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Objective: This study aimed (1) to simulate pedicle screw pullout after intraoperative external wall perforation and (2) to assess restoration strength with different thread designs in the pedicle screw instrumentation for osteoporotic thoracic vertebrae., Methods: Twenty fresh-frozen human cadaveric thoracic vertebra bodies were prepared and divided into 4 groups: group 1, 5.5 mm × 45 mm polyaxial single thread pedicle screws (PASTS); group 2, after wall injury 5.5 mm × 45 mm PASTS; group 3, 6.5 mm × 45 mm PASTS after wall injury; and group 4: 6.5 mm × 45 mm polyaxial mixed-threaded screws after wall injury. While group 1 was the control group, groups 2, 3, and 4 were used as study groups after the lateral wall breach. All prepared screw units were placed on a universal pullout measurement testing device., Results: The mean bone mineral density for 20 thoracic vertebrae was 0.57 ± 0.12 g/cm2 (range 0.53-0.6 g/cm2 ). The mean pullout strength was 474.90 Newtons (N) for group 1, 412.85 N for group 2, 475.4 N for group 3, and 630.74N for group 4. The lateral wall breach caused a 14.1 % decrease in average pullout strength compared with the initial screw pullout. Mixed (double)-threaded screws increased pullout strength compared to 6.5 mm screws (P=.036) Conclusion: Using a 1 mm thicker polyaxial pedicle screw or mixed (double)-threaded pedicle screw seems to increase pullout strength; however, this was statistically significant only for group 4. In the thoracic spine, the redirection possibility of the pedicle screw is limited, and augmentation with cement will not be appropriate due to the risk of wall injury-related leakage. Therefore, care should be taken to avoid violating the lateral cortex by using appropriate pedicle entry points and trajectories.

Objectives: Greulich-Pyle (GP) is one of the most used method for bone age determination (BAD) in various orthopedic, pediatric, radiological, and forensic situations. We aimed to investigate the inter- and intra-observer reliability of the GP method between the most relevant disciplines and its applicability to the Turkish population., Methods: One-hundred and eighty (90 boys, 90 girls) patients with a chronological age younger than 18 (mean 9.33) were included. X-rays mixed by the blinded investigator were evaluated by two orthopedists, two radiologists, and two pediatric endocrinologists to determine skeletal age according to the GP atlas. A month later the process was repeated. As a statistical method, Paired t-test was used for comparison, an Intraclass Correlation Coefficients test was used for reliability and a 95 % confidence interval was determined. Results were classified according to Landis-Koch., Results: All results were consistent with chronological age (p<0.001), according to the investigators' evaluations compared with chronological age. At the initial evaluation, the interobserver reliability of the method was 0.999 (excellent); at the second evaluation, the interobserver reliability was 0.997 (excellent). The intra-observer reliability of the method was 'excellent' in all observers. When results were separately evaluated by gender, excellent intraobserver correlation and excellent correlation with chronological age were found among all researchers (>0.9). When X-rays were divided into three groups based on age ranges and evaluated, 'moderate' and 'good' correlations with chronological age were obtained during the peripubertal period., Conclusions: The GP method used in skeletal age determination has excellent inter- and intra-observer reliability. During the peripubertal period, potential discrepancies in bone age assessments should be kept in mind. This method can be used safely and reproducibly by the relevant specialists., (© 2023 Walter de Gruyter GmbH, Berlin/Boston.)

Aim: To investigate the importance of thoracic kyphosis (TK) for treatment preference in patients with Lenke Type 5C adolescent idiopathic scoliosis by comparing radiological outcomes of the patients who underwent selective fusion (SF) or nonselective fusion (NSF)., Material and Methods: Twenty-nine patients with Lenke Type 5C AIS were included and then divided into two groups as per the fusion procedure used in the surgical treatment. SF group including 16 patients (14 female patients; mean age = 15.56 yr; age range, 14?18) with normal TK and NSF group including 13 patients (nine female patients; mean age = 15.54 yr, age range, 13?18) with thoracic hyperkyphosis. Thoracolumbar/lumbar (TL/L) Cobb, thoracic (T) Cobb, TK and lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), and sacral slope (SS) were measured on standing spine radiographs preoperatively and at the final follow-up. The correction rates (CRs) of Cobb angles and the difference in each other radiological parameters were calculated., Results: No significant differences were observed in the mean CRs of TL/L Cobb and T Cobb angles, PI, SS, and PT (p=0.313, p=0.444, p=0.51, p=0.472, and p=0.14, respectively). However, significant differences were observed in the mean TK angle, which was ?2.13° ± 13.52° (range, 29?27°) in SF group and 28.46° ± 15.05° (range, ?4°?°47°) in NSF group (p=0.001), and LL angle was 0.88° ± 14.23° (range, ?21°?32°) in SF group and 11.54° ± 17.79° (range, ?31°?34°) in NSF group (p = 0.016)., Conclusion: In patients in whom Lenke?s sagittal modifier is N, SF can be performed efficiently. NSF can be preferred for those with (+) Lenke?s sagittal modifiers as it provides better TK control.

