneal blocking. It has not been studied primarily in children with spina bifida. We report a prospective series, we present the results of hind foot valgus deformity of children with spina bifida, using Grice talocalcaneal arthrodesis with a tricortical iliac bone graft. Materials and Methods: Between May 2000 and December 2003, 21 patients with bilateral (42 feet) valgus deformity of feet underwent surgery. There were 7 males and 14 females. The mean age of patients was 67.7 months (range 50-108 months). Results: The total number of feet that had nonunion was 11, in 7 of them the grafts were completely reabsorbed and the outcome of all these feet was unsatisfactory. Four feet had partial union of which three had unsatisfactory and one had satisfactory outcome. Sixteen feet had residual valgus deformity at the last followup visit, 10 patients had nonunion, and 6 had inadequate correction . Mean preoperative talocalcaneal and calcaneal pitch angles were 48.5΀ and 31.9΀, respectively, which decreased to 38.5΀ and 29.1΀, respectively, postoperatively. The decrease in talocalcaneal angle and calcaneal pitch was significant between preoperative and postoperative measurements ( P Conclusion: Grice subtalar arthrodesis technique is still a valuable option for valgus foot in patients with spina bifida. In this study, we found more encouraging results in older patients.

In vitro experimental study.This study aimed to evaluate the biomechanical properties of bicortically placed and laterally oriented screws, which may represent an alternative approach for challenging sites during direct vertebral rotation (DVR).DVR corrects the transverse plane deformity and the thoracic hump in idiopathic scoliosis. However, instrumentation of the convex side of the scoliosis apex may pose a challenge, not allowing the placement of suitable sized screws in adequate direction.Forty-eight calf vertebrae were used and each vertebral body was instrumented with 1 pedicle screw as follows: unicortical group (n=16), a short screw was unicortically placed and directed laterally; bicortical group (n=16), a short screw was bicortically placed again in lateral direction; control group (n=16), a screw with ideal length and direction was placed. Vertebral bodies were rigidly anchored in a custom device. Each screw was rotated using a constant length lever arm while collecting "force to failure" data.Significantly better results were obtained with bicortical screwing when compared with unicortical screwing (335.4±45.6 vs. 239.5±58.50 N, P0.001). However, mean "force to failure" was significantly higher in the controls than in the bicortical group (415.8±49.2 vs. 335.4±45.6 N, P0.001).Bicortical screw placement may provide a biomechanically superior construct than unicortical screw placement for resisting DVR maneuver during scoliosis correction. This technique may represent an effective and safe approach, particularly for the convex side of the scoliosis apex, with increased resistance to derotational forces and decreased risk of bone failure. Further clinical studies are warranted for firmer conclusions.

Osteonecrosis of the femoral head, a disease primarily affecting young adults, is often associated with the collapse of the articular surface and subsequent arthrosis. Some authors have reported good results with the use of vascularized and non-vascularized fibular grafts to treat osteonecrotic lesions of the femoral head. The aim of this study was to compare the results of vascularized fibular grafting with that of non-vascularized fibular grafting in the treatment of femoral head osteonecrosis.Between January 1999 and June 2008, 11 osteonecrotic hips of 8 patients who underwent vascularized fibular grafting and 15 osteonecrotic hips of 13 patients who underwent nonvascularized fibular grafting were compared according to etiology, stage, age, sex, preoperative and postoperative first year Harris hip and VAS scores.Steroid use was the most common etiologic factor, found in 26 hips of 21 patients in the entire patient population. There was no significant difference between the two groups according to their age, sex and preoperative Harris hip scores (p0.05). According to the Ficat staging system for radiological evaluation, 4 hips were Grade 2A, 4 hips were Grade 2B, and 3 hips were Grade 3 in the vascularized group and 8 hips were Grade 2A, 3 hips Grade 2B, 3 hips Grade 3 and one hip was identified as Grade 4 in the non-vascularized group. When the Harris hip and VAS scores of both groups were evaluated, the group treated by vascularized fibular grafting had significantly higher scores than the ones treated by non-vascularized fibular grafting in the other group (p0.05). Furthermore, when the Harris hip and VAS scores of preoperative and postoperative first year of vascularized fibular grafting patients were compared, there were significantly higher scores after the surgery.Although there was no significant radiological difference in the early results of both surgical techniques, the clinical results of vascularized fibular grafting treatment were significantly better than the results of non-vascularized fibular grafting treatment in the osteonecrosis of the femoral head. Vascularized fibular grafting improves the clinical status at an early period and prevents subchondral collapse.

