Lowest instrumented vertebrae selection in posterior fusion of Lenke 3C/6C adolescent idiopathic scoliosis: L3 versus L4, when LEV is L4.

INTRODUCTION: In structural thoracolumbar/lumbar (TL/L) curves, lowest instrumented vertebra is selected mostly as the lower end vertebra (LEV). To save more lumbar mobile segments, fusion may be stopped one level proximal. This study aimed to compare the radiologic and functional outcomes of Lenke type 3C and 6C adolescent idiopathic scoliosis patients according to distal fusion level. MATERIALS AND METHODS: 109 patients with Lenke 3C and 6C AIS, which had L4 as LEV and underwent posterior fusion were retrospectively evaluated. Lowest instrumented vertebra (LIV) was selected intraoperatively either as L3 or L4 depending on the disc alignment below LIV. In 49 patiens LIV was L3, while 60 patients were fused to L4. Two groups were compared according to radiologic and clinical outcomes preoperatively and two years postoperatively. Operation times were recorded. RESULTS: Preoperative values of both groups were similar. Regarding postoperative radiographic values, only LIV disc angle was different between groups, which was significantly higher in L3 group at two years follow-up. Coronal or sagittal imbalance was not observed. Surgical times and postoperative clinical outcomes were also similar. CONCLUSIONS: In TL/L curves which have L4 as LEV, satisfactory results can be achieved with stopping the fusion at L3, if a proper disc alignment below LIV can be obtained intraoperatively. Higher amount of LIV disc angle in L3 group did not cause coronal and sagittal imbalance. Although clinical outcomes are similar with stopping at L3 or L4, fusion to L3 may be prefered to save one more mobile disc.

Selection of distal fusion level in posterior instrumentation and fusion of Scheuermann kyphosis: is fusion to sagittal stable vertebra necessary?

PURPOSE: Distal junctional kyphosis (DJK) is a major instrumentation-related complication after the surgical correction of Scheuermann kyphosis (SK). The exact criteria to avoid DJK have been controversial. It has been recommended to include the SSV into the fusion by some authors, while others suggest that fusion to FLV is sufficient. The purpose of this study was to investigate the occurrence of DJK in relation to distal fusion level selection in SK surgery by investigating the relationship between the sagittal stable vertebra (SSV), first lordotic vertebra (FLV), and the lowest instrumented vertebra (LIV). METHODS: 54 patients (mean age: 21.2 years, range 12-43; male/female: 20/34) with SK who were treated by posterior segmental instrumentation and fusion were prospectively evaluated. Patients were allocated into 3 groups according to distal fusion level. In group 1, SSV was chosen as LIV (n = 20), and in group 2, LIV was the FLV (n = 16). Third group consisted of 18 patients in whom SSV and FLV was the same vertebra. Distal junctional angle, sagittal plane analysis, and clinical outcomes according to SF-36 were evaluated. RESULTS: Mean preoperative kyphosis angles were 77.2°, 73.4°, and 76.7° in groups 1, 2, and 3, respectively (p = 0.281), which decreased to 38.1°, 37.3°, and 37.8° postoperatively at final follow-up (p = 0.988). Mean follow-up time was 28.3 months. Correction amounts were similar between the groups (p = 0.409). 3 patients in SSV group, 5 patients in FLV group, and 3 patients in SSV-FLV group developed DJK, which was statistically insignificant. The C7 sagittal plumbline, lumbar lordosis, and pelvic parameters were not significantly different before or after surgery between the groups. Preoperative and postoperative results of SF-36 questionnaire were similar in all the groups. None of the patients who had DJK required revision surgery during the follow-up time. CONCLUSION: Proper selection of distal fusion level is important in order to prevent DJK after SK surgery. According to this study, it is not necessary to extend the fusion down to the SSV. Fusion to FLV is sufficient and saves a level.

Prevention of proximal junctional kyphosis after posterior surgery of Scheuermann kyphosis: an operative technique.