Background: Biphalangealism has been evaluated in many studies and has been shown as a common variant. Its frequency varies according to the populations. This epidemiological study aimed to determine the prevalence of biphalangealism for each toe in the Turkish population and compare it with other populations., Methods: The local hospital radiological database was searched for all consecutive foot radiographs, obtained between 2014 and 2018. Anteroposterior (AP) and oblique radiographs obtained to evaluate trauma or foot pathologies were included. Two-phalangeal toes according to radiographical views were defined as biphalangeal and other three-phalangeal toes were defined as normal., Results: A total of 2,881 radiographs of 2,710 adult patients met the incusion criteria. There were 1,558 (57.5%) female and 1,152 (42.5%) male patients. The cases were unilateral in 2,539 patients and bilateral in 171 patients. The overall prevalence of biphalangeal third toe was 0.29%, fourth toe was 1.29%, and fifth toe was 23.3%., Conclusions: The presence of pedal biphalangealism is a common variant and its frequency varies according to the populations. The exact cause is still unclear. Further studies are required to assess the clinical impact of biphalangealism.

Background: It is well-known that hallux valgus (HV) alters foot biomechanics. In different populations, HV and postural stability has been studied, but HV and the adolescent ballet dancer has not been studied. The aims of this study were to explore the effect of HV on adolescent ballet dancers' balance and to assess the health-related quality of life (HRQOL) of adolescent ballet dancers with HV., Methods: Female ballet dancers aged 8 to 16 years were screened prospectively and divided into two groups: those with HV (group 1) and those without HV (group 2). The HV diagnosis was made clinically. The groups were compared according to balance parameters and HRQOL questionnaires., Results: In group 1 (n = 31) and group 2 (n = 24), the mean age was 11.6 years and 12.2 years, respectively. Mean first metatarsophalangeal angle was 13.4° (range, 10°-15°) in group 2 and 19.8° (range, 16°-25°) in group 1. A statistically significant difference was found according to the nonparametric Mann-Whitney U test results in the comparison of HV angle between groups. According to Spearman rho correlation analysis, it was determined that the increase in HV angle caused deterioration in the flamingo static balance test (r = 0.552; P = .019). No significant relationship was found between HRQOL questionnaires and the presence of HV (P > .05)., Conclusions: Adolescent ballet dancers experience static balance impairment due to HV angle increase. Clinical measurement of HV and application of balance parameters made easy without need of set ups to perform evaluation with high numbers of participants in concordance with the literature.

Objective: Patients with a C6 radiculopathy-mimicking complaint are always in the gray zone if the diagnosis is not clear. The aim of the study is to make the diagnosis clear if the neck and shoulder pain is caused by a dynamic stenosis of the neural foramen at the C5-C6 level., Methods: Patients with a C6 radiculopathy-mimicking complaint were included in the study. Patients had a cervical spine magnetic resonance imaging (MRI) at the normal limits, or a minimal protrusion at the C5-C6 level underwent a dynamic MRI procedure. We measured the foraminal area and spinal cord diameter (SCD) at the C5-C6 level by using the PACS system ROI irregular are determination integral embedded to PACS. Inter- and intraobserver reliability of measurements was evaluated. Results were analyzed statistically, and a p value< 0.05 was accepted as statistically meaningful., Results: A total of 23 patients between January 2019 and June 2019 were included in the study. There were 10 men and 13 women, and the mean age was 41.3 (range 33-53). Foraminal area decrease at C5-C6 in extension and increase in flexion when compared with the neutral position was statistically significant ( p < 0.001). Foraminal area changes between the complaint side and the opposite side was not statistically different ( p > 0.05). Interobserver and intraobserver reliability of measurements were classified as in almost perfect agreement., Conclusions: Our present work presented dynamic and positional foraminal changes in MRI with radiculopathy-mimicking patients. Soever, we did not find a difference between the clinical complaint side and the opposite side in radiculopathy-mimicking patients. Cervical radiculopathy pain should not be attributed only to foraminal sizes. PACS embedded irregular area measurement integral allows the easy measure of a big number of patients without additional set-up and digital work requirements., Competing Interests: The authors have no conflicts of interest to declare., (Copyright © 2022 Ozcan Kaya et al.)