Static magnetic fields are a type of electromagnetic fields used in clinical practice. To ascertain what effect a static magnetic intramedullary device implanted in the rabbit femur had on fracture healing, 20 male New Zealand white rabbits with magnetic/nonmagnetic intramedullary implants were examined histologically, radiologically and for bone mineral density. Three groups were constituted according to the poles of the magnets. During surgery the intramedullary device was driven into the medulla. A femoral osteotomy was created with a mini Gigli wire at the centre point of the rod. Radiographs were obtained at the second and fourth weeks. Histological examination and bone mineral density were evaluated at the fourth week. The results of this study verified that an intramedullary implant with a static magnetic field improves bone healing in the first two weeks radiologically and that the configuration difference in magnetic poles has an effect on bone quality. Static magnetic fields have minor effects on bone mineral density values.

The migration of various internal fixation devices, especially Kirshner (K) wires, is well established. The wires usually follow a retrograde path, protruding near the entry point. When they migrate in the other direction, serious problems may occur. Migration of K-wires to the lung, heart, spleen, subclavian artery, pulmonary artery and aorta have been reported in a few cases. A 26-year-old male with chest pain was seen in our clinic. The patient had been operated for left distal clavicle fracture two years before. No abnormality was noted on the physical examination. Radiographs showed migration of the wire outside the clavicle across the sternum to the opposite hemithorax. The pin was removed through the incision over the sternum under direct vision with thoracoscope. The pin was extrapleurally located. There was no additional morbidity attributed to thoracoscopy or chest tube. In conclusion, K-wires can easily migrate, resulting in serious complications. Close follow-up should be done after internal fixation.

We evaluated our treatment algorithm used in adult patients with tuberculous spondylitis together with long-term treatment results.The study included 55 adult patients (26 males, 29 females; mean age 50 years; range 23 to 71 years) with tuberculous spondylitis. The patients underwent four different treatment methods including non-operative treatment (NO, 6 patients), posterior debridement, fusion and instrumentation (PDFI, 21 patients), anterior debridement, instrumentation and fusion (ADIF, 21 patients), and finally, urgent radical debridement (RD, 11 patients) due to financial limitations of the patients. All the patients received antituberculous therapy for 12 months. On presentation, 17 patients (30.9%) had neurologic deficits (ADIF, 6 patients; RD, 11 patients). Neurologic assessment was made according to the Frankel grading system. The results were evaluated with respect to kyphosis, sagittal balance, neurologic recovery, and patient satisfaction. The mean follow-up period was 95.3 months (range 66 to 114 months).Radiographically, successful bone fusion was achieved in all the patients. Following treatment, all surgically treated groups exhibited decreases in the kyphotic angle. The mean correction was significantly greater in ADIF (17.5 degrees ) and PDFI (12.1 degrees ) groups compared to the RD group (4.9 degrees ) (p0.05). Final increases in the kyphotic angle were 0.7 degrees , 1.2 degrees , 1.4 degrees , and 1.6 degrees in NO, PDFI, ADIF, and RD groups, respectively. The mean sagittal deviations in the first postoperative month were +2 mm, +11 mm, +12 mm, and +14 mm in NO, PDFI, ADIF, and RD groups, respectively, which remained unchanged till the end of follow-up. Complete neurologic recovery was obtained in all but one patient. All the patients expressed satisfaction with the treatment. No recurrences or reactivation of disease were observed.This study showed that, with appropriate patient selection, the results of NO, PDFI, and ADIF were satisfactory and comparable.

Centralising devices were introduced to ensure that the prosthesis is implanted in a neutral position and that a cement mantle of optimal thickness is achieved proximally and distally. A distal centralising device (DCD) is compared with a proximal midshaft centralising device (PCD) to test which one provides a more neutral prosthetic alignment. Thirty consecutive patients undergoing hemiarthroplasties for femoral neck fractures were studied prospectively. Patients were blindly randomised to receive either a femoral component with proximal midshaft centraliser or distal centraliser. Both components were implanted following the manufacturer’s protocol. Postoperative true anteroposterior and lateral radiographs were made to assess the stem position. There was no statistically significant difference between the two groups in zones 1, 2, 3, 4, 5, 6 and 7 in both anteroposterior and lateral radiographic measurements. DCP and PCD both have similar centralisation and cement mantle. Future studies should be done to evaluate their long-term effect.