STUDY DESIGN: A prospective randomized study. OBJECTIVE: To introduce an operative technique that prevents proximal junctional kyphosis (PJK) in Scheuermann disease after a segmental posterior spinal instrumentation and fusion. SUMMARY OF BACKGROUND DATA: PJK is the progression of kyphotic deformity at the proximal end of a construct >10 degrees, and it can be seen up to 30% after posterior Scheuermann kyphosis surgery. After posterior fusion the biomechanics of the spine changes and the loss of motion at the fused levels is compensated by increased motion at other unfused segments. As a result significant amount of additional force is placed on the proximal junction. With our operative technique, we aimed to have a smooth passage from rigid to mobile segments and to decrease the stress on proximal junction during cantilever reduction to prevent PJK. METHODS: A total of 60 consecutive patients (mean age: 18.27±3.19, male/female: 28/32) who were surgically treated for Scheuermann kyphosis in our institution were recruited into this study and were prospectively evaluated. Patients were divided into 2 groups according to upper-most screw fixation technique. In group 1, a standard screw insertion technique was used (ST group). The technique was modified in group 2 (MT group), leaving 2 threads out of the posterior cortex. There were 29 patients in group 1 (ST) and 31 patients in group 2 (MT). Patients had an average follow-up time of 24.2 months (range, 19-48 mo). Evaluated radiographic parameters were preoperative and postoperative kyphosis angle, and proximal junctional angle (PJA) at last visit. PJA was defined as the angle between the caudal endplate of the upper instrumented vertebra and the cephalad endplate of 2 suprajacent vertebrae above the upper instrumented vertebra. PJA exceeding 10 degrees was accepted as PJK. Quality of life measurement was assessed preoperatively and postoperatively with SF-36 questionnaire. RESULTS: Correction amounts in ST group and MT group were 46.8% and 43.7%, respectively, which was statistically insignificant. The mean PJA was 8.08±2.96 degrees and 4.44±1.55 degrees in ST and MT groups, respectively, which demonstrated a statistically significant difference (P=0.001). Five patients in ST group had a PJA exceeding 10 degrees (PJK), whereas PJK was not seen in MT group (P=0.022). The improvement in physical component summary of SF-36 was significantly better in MT group; however, mental component summary was similar in both groups. CONCLUSIONS: This study introduces a new technique that may have an effect in preventing PJK. Our results seem to be satisfactory, but additional studies with more patients and longer follow-up times are needed to further delineate the feasibility of this technique.

The effects of human amniotic fluid and different bone grafts on vertebral fusion in an experimental rat model.

OBJECTIVE: The high risk of nonunion represents a challenge in vertebral surgery, thus stimulating new strategies to improve fusion rates. We investigated the effect of 2 different bone grafts and amniotic fluid application on radiologically and histologically evaluated vertebral fusion in an experimental rat model. MATERIALS AND METHODS: Forty-eight 24-week-old Sprague Dawley rats were included and assigned into 1 of 4 groups: allograft group, allograft plus human amniotic fluid group, demineralized bone matrix (DBM) group, or DBM plus human amniotic fluid group. After decortication and L4-L6 spinal fusion, study treatments were applied. Fusion in each rat was examined radiologically and histologically 8 weeks after the intervention. RESULTS: The group that received only allograft had better radiologic scores (median = 3.5; range = 3-4) when compared with the group that received only DBM (median = 2; range = 1-4) (P = 0.002); however, histologic scores did not differ. When amniotic fluid was added to the grafting, allograft-based treatments performed better than DBM-based treatments both on radiologic (median = 4; range = 3-4 vs median = 3; range = 3-4; P = 0.003) and histologic (median = 7; range = 6-7 vs median = 5; range = 3-6; P < 0.001) evaluation. Addition of amniotic fluid did not result in better outcomes in the rats that received DBM-based treatments but based on histologic evaluation, rats that received allograft-based treatments benefited from this application. CONCLUSIONS: Amniotic fluid seems to have an enhancing effect on posterior spinal fusion, particularly when combined with allograft.

Cardiovascular effects of abduction shoulder sling in elderly patients; is it really safe?