The pullout strength of the pedicle screws after direct vertebral rotation (DVR) maneuver is not known. This biomechanical study was performed to quantitatively analyze the pullout strength of a pedicle screw after DVR maneuver using human cadaveric vertebrae. Thoracic vertebral bodies from three cadavers were harvested and stripped of soft tissues. Thirty pedicles of 15 vertebrae were separated into two groups after bone mineral density measurements. Polyaxial 5.5 mm pedicle screws with appropriate length were inserted with a freehand technique for each pedicle. One Kirschner wire was inserted to the anterior part of each vertebral corpus the half depth of each corpus was embedded into PVC pipes using polyester paste. In the DVR group, each screw was pulled horizontally with 2 kg (~20 N) load over a screwdriver rigidly attached to the screw, and a DVR maneuver was simulated. The control group did not load with a DVR maneuver. Samples were placed on a universal testing machine and pullout loads were measured. The Mann-Whitney U test was utilized, and the P value <0.05 was considered as statistically significant. In the DVR group, the mean pullout strength was 183.35 N (SD ± 100.12), and in the control group, the mean pullout strength was 279.95 N (SD ± 76.26). Intergroup comparisons revealed that DVR maneuver significantly decreases the pullout strength (P = 0.012). The results of this study confirm that the pullout strength of pedicle screw significantly decreases by approximately 35% when DVR maneuver is applied., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Proximal junctional kyphosis - PJK has been defined by a 10 or greater increase in kyphosis at the proximal junction as measured by the Cobb angle from the caudal endplate of the uppermost instrumented vertebrae (UIV) to the cephalad endplate of the vertebrae 1 segments cranial to the UIV. In this biomechanical study, it is aimed to evaluate effects of interspinosus ligament complex distruption and facet joint degeneration on PJK development., Materials and Methods: Posterior instrumentation applied between T2 - T7 vertebrae using pedicle screws to randomly selected 21 sheeps, divided into 3 groups. First group selected as control group (CG), of which posterior soft tissue and facet joints are protected. In second group (spinosus group, SG) interspinosus ligament complex which 1 segment cranial to UIV has been transected, and third group (faset group-FG) was applied facet joint excision. 25 N, 50 N, 100 N, 150 N and 200 N forces applied at frequency of 5 Hertz as 100 cycles axial to the samples. Then, 250 N, 275 N and 300 N forces applied static axially. Interspinosus distance, kyphosis angle and discus heights was measured in radiological evaluation. Abnormal PJK was defined by a proximal junctional angle greater than 10 0 and at least 10 0 greater than the corresponding preoperative measurement., Results: In CG group, average interspinosus distance was 6,6 ± 1.54 mm and kyphosis angle was 2,2 ± 0.46° before biomechanical testing, and they were measured as 9,4 ± 1.21 mm and 3,3 ±0.44° respectively after forces applied to samples. In SG group, average interspinosus distance was 6,2 ± 1.72 mm and kyphosis angle was 2,7 ± 1.01° before experiment, and they were measured as 20,8 ± 5.66 mm and 15,1 ± 2.34° respectively after forces applied to samples. In FG group, average interspinosus distance was 4,8 ± 1.15 mm and kyphosis angle was -1 ± 4.14° before experiment, and they were measured as 11,1 ±1.96mm and 11 ± 2.87° respectively after forces applied to samples. In comparison to group CG, statistically significant junctional kyphosis was seen on both FG and SG group after statistical analysis. (p < 0.05). PJK was seen statistically significant more on SG group than FG group. (p < 0.05). Not any statistically significant difference was seen on measurement of disk distances among three groups. (p > 0.05) CONCLUSIONS: Protecting interspinosus ligament complex and facet joint unity during posterior surgical treatment for spine deformation is vital to prevent PJK development. Based on our literature review, this is the first biomechanical study that reveals interspinosus ligament complex are more effective on preventing PJK development than facet joints., (Copyright © 2019 Turkish Association of Orthopaedics and Traumatology. Production and hosting by Elsevier B.V. All rights reserved.)