An animal model of vertebral instability was used to analyze the effect of chronic lumbar instability on the peridural vasculature and fibrosis formation. Fifty mature male domestic rabbits were divided into five equal groups. The vertebral instability was performed by excision of supra and interspinous ligaments between L2-L3 and L3-L4, excision of transverse and spinous processes and making bilateral laminectomies and facetectomies in groups I, II, III and IV. In group V only para vertebral muscle dissection was performed without vertebral instability. The simulation of the long term effects of overuse model on unstable spines (chronic instability) were performed with the use of Electrical Neuromuscular Stimulator to simulate cyclic flexion–extension movement in groups I, II. The rabbits in group I and III were sacrified for the histological evaluation at postoperative fifth day. The rabbits in groups I II, IV and V were sacrified at postoperative 21st day. There was no peridural venous endothelial injury or stasis but there was an increased amount of polymorph nuclear leukocytes in both group I (unstable-overuse) and group III (unstable-no overuse) after sacrification at postoperative fifth day. Peridural fibrosis and also vascular changes with different grades were seen in group II, VI and V after sacrification at postoperative 21th day. The grade of the venous changes and the mean amount of peridural scar formation were prominently higher in group II (unstable-overuse) than in group IV (unstable-no overuse) and V (control group). There was no difference between group IV and V for peridural scar formation and vascular changes. In conclusion, the instability of the lumbar spine with overuse could be a cause of peridural venous circulatory impairment, resulting in fibrosis formation.

Multiple enchondromatosis (Ollier's disease) is a rare disease characterized by widespread enchondromas. In general, the short tubular bones of the hand are involved, with progressive lesions resulting in cosmetic problems and functional deformities. Diaphysectomy and reconstruction with structural autografts or allografts are usually recommended in the treatment of extensive enchondromas involving the fingers. Curettage and grafting and ray amputation are other surgical procedures that can be applied depending on the severity of involvement. A 25-year-old woman with enchondromatosis presented with severe swelling and deformities on her fingers in both hands. The majority of the lesions were managed by diaphysectomy and reconstruction with structural grafts; ray amputation, curettage and grafting were performed for more severe lesions. During a long-term follow-up (left hand 6 years, right hand 5.5 years) cosmetic and functional results were acceptable.

Superior excursion of the humeral head on the face of the glenoid was investigated to determine whether a relationship exists between the degree of humeral head excursion and the identity of the injured tendon in a shoulder with a torn rotator cuff. Twenty-seven patients with unilateral full-thickness rotator cuff tears diagnosed by either positive arthrogram or magnetic resonance imaging were included in this study. Three groups were formed based on intraoperative findings: 10 patients had isolated supraspinatus tendon tears (group 1), 11 patients had supraspinatus and infraspinatus tears (group 2), and 6 patients had supraspinatus, infraspinatus, and subscapularis tendon tears (group 3). There was no statistically significant difference between the degree of humeral head excursion in groups 1 and 2. However, patients in group 3 had a statistically significantly higher degree of excursion of the humeral head (P.05) when compared with groups 1 and 2. In addition, an inverse relationship between the degree of humeral head excursion and preoperative Constant scores was found. Superior excursion of the humeral head on the glenoid had a significantly higher incidence in patients with subscapularis tears, and a larger amount of excursion was present in patients who had lower preoperative Constant scores.

Diagnosis and management of chronic dislocations of the glenohumeral joint remain challenging. These dislocations usually occur in debilitated patients with a poor bone quality and they often have a decreased rehabilitation potential. Treatment can only be successful with early recognition of the condition, careful patient selection, and implementation of appropriate surgical techniques. This article reviews current information on clinical evaluation, preoperative radiologic investigations, and treatment strategies in patients with chronic dislocations of the glenohumeral joint and associated articular surface defects.