OBJECTIVE: The purpose of the prospective study is to investigate the cardiovascular effects of abduction shoulder sling (ASS) in elderly patients who underwent rotator cuff surgery. METHODS: The study included 49 consecutive patients older than 50 years (mean 59.3 ± 8.2 years) who underwent arthroscopic rotator cuff repair surgery and used ASS in postoperative period. All cases underwent Holter electrocardiographic monitoring before (24 h) and after (48 h) the operation. The Holter findings were read by an experienced cardiologist and a pause of longer than 3 s and heart rate of <40 bpm was evaluated as significant bradycardia. RESULTS: One patient (61-year-old male) described feeling faint (presyncope) which was confirmed with the Holter finding of a pause more than 3 s which occurred in the day time. Two other patients (52-year-old male, and 62-year-old female) reported severe dizziness (hypotensive attack) which required admission to a general practitioner. However, Holter findings were normal in these patients. These three cases were referred to cardiology department for evaluation of carotid hypersensitivity syndrome (CSH). CSH was confirmed with tests made with provocative maneuvers in a sitting position. CSH was defined as at least 3 s of asystole (cardio-inhibitor type) during carotid massage or systolic blood pressure falling below 50 mmHg (vaso-depressor type). All three patients were obese patients and BMI was higher than 30. CONCLUSIONS: ASS may trigger CSH in short necked and obese patients by exerting mechanical stimulation to the carotid sinus. These patients should be informed about symptoms and signs of CSH and educated on the proper use of ASS and correct positioning of shoulder strap. CSH should be kept in mind in patients who present with dizziness, presyncope and palpitation during the postoperative period.

Clinical and radiological results of surgically treated patients with adolescent idiopathic scoliosis and the effects of pulmonary rehabilitation on respiration functions.

BACKGROUND: In the present study, we aimed to evaluate the effects of pulmonary rehabilitation on respiratory functions after the surgery on the basis of early radiological findings, pain degree, function, and satisfaction scores in operated patients with adolescent idiopathic scoliosis (AIS). METHODS: Thirty patients with AIS were included in the present study, who were divided into 2 groups. Scoliosis surgery and diaphragmatic breathing and pursed lip exercises were applied in Group 1 (n = 15), whereas merely scoliosis surgery was applied in Group 2 (n = 15). Pulmonary functions, arterial blood gas analysis, Cobb and kyphosis angles, apical vertebral rotation, and apical vertebral translation were measured before and 1st and 6th months after the surgery. Using the SRS-30 test, the psychosocial statuses of the patients and their satisfaction degrees with surgery applied were measured before and after the surgery. RESULTS: Six months after the surgery, the values of Cobb and kyphosis angles and apical vertebral rotations, and apical vertebral translation of the patients were determined to be significantly ameliorated, which is consistent with the literature. Forced vital capacity (l) and forced expiratory volume in the first second (l/s) were observed to be significantly improved in both groups after the surgery (respectively, P = .001, P = .014, P = .001, P = .005). In addition, the partial pressure of oxygen (pO2) value was found to be significantly increased 6 months after the surgery compared with that before the surgery in Group 2 (P = .022). SRS-30 showed that most of the scores in Group 1 were dramatically increased; a significant difference between the groups was not recorded. CONCLUSION: Patients with AIS have been found to be satisfied with the surgery. Conversely, pulmonary rehabilitation has been shown to slightly improve the respiratory functions in the patients with AIS, 1 and 6 months after the surgery.

Reliability of 2 Smartphone Applications for Cobb Angle Measurement in Scoliosis.

BACKGROUND: As mobile technology has evolved, smartphone applications have been used for radiographic angle measurements in daily clinical practice. This study aimed to assess the reliability of 2 smartphone applications (iPinPoint and Cobbmeter) in measuring scoliosis Cobb angles compared with picture archiving and communication system (PACS) tools. METHODS: Anteroposterior whole spinal digital radiographs of 50 patients were retrospectively analyzed. Four observers measured Cobb angles of predetermined major structural curves using the tools in the PACS software and 2 smartphone applications. The inter- and intraobserver reliabilty were measured using intraclass correlation coefficients (ICC). RESULTS: Very good interobserver agreement was seen with PACS, iPinPoint, and Cobbmeter measurements (ICC, 0.991, 0.980, and 0.991, respectively). Intraobserver reliability of the 4 observers was also very good for all techniques (ICC > 0.9 for all observers). CONCLUSIONS: Both smartphone applications were reliable in measuring scoliosis Cobb angles, with reference to PACS tools. They may be useful when digital or manual mesurement tools are not available.

Computed Tomography-Based Morphometric Analysis of Thoracic Pedicles: An Analysis of 1512 Pedicles and Their Correlation with Sex, Age, Weight and Height.