We report the outcomes of mechanical prophylaxis and chemoprophylaxis in patients who underwent elective surgery for idiopathic adolescent scoliosis (AIS).We retrospectively studied the patients who underwent posterior spinal instrumentation for AIS. The patients were divided into three groups: Group A low-molecular-weight heparin (LMWH) started at 8 hours after surgery; Group B LMWH started at 24 hr after surgery; Group C did not receive chemoprophylaxis. The data about wound oozing, need for transfusion, preoperative and postoperative hemoglobin level, length of stay in hospital, interval from the surgery to removal of closed suction drainage tube, postoperative blood loss from closed suction drain, deep venous thrombosis (DVT), and pulmonary embolism (PE) were investigated.The mean age and Lenke classification for all the groups were similar. No DVT or PE was detected in any group. The mean blood loss from the drain was higher in Group A (400 mL) and Group B (450 mL) when compared to Group C (150 mL) (P = .001). There were more wound oozing in Groups A (5) and B (6) than in Group C (3) (P = .585). Three patients in Group B, 3 patients in Group A, and no patient in Group C had superficial infections. However, there was no statistical difference between the groups (P = .182). Postoperative hospital stay was significantly longer in Groups A (6 days) and B (6 days) then in Group C (5 days) (P = .001).Our current study claims that chemoprophylaxis is not necessary for the patients without risk factors after AIS surgery. Early mobilization and mechanoprophylaxis represents adequate prophylaxis in addition to pain management and well hydration in patients' routine treatment. The complications of chemoprophylaxis are not correlated to the initiation time of prophylaxis.

Background: Gout is a purine metabolism disease. Tophaceous gout may cause joint destruction and other systemic problems and sometimes may be complicated by infection. Infection and sinus with discharge associated with tophaceous gout are serious complications, and treatment is difficult. We present a patient with tophaceous gout complicated by infection and discharging sinus treated by bilateral amputation at the level of the first metatarsus., Methods: A 43-year-old man previously diagnosed as having gout, and noncompliant with treatment, presented with tophaceous gout associated with discharging sinus and infection on his left first metatarsophalangeal joint. Because of the discharging sinus associated with the tophaceous deposits, the soft-tissue and bony defects, and the noncompliance of the patient, amputation of the first ray was undertaken, and a local plantar fasciocutaneous flap was used to close the defect. After 8 months, the patient was admitted to the emergency department with similar symptoms in his right foot, and the same surgical procedure was performed., Results: One year after the second surgery, the patient had no symptoms, there was no local inflammatory reaction over the surgical areas, and laboratory test results were normal., Conclusions: Gout disease with small tophi often can be managed conservatively. However, in patients with extensive lesions, risk of superinfection justifies surgical treatment. Results of complicated cases are not without morbidity; therefore, early surgical treatment may prevent extremity loss and further complications. In severe cases, especially with compliance issues, amputation provides acceptable results.

Background: It is a randomized study to compare cement penetration on x-rays after total knee arthroplasty (TKA) among 3 different ways to use tourniquets; application during the surgery, application only with implantation prosthesis and with no tourniquet use., Methods: A total 69 knees of 59 patients were included in the study in a quasirandom manner. Each patient had physical exams and standard radiographic evaluations at 6 weeks after the TKA procedure. Outcome evaluations included visual analog scale (VAS) scores, Knee Society Scores (KSS), blood transfusion, and drainage status after surgery for all groups. For radiographic review, the tibial plateau was divided into zones in the anterior-posterior and lateral views, according to the Knee Society Scoring System., Results: The average age of the patients who were eligible for the study was 65.05 (range 46-81) years. All 59 patients included in the study were female patients. Group 1 consisted of 24 patients who had TKA with use of a tourniquet during the entire operation. Group 2 consisted of 20 patients who had TKA with use of tourniquet only at the time of cementing and group 3 consisted of 25 patients with no use tourniquet. There is no significant difference in early cement penetration among the groups (group 1 2.50 mm, group 2 2.28 mm, group 3 2.27 mm; group 1 vs 2 P = .083, group 1 vs 3 P = .091, group 2 vs 3 P = .073). There is no significant difference for postoperative drainage among the 3 groups (group 1 245 mL, group 2 258.76 mL, group 3 175.88 mL; group 1 vs 2 P = .081, group 1 vs 3 P = .072, group 2 vs 3 P = .054). There was no need to transfuse more than 1 unit in any patient. The VAS score was significantly higher (group 1 3.58, group 2 1.55, group 3 1.52; group 1 vs 2 P = .022, group 1 vs 3 P = .018, group 2 vs 3 P = .062) and KSS was significantly lower in the tourniquet group (group 1 63, group 2 79, group 3 82; group 1 vs 2 P = .017, group 1 vs 3 P = .02, group 2 vs 3 P = .082)., Conclusion: We do not suggest long-duration tourniquet use, which can lead higher pain scores and reduce functional recovery after total knee arthroplasty.