Shoulder complaints are one of the leading reasons for a doctor's visit in athletes involved in overhead activities, and among them, dislocation and subluxation are very frequent clinical presentations. Although diagnosis and management of shoulder problems are more clear-cut in traumatic cases, atraumatic cases may be quite troublesome. In order to facilitate the interval between the presentation of complaints and institution of appropriate treatment, many issues should be appreciated including the anatomy, etiology, pathogenesis, clinical evaluation, and treatment of shoulder disorders. This review aims to outline the current approach to shoulder problems arising from instability in the light of the most recent literature.

Biomechanical studies have shown that the biceps tendon and the superior labrum have significant contributions to the glenohumeral stability. Since superior labrum anterior-posterior (SLAP) lesions pose diagnostic difficulties, they should be kept in mind when evaluating a painful shoulder. Although magnetic resonance arthrography is of great use in diagnostic studies, diagnostic arthroscopy is still the best method for these lesions. Treatment may vary depending on the type of the lesion. As our knowledge about the glenohumeral anatomy enhances, success rates of the arthroscopic treatment of SLAP lesions will increase.

We evaluated the results of surgical management of hip instability in children with spina bifida (SB).Twenty-eight hips of 26 patients (16 girls, 10 boys; mean age 4.5 years; range 3 to 6 years) were surgically managed for hip instability (subluxation/dislocation) associated with SB. Twenty-four patients (2 bilateral dislocations) had low-level lesions (L4-sacral) and a potential to walk, of which 16 patients presented with unilateral dislocation with functional problems including significant (2 cm) limb-length discrepancy and scoliosis. Two patients had high-level lesions (thoracic-L3) associated with unilateral dislocations and were unable to walk. Those with a high-level lesion and some patients (9/26 hips) with a low-level lesion also had hip flexion contractures. Treatment included open reduction, pelvic osteotomy, proximal femoral osteotomy when necessary, and a spica cast. The patients were clinically and radiographically monitored for a mean of 38 months (range 30 to 48 months).Of 16 patients with functional problems, 14 patients had improvement in their gait patterns, while limb-length discrepancy and scoliosis persisted in two. The remaining 10 patients maintained their preoperative functional statuses. The mean range of motion of the hips decreased postoperatively; however, none of them developed joint stiffness. Early postoperative complications included superficial wound infections in three patients, and distal femoral diaphyseal fractures in two patients. Three patients required removal of the implants in the sixth month due to subcutaneous prominence thereof. Late radiographs of three patients showed recurrent subluxations, which did not require any intervention.Although surgical treatment of hip problems associated with high-level lesions may be unrewarding in children with SB, those associated with low-level lesions can be successfully managed with proper surgical indications.

Transient osteoporosis of the hip is a rare disease of unknown etiology. It is usually seen in middle-aged men and women in the third trimester of pregnancy and is associated with hip pain. It typically runs a benign course with eventual resolution of symptoms. We report three patients who presented with unilateral hip pain that started in the third trimester of pregnancy. Diagnosis of transient osteoporosis of the hip was made with the help of clinical and radiologic studies. Treatment was comprised of pain control therapy with diclofenac sodium (100 mg/day) for three months, bed rest for a month followed by mobilization with a walking aid. The follow-up period was at least 24 months. Clinical improvement occurred in the third month in one patient, and at the end of six months in the remaining patients. Complete radiologic improvement was seen at the end of 12 months.

We studied 117 adult patients undergoing posterior lumbar spinal fusion and instrumentation using bone grafts from the iliac crest between February 1999 and January 2001. All patients had degenerative disease of the lumbar spine, and all were operated upon by the same surgeon. Patients were randomized to have the iliac bone graft harvested either through a separate incision (traditional approach) or utilizing the same midline incision as used for the spinal surgery (intrafascial approach). Total volume of harvested graft, blood loss, pain, complications, and patient satisfaction were evaluated with a minimum of 2-year follow-up. There were no infections. The average volume of harvested bone was 17.2 cc versus 14.7 cc; total blood loss was 168 cc versus 96 cc; total complication rate was 20% versus 8%, and overall satisfaction rate was 81% versus 96%, respectively. The intrafascial graft harvesting technique minimizes morbidity and increases patient satisfaction compared with the traditional bone harvesting technique.