AIM: To examine the morphological features of thoracic pedicles in a Turkish population. MATERIAL AND METHODS: This retrospective study was performed with the patients who were underwent thoracic CT for any reason such as trauma or pulmonary disorder. Patient's age, height, weight, and sex were recorded and pedicle length (PL), transverse pedicle diameter (TPD), sagittal pedicle diameter (SPD) and, transverse pedicle angle (TPA) were measured. The right and left pedicles were separately measured. The data obtained was analyzed and compared with other studies in the literature. RESULTS: The highest mean TPA value was 33° at T1, whereas the lowest mean TPA value was 3° at T12. The highest mean PL value was 39.6 mm at T11, whereas the lowest mean PL value was 33.7 mm at T1. The lowest mean SPD value was 7.2 mm, which was measured on T1, and the maximum mean SPD was 11.7 mm on T12. The minimum mean TPD value was 3.8 mm at T5 and the maximum value was 6.2 mm at T1. There was a statistically significant positive correlation between pedicle length and height in all vertebrae. Age had no effect on the morphological features of the thoracic pedicle. In males, PL, TPD, and SPD were higher than females. CONCLUSION: Compared with other populations, the Turkish population has a smaller pedicle width on sagittal and transverse planes, and their PL and medial angling is similar to those of other populations. Male patients who are taller and overweight have higher pedicle width and length.

Neuroprotective Effects of Lacosamide in Experimental Peripheral Nerve Injury in Rats : A Prospective Randomized and Placebo-Controlled Trial.

OBJECTIVE: To evaluate the neuroprotective effects of lacosamide after experimental peripheral nerve injury in rats. METHODS: A total of 28 male wistar albino rats weighing 300-350 g were divided into four groups. In group I, the sciatic nerve exposed and the surgical wound was closed without injury; in group II, peripheral nerve injuries (PNI) was performed after dissection of the nerve; in group III, PNI was performed after dissection and lacosamide was administered, and in group IV, PNI was performed after dissection and physiological saline solution was administered. At 7 days after the injury all animals were sacrificed after walking track analysis. A 5 mL blood sample was drawn for biochemical analysis, and sciatic nerve tissues were removed for histopathological examination. RESULTS: There is low tissue damage in lacosamide treated group and antioxidant anzymes and malondialdehyde levels were higher than non-treated and placebo treated group. However there was no improvement on clinical assessment. CONCLUSION: The biochemical and histological analyses revealed that lacosamide has neuroprotective effect in PNI in rats. This neuroprotective capacity depends on its scavenger role for free oxygen radicals by increasing antioxidant enzyme activity.

Neuroprotective Effects of Lacosamide in Experimental Traumatic Spinal Cord Injury in Rats.

AIM: To evaluate the effects of lacosamide on traumatic spinal cord injury (SCI) in rats. MATERIAL AND METHODS: A total of 28 male Wistar albino rats, each weighing 300-350 g, were included. They were randomly assigned to four groups. In Group 1, only a laminectomy was performed; in Group 2, SCI was performed after laminectomy; in Group 3, SCI was performed after laminectomy followed by lacosamide administration, and in Group 4, SCI was performed after laminectomy followed by physiological saline administration. After 48 hours, all animals were sacrificed, blood samples were drawn, and their spinal cords were removed. The serum levels of catalase, glutathione peroxidase (GPx), superoxide dismutase (SOD) and malondialdehyde (MDA) were measured, and the spinal cord specimens were examined for neuronal degeneration (PND). RESULTS: The MDA level was the lowest and the antioxidant enzyme levels were the highest in Group 3. There were statistically significant differences between Group 3 and the others in their PND score, serum MDA, SOD, GPX and catalase levels (p < 0.05). CONCLUSION: Lacosamide has a neuroprotective effect in SCI in rats that is related to its ability to decrease the production of reactive oxygen species by increasing antioxidant enzyme expression, inhibit lipid peroxidation and attenuate glial cell activation.

Spontaneous Reduction of Elbow Dislocation with Entrapment of Medial Epicondyle in Children: A Case Report.

Introduction: Elbow dislocation accounts 3-6% of all pediatric elbow injuries. Medial epicondyle is the most common fracture related to the elbow dislocation in pediatric population. About 15-18% of medial epicondyle fractures related to dislocation present with the incarceration of medial epicondyle in the elbow joint after reduction. This situation is the only absolute surgical indication for epicondyle fracture in this population. Case Report: A 15-year-old male children admitted to the emergency department with swelling, pain, and limitation of elbow range of motion after falling off a horse. Plain radiographs of the elbow revealed incongruity and increase in joint space of the elbow. When looked at carefully the medial epicondyle was seen not in the anatomic position but in the joint.Urgent surgery was performed. The medial epicondyle was removed from the joint and fixed its position with a 4 mm diameter cannulated lag screw, under fluoroscopy control. Then, the tear of the origin of flexor muscle groups on medial epicondyle was repaired with a 5.5 mm suture anchor. Conclusion: Due to the well-established association between elbow dislocation and incarcerated medial epicondyle fracture, it is easy to address the entrapment of bone fragment into the joint if any suspicion exists after reduction. However, spontaneous reduction of elbow dislocation is also possible, and it leads to the challenge of diagnosis. Due to that reason, surgeon must suspect the possibility of medial epicondyle entrapment if there is gross swelling, crepitation, and limitation of elbow range of motion although there is no dislocation.