The aim of this study is to compare the effects of high versus low implant density on correction in Lenke type 5 adolescent idiopathic scoliosis (AIS) patients. A retrospective study of 59 Lenke type 5 AIS patients treated at a single institution were divided into to 2 groups according to implant density. Implant density, preoperative, early postoperative, and last follow-up thoracolumbar/lumbar (TL/L) curves were measured. Thirty-one constructs were high and 28 constructs were low density. The groups were similar in terms of age, sex, Cobb angle, and follow-up time. Mean implant density in low density group and high density group was 75.4% and 96.6%, respectively. High versus low-density comparison showed that there is no significant difference with regard to curve correction in early postoperative and last follow-up periods. The results show that pedicle screw density being low or high, does not affect curve correction rates in the short and long term in our patients., (Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Objective: The aim of this study was to investigate the effect of distal fusion level selection on the distal junctional kyphosis (DJK) in Scheuermann kyphosis (SK) patients who underwent posterior fusion., Methods: Thirty-nine SK patients who underwent posterior fusion with a minimum follow-up of 3 years were retrospectively evaluated. According to the distal fusion level, patients were divided into 3 groups. Group S; lowest instrumented vertebra (LIV) was the sagittal stable vertebra (SSV), Group F; LIV was the first lordotic vertebra (FLV) and, Group L; LIV was the lower end vertebra (LEV). DJK was evaluated according to distal level selection., Results: Thoracic kyphosis (TK) decreased from 73.3° (SD ± 7.9°) to 39° (SD ± 8.7°) postoperatively, with a mean correction rate of 46% (SD ± 13) (p < 0.0001). In 11 patients, FLV and SSV was the same vertebra. In remaining 28 patients, 10 patients were in Group S, 15 patients were in Group F and 3 patients were in Group L. In Group S, none of them developed DJK, however, DJK was observed 9 of 15 patients in Group F. DJK was developed in all cases in Group L. There is a statistically higher risk for developing DJK when FLV or LEV was selected as LIV (p < 0.05)., Conclusion: Selecting SSV for the distal fusion level has been found to be effective for preventing DJK. Selecting distal fusion level proximal to SSV will increase the risk of DJK which may become symptomatic and require revision surgery., Level of Evidence: Level IV, therapeutic study., (Copyright © 2017 Turkish Association of Orthopaedics and Traumatology. Production and hosting by Elsevier B.V. All rights reserved.)

Background: Prospective study., Objective: To determine the change in spinal sagittal parameters which may occur throughout the day in healthy population., Methods: Thirty-five healthy hospital employees were enrolled in the study. Two standing left lateral orthoroentgenograms were obtained at 8.00 a.m and at 6.00 p.m. Six spinopelvic parameters were measured on the X-rays. Thereafter, the subjects were divided into two cohorts according to their BMI as low BMI and high BMI., Results: Thirty-five subjects with a mean age of 25.97 ± 8.21 were evaluated. No significant change was found between morning and evening measurements for any of the parameters. Direct relationship was shown between thoracic kyphosis (TK) and lumbar lordosis (LL), lumbar lordosis and sacral slope (SS), pelvic tilt (PT) and pelvic incidence (PI) minus lumbar lordosis, sagittal vertebral axis (SVA) and pelvic incidence minus lumbar lordosis. In addition an inverse relationship was found between sacral slope and pelvic tilt, sacral slope and pelvic incidence minus lumbar lordosis, thoracic kyphosis and pelvic incidence minus lumbar lordosis, sacral slope and pelvic tilt, sagittal vertebral axis and lumbar lordosis (p< 0.05). Sagittal vertebral axis were found to be higher in the high BMI group, and daily change was lower but the differences were not statistically significant. Only the change in pelvic tilt value was found to be statistically significant in low BMI group., Conclusion: Routine workload in a hospital environment does not cause significant change in the spinopelvic parameters throughout the day.