We presented our experience with the diagnosis and treatment of low back pain in children.We retrospectively reviewed 29 children (15 girls, 14 boys; mean age 12 years; range 9 to 17 years) who were treated for low back pain and had appropriate follow-ups. Etiologic causes were sought by clinical evaluation, radiologic studies, and laboratory tests. Patients with unknown etiology underwent symptomatic treatment. The mean follow-up period was 42 months (range 12 to 96 months).Etiology was determined in 26 patients (89%), which included spondylolysis/spondylolisthesis (n=8), Scheuermann's disease (n=6), neoplasia (n=5), discitis/vertebral osteomyelitis (n=4), and lumbar disc herniation (n=3). Spondylolysis was managed conservatively, except for one patient who had in situ spinal fusion for associated spondylolisthesis. Five patients with Scheuermann's disease were treated conservatively, while one patient required spinal fusion. Surgical treatment with biopsy, curettage, and bone grafting was performed for all neoplasias, but one which was followed-up conservatively. Two patients with discitis were managed with antibiotic treatment and two patients with vertebral osteomyelitis (Pott's abscess) underwent both medical treatment and surgical drainage and stabilization with strut graft. Lumbar disc herniation was treated conservatively in two patients, while one had surgical treatment with excision of disc fragments and limited laminectomy. Finally, all the patients became asymptomatic on final examinations.Serious consideration should be given to persistent low back pain in children. Clinical, radiologic, and laboratory findings can be elaborated into etiologic diagnoses and complete relief can be achieved with appropriate treatment.

We evaluated the long-term results of rotator cuff tears treated by open surgical repair.Ninety shoulders of 88 patients (36 females, 52 males; mean age 57 years; range 36 to 75 years) with rotator cuff tears were treated by open surgical repair and acromioplasty. A three-staged rehabilitation program was implemented following surgery. Objective evaluations were made with the use of the Constant-Murley scoring system. Pain was assessed through a visual analog scale. The mean follow-up period was 61 months (range 24 to 102 months).The mean Constant-Murley score increased from preoperative 41.7 (range 12 to 82) to postoperative 79.7 (range 42 to 100) (p0.0001). The mean preoperative and postoperative pain scores were 7.5 (range 4 to 10) and 1.25 (range 0 to 5), respectively (p0.0001). Only eight patients (9%) showed dissatisfaction with the surgical outcome. The remaining 80 patients (91%) were satisfied with the outcome and returned to their previous night comfort and daily activities. None of the patients had postoperative nerve palsy or limitations in shoulder functions. Two patients (2.2%) developed superficial soft tissue infections that disappeared following multiple wound debridements.Our long-term results favor open surgical repair and acromioplasty in the treatment of patients with rotator cuff tears.

We evaluated the results of arthroscopic or open anterior acromioplasty after a mean follow-up of two years in the treatment of impingement syndrome.The study included 145 patients who underwent anterior acromioplasty through open surgery (90 patients; mean age 56 years; range 36 to 70 years) or arthroscopic surgery (55 patients; mean age 49 years; range 32 to 58 years). Comparisons were made between both groups with regard to preoperative and postoperative Constant scores, activity, pain, range of motion, and strength scores, and durations for postoperative pain, hospital stay, and return to work. The mean follow-up was 24 months (range 12 to 60 months) for both groups.The mean Constant scores increased from preoperative 32.6 to postoperative 80.5 and from 25.5 to 83.1 with open and arthroscopic surgery, respectively. No significant differences were found between the two groups with regard to pre- and postoperative Constant scores, activity, pain, range of motion, and strength scores (p0.05). However, patients who underwent arthroscopic surgery exhibited shorter durations in the following: hospital stay (1.36 vs 1.72 days), delay in return to work (9 vs 16 days), and postoperative pain (6 vs 8 weeks) (p0.05). According to subjective patient evaluations, arthroscopic results were good or excellent in 47 patients (85.5%), satisfactory in six patients (10.9%), and poor in two patients (4.6%); open surgery results were good or excellent in 76 patients (84.4%), satisfactory in 10 patients (11%), and poor in four patients (4.6%).Both treatment options seem to be equally effective in the treatment of impingement syndrome in the absence of rotator cuff tears.