How accurate is visual estimation of perioperative blood loss in adolescent idiopathic scoliosis surgery?

OBJECTIVE: The aim of this study was to assess whether the visual estimation method for perioperative blood loss is accurate in adolescent idiopathic scoliosis surgery. METHODS: Sixty-five consecutive patients, who were operated on from 2012 to 2015 and had a diagnosis of AIS, were included into the study. Gender, age, preoperative weight and height, preoperative major curve magnitude and T5‒T12 kyphosis angles, the fusion level, and the time of surgery were recorded. Perioperative blood loss was estimated by the same anesthesiologist for all patients. Then, an experienced surgeon estimated the perioperative blood loss by a gravimetric method, and the results were compared. RESULTS: Seventeen (26.2%) of the patients were male and 48 (73.8%) were female. The mean age was 15.8 ± 1.9. The mean height of the patients was 162.1 ± 8.9 cm and the mean weight was 52.6 ± 8.9 kg. The mean preoperative major curve magnitude and kyphosis angles were 49.5 ± 9.2 and 47.1 ± 12.7 respectively. The mean estimate of the surgeon was 1009 ± 404.5 ml and the mean estimate of the anesthesiologist was 434 ± 217.6 ml and the difference was statistically significant (p < 0.05). Moreover, if blood loss was high during the operation, the difference between the estimates of the surgeon and anesthesiologist was also higher. CONCLUSIONS: Even in operations where most of the blood goes into a suction canister, such as for AIS, a visual estimation method is not accurate. A short training regarding optimizing the amount of blood contained in sponges that are not fully soaked may be sufficient to improve this method.

The effect of upper instrumented vertebra level on cervical sagittal alignment in Lenke 1 adolescent idiopathic scoliosis.

BACKGROUND: This study aimed to evaluate the relationship between upper instrumented vertebra (UIV) level and cervical sagittal alignment (CSA) in Lenke 1 adolescent idiopathic scoliosis (AIS) patients, treated with posterior instrumentation. The hypothesis was that higher level of UIV would cause decreased cervical lordosis. METHODS: Sixty-three Lenke 1AIS patients that underwent posterior fusion with pedicle screw instrumentation were retrospectively evaluated. Patients were divided into three groups according to UIV level (T2, T3, T4). Twenty patients without spinal deformity made up the control group. Patients were compared at two years follow-up according to radiographic changes in coronal and sagittal planes. Main sagittal parameters were C2-C7 cervical lordosis (CL), T1 slope, T1-T5 and T5-T12 kyphosis. Clinical outcomes were assessed using scoliosis research society (SRS)-22, short form (SF)-36 and neck disability index (NDI) questionnaires. RESULTS: Preoperative sagittal plane values of AIS patients were similar to the control group. C2-C7 CL, T1-T5 kyphosis and T1 slope significantly decreased postoperatively in T2 and T3 groups (p<0.05). These parameters were not changed significantly in T4 group after the surgery. T5-T12 kyphosis did not change significantly in all groups. SRS-22 and SF-36 scores significantly improved (p<0.05), while NDI scores were not changed significantly after the surgery. CONCLUSIONS: In Lenke 1 AIS, treated with segmental all pedicle screw instrumentation using precontoured rods and rod rotation maneuver, postoperative decreased CL is more likely to occur if the UIV is selected as T2 or T3. Decreased CL seems to be caused by reduced T1-T5 kyphosis and T1 slope. However the decrease in CL did not effect clinical outcome scores, including NDI, adversely. Hence, extending the fusion to appropriate level for shoulder balance seems reasonable. LEVEL OF EVIDENCE: IV.

Lowest Instrumented Vertebrae Selection for Posterior Fusion of Lenke 5C Adolescent Idiopathic Scoliosis: Can We Stop the Fusion One Level Proximal