Objective: The aim of this study was to evaluate preoperative and postoperative spinopelvic parameters and the influence of lowest instrumented vertebrae on sagittal parameters in Lenke 5 Adolescent Idiopathic Scoliosis (AIS) patients., Methods: A total of 42 patients (37 females, 5 males; mean age: 16.71 ± 3.46 years) were included in the study. Preoperative and postoperative last follow up lumbar lordosis (LL), thoracic kyphosis (TK), pelvic tilt (PT), pelvic incidence (PI) and sacral slope (SS) angles measured. By stopped fusion in L3, L4 or L5 we divided the group into three parts., Results: Mean follow-up was 43 months. Preoperatively, the mean TK and LL were 36.8° and 55.3°. At the last follow up, the mean TK and LL were 27.1° and 49.0° degrees, respectively. Preoperatively, the mean PI, PT and SS were 53.3°, 16.1° and 37.4° degrees. At the last follow up, the mean PI, PT and SS were 52.7°, 19.9° and 33.0° respectively. Significant differences were observed for SS (p = 0.003), TK (p = 0.004), LL (p = 0.012) and PT (p = 0.013) postoperatively for all patients. According the L3 and L4 groups there is significant difference in SS, LL (p = 0.013) and PT (p = 0.018) which means a significant decrease occurs in SS and LL when the distal fusion level changes from L3 to L4 but significant increase in PT in L3 group to compensate spinopelvic change after surgery., Conclusion: The selection of more distal level for fusion adversely affects the compensation mechanisms of sagittal balance in Lenke 5 AIS patients., Level of Evidence: Level IV, Therapeutic study., (Copyright © 2017 Turkish Association of Orthopaedics and Traumatology. Production and hosting by Elsevier B.V. All rights reserved.)

Background: Investigation of the expression of platelet-derived growth factor (PDGF)-β and glial fibrillary acidic protein (GFAP) in rats with spinal cord injury as a marker of neurologic recovery between groups treated with erythropoietin (EPO) and methylprednisolone (MP)., Methods: Thirty adult female rats were randomly divided into three even groups. A laminectomy was applied to thoracic ninth vertebra and contusion injury was induced by extradural application of an aneurysm clip. Group 1 rats received one-time intrathecal administration of normal saline, group 2 rats received MP, and group 3 rats received EPO. Motor neurological function was evaluated by the Basso, Beattie, and Bresnahan (BBB) locomotor rating scale. Thirty days after the surgery, T8-10 segments of the spinal cords were extracted and the immunohistochemical assay revealed the number of PDGF-β- and GFAP-positive cells., Results: Evaluation of the last control animal showed that BBB score in the EPO group showed an increase from 1 to 12 ( p < 0.05). The immunohistochemical assay revealed that the number of PDGF-β- and GFAP-positive cells was significantly higher in EPO group ( p = 0.000) when compared to MP and control groups. After studying the effect of PDGF-β expression on the locomotor function, we determined that PDGF-β expression and locomotor function after a spinal injury has a strong relationship ( p < 0.05)., Conclusion: EPO seems to better increase the expression of PDGF-β, thus produce better results in locomotor functions when compared to MP.

Background: Posterior spinal instrumented fusion has received widespread acceptance in adolescent idiopathic scoliosis (AIS) treatment, there have been some potential complications resulted from screw misplacement. Esophagus is one of the vital structures close to the upper thoracic vertebras and is at risk for potential injury., Methods: A 15-year-old girl who underwent posterior instrumented fusion for AIS was admitted to our department 10 years later with a complaint of dysphagia due to an esophageal perforation from a malpositioned T4 pedicle screw (PS). After implant removal and nasogastric tube placement, oral feeding was started after 3 days and the patient was discharged from hospital after 1 week., Results: In 12 weeks, the esophageal perforation healed without complications., Conclusions: This is the first case report of esophageal perforation by a posterior PS in an AIS patient. Esophagus is close to the upper thoracic vertebras and an anterior cortical perforation can cause esophageal injury if longer than 35 mm PSs are used. This unusual but potential complication must be kept in mind in scoliosis surgery., Level of Evidence: Level IV-case report.