Thirty feet with hallux valgus (HV) having grade 2 and 3 sesamoid stations on AP radiographs were examined after Lindgren-Turan oblique distal metatarsal osteotomy with a minimum follow-up of 12 months. Adductor tendon release from the lateral sesamoid was not performed to determine the isolated effect of distal metatarsal osteotomy on metatarsosesamoidal reduction. Of the 30 feet, 20 (67%) had reduced and 10 (33%) unreduced sesamoids at the follow-up. Ultimately, distal metatarsal osteotomy (DMO) with lateral shifting of the first metatarsal head more than 7.2 mm was found to reduce the sesamoids in the great majority of the cases (95% CI 7.243-9.757). Sesamoid release is redundant for metatarsosesamoidal reduction if sufficient lateral shift of the first metatarsal head over the sesamoids is accomplished.

During the past decade, arthroscopy has become an accepted tool for the evaluation and management of shoulder disorders. The glenohumeral joint, subacromial space, acromioclavicular joint, and even the scapulothoracic articulation can be assessed through arthroscopy. Proper portal placement allows a safe access without risk for neurovascular, tendon, or articular injuries. Anterior acromioplasty is probably the most common arthroscopic procedure performed in the shoulder, with reported results similar to open techniques. This article focuses on the arthroscopic treatment of impingement syndrome in the light of published data, together with its technical aspects.

A thirty-nine-year-old man presented with a complaint of low back pain with a history of 20 years. Cervical and thoracolumbar radiographs showed wide calcification areas and ankylosis in the intervertebral discs. Observation of blue-gray pigmentation around his nose and ears suggested a diagnosis of ochronosis, which was confirmed by the detection of high levels of homogentisic acid in the urine and dark urine color following alkalization. Ochronosis should be included in the differential diagnosis in patients with chronic low back pain, calcified intervertebral discs, and black pigmentation in cartilagenous and collagenous tissues.

Several clinical and experimental reports have evaluated the spinal application of bioabsorbable material for plating the anterior lumbar and cervical spine, and in anterior and posterior lumbar interbody spinal fusion. Nevertheless, the use of these materials in posterolateral interlaminar fusion has yet to be elucidated in the literature. The effects of bioabsorbable self-reinforced polylactide rod (SR-PLLA) implantation, rigid fixation (K-wire) and non-implantation with posterior interlaminar fusion were compared using a rabbit model. Twenty-four mature domestic rabbits were divided into three groups. Eight received implantation with SR-PLLA, eight with K-wire, and eight were fused without instrumentation. The animals were killed at 12 weeks and evaluated by posteroanterior radiography, manual palpation and histological examination for the presence of fusion. Successful fusion was achieved in all of the animals in both implanted groups (SR-PLLA and K-wire), whereas solid fusion was not detected in any of the specimens in the non-implanted group. Computed tomography (CT) scans were used to detect fusion mass volume. The fusion mass in the SR-PLLA implanted group had a mean volume of 1,196 mm(3)+/- 167 mm(3) vs 1,061 mm(3)+/- 181 mm(3) for the K-wire implanted group (not significant) and 711 mm(3 +/-)407 mm(3) (p < 0.05) for the non-implanted group. The results of this study suggest that the stabilization properties of both SR-PLLA rods and K-wire seem to be sufficient for spinal fusion, but using SR-PLLA is especially advantageous, since they do not require a removal operation and do not interfere with magnetic resonance imaging (MRI).

From 1992 to 1997 a series of 12 multiply operated (averaging 2.5 previous operations) patients with recurrent peridural fibrosis and postlaminectomy kyphosis underwent surgery at our clinic. The surgery was designed to restore the physiological lordosis and relax tethered cord and epidural veins by transpedicular decancellation osteotomy at a vertebra other than the vertebra with peridural fibrosis. This paper presents the long-term functional outcome of these 12 patients. Clinical assessments were conducted pre-operatively and at 3-month intervals postoperatively and included X-ray assessment and evaluation of the patients' functional status by Oswestry Disability Index (ODI) and of pain by visual analogue scale (pain VAS). All symptoms and the pain due to peridural fibrosis disappeared in the early postoperative period. Patients had tower disability and pain scores at their early and long-term follow-ups (follow-up period 24-74 months, mean 36.3 months). For patients with failed medical therapy for peridural fibrosis accompanied by lumbar kyphosis or hypolordosis, transpedicular decancellation osteotomy should be the surgical treatment of choice.