Purpose: To comparatively evaluate the biomechanical alterations those occur in the sagittal plane of sacropelvic junction in angular kyphosis (AK) and Scheuermann kyphosis (SK) patients after surgery., Methods: The spine radiographs of 52 patients operated for short-segment AK (n = 20) or SK (n = 32) were studied. Main outcome measures were sacral slope, pelvic incidence, pelvic tilt, lumbar lordosis, and thoracic kyphosis angles., Results: In AK group, local and thoracic kyphosis angles, as well as lumbar lordosis angle, showed statistically significant reduction with surgery. Thoracic kyphosis and lumbar lordosis angles were reduced significantly in SK group. Postoperatively, there were significant differences between groups in lumbar lordosis, pelvic tilt angle, and sacral slope (p = 0.021, p = 0.001, and p = 0.027, respectively). Thoracic kyphosis angle and sacral slope were increased, and there was a remarkable correlation between thoracic kyphosis and lumbar lordosis values in the AK group., Conclusions: The results of this study suggest that a significant sacropelvic improvement can be achieved by balanced sagittal vertical axis and T1 spinopelvic leading to a good sagittal alignment of spine in patients with AK and SK. Changes seen in morphological parameters after surgery may be closely related with baseline biomechanics and structure of the spine and pelvis. Therefore, further clinical and scientific trials are necessary both to elucidate the biomechanics, their clinical implications, and to develop new techniques and models for spine and pelvis surgery.

Growing rod is a commonly used surgery for early-onset scoliosis (EOS). However, the effect of growing-rod lengthening on the spinopelvic alignment is unclear. In this study, 21 EOS patients treated by growing rod were evaluated retrospectively and thoracic kyphosis (TK), lumbar lordosis (LL), pelvic incidence (PI) , sacral slope (SS), pelvic tilt (PT), and sagittal vertical axis (SVA) were measured. Preoperatively, the mean TK, LL, PI, PT, SS, and SVA were 27.4°, 35.2°, 43.8°, 7.5°, 33.8°, and 47.7 mm respectively. After the last lengthening, TK, LL, PI, PT, SS, and SVA were 28.3°, 28.06°, 41.4°, 7°, 5.2°, and 42.6 mm, respectively. The sagittal plane parameters in our EOS patients were not significantly altered during the lengthening period.

Background: Infection after open fractures is a common complication. Treatment options for infections developed after intramedullary nailing surgery remain a topic of controversy. We therefore used a rat fracture model to evaluate the effects of infection on osseous union when the implant was maintained., Questions/purposes: In a rat model, (1) does infection alter callus strength; (2) does infection alter the radiographic appearance of callus; and (3) does infection alter the histological properties of callus?, Methods: An open femoral fracture was created and fixed with an intramedullary Kirschner wire in 72 adult male Sprague-Dawley rats, which were divided into two study groups. In the infection group, the fracture site was contaminated with Staphylococcus aureus (36 animals), whereas in the control group, there was no bacterial contamination (36 animals). No antibiotics were used either for prophylaxis or for treatment. We performed biomechanical (maximum torque causing failure and stiffness), radiographic (Lane and Sandhu scoring for callus formation), and histologic (scoring for callus maturity) assessments at 3 and 6 weeks. The number of bacteria colonies on the femur, wire, and soft tissue inside knee were compared to validate that we successfully created an infection model. The number of bacteria colonies in the soft tissue inside the knee was higher in the infection group after 6 weeks than after the third week, demonstrating the presence of locally aggressive infection., Results: Infection decreased callus strength at 6 weeks. Torque to failure (299.07 ± 65.53 Nmm versus 107.20 ± 88.81, mean difference with 95% confidence interval, 192 [43-340]; p = 0.007) and stiffness at 6 weeks (11.28 ± 2.67 Nmm versus 2.03 ± 1.68, mean difference with 95% confidence interval, 9 [3-16]; p = 0.004) both were greater in the control group than in the group with infection. Radiographic analysis at 6 weeks demonstrated the fracture line was less distinct (Lane and Sandhu score of 2-3) in the infection group and complete union was observed (Lane and Sandhu score of 3-4) in the control group (p = 0.001). Semiquantitative histology scores were not different between the noninfected controls and the rats with infection (score 10 versus 9)., Conclusions: Retaining an implant in the presence of an underlying infection without antibiotic treatment leads to weaker callus and impedes callus maturation compared with noninfected controls in a rat model. Future studies might evaluate whether antibiotic treatment would modify this result., Clinical Relevance: This model sets the stage for further investigations that might study the influence of different interventions on fracture healing in implant-associated osteomyelitis. Future observational studies might also evaluate the histological properties of callus in patients with osteomyelitis.

The aim of this study was to reveal whether a meaningful difference is caused by measuring the alpha angle in hip ultrasonography manually or digitally to help the early diagnosis and treatment of DDH and observe the treatment implications of any such difference. All ultrasound images were obtained by same orthopaedist, and each hip was measured twice by two investigators with different levels of experience. Standard images were taken, and a printout of the standard images were obtained. The alpha angle was measured digitally by using the sonography device. The alpha angle was also measured by pencil, ruler and goniometer on the printout after 2 days. One hundred and two hips of 51 babies, at a mean age of 14 weeks, were assessed. The mean alpha angle measured manually with a goniometer was 64.4° (±1.6°), while that measured on the ultrasonography device was 65.3° (±0.9°). This difference was found to be statistically different (p = 0.016). Typology changes occurred in a total of 10 hips out of 102 as a result of manual and digital measurements. However, this study showed reduction in alpha angle variation and considerable advantages for manual alpha angle measurement with pencil and goniometer on a printout compared to computer-based measurement; future studies are needed to understand these differences caused by each measurement method.

Introduction: Femoral neck stress fractures are not uncommon. Several causes exist about these fractures. Osteomalacia is one of the most common cause of insufficiency fractures and coxa vara can produce a focal concentration of mechanical stress in the femoral neck and may cause stress fractures. This case study is about the co-existence of these two pathologies in a patient with bilateral femoral neck stress fracture., Presentation of Case: A 26-year-old woman admitted to our department with a complaint of bilateral groin pain and diagnosed as bilateral coxa vara and osteomalacia. Medical treatment for osteomalacia and staged bilateral Pauwels' osteotomy was performed. After 2 years of follow-up, good result was obtained., Discussion: There are several risk factors for stress fractures and osteomalacia and coxa vara are two of the causes. Osteomalacia results in softening of the bones and coxa vara can produce a focal concentration of stresses in the femoral neck., Conclusion: Joint and bone pain without any trauma should be investigated and bone metabolism disorders should be kept in mind. There might be co-existing factors related with stress fractures, and they must be treated simultaneously., (Copyright © 2015 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction: Bilateral femoral neck fractures without major trauma are rare and related to several conditions. Insufficiency fractures due to the use of anti-epileptic drug are one of the rare causes. This case study is about bilateral femoral neck insufficiency fractures resulting from chronic use of anti-epileptic drug., Presentation of Case: A 26-year-old woman was referred to our emergency department with a complaint of bilateral groin pain and a 12-year history of irregular carbamazepine use. The diagnosis was bilateral femoral neck insufficiency fractures due to irregular long-term carbamazepine use. One-stage bilateral dynamic hip screw osteosynthesis was performed. After 2 years of follow up, good result was obtained., Discussion: There are several risk factors for insufficiency fracture, and antiepileptic drug related osteoporosis is one of the reason. These drugs have negative effect on bone methabolism and bone mineral density., Conclusion: To our knowledge, this is the first case in the literature of bilateral femoral neck insufficiency fracture due to chronic carbamazepine use. Joint and bone pain with a history of long-term use of anti-epileptic drug should be investigated carefully, and insufficiency fractures should be kept in mind., (Copyright © 2014 The Authors. Published by Elsevier Ltd.. All rights reserved.)

The aim of this study is to assess the biomechanical advantage of adding strut allograft and the effect of its position on the construct in Vancouver type B1 fractures. Fifteen forth-generation synthetic femurs were used and created a fracture model at the tip of prosthesis, and subsequently fixated with a lateral plate only, lateral plate and medial strut, lateral plate and anterior strut. Rotational and axial tests were performed. In all loading tests, the plate with medial strut group was stiffer than the other constructs and had higher failure load values and had less displacement in the fracture site. A combination of a plate with a medial strut allograft provides more mechanical stability on periprosthetic femoral fractures near the tip of a total hip arthroplasty., (Copyright © 2014 Elsevier Inc. All rights reserved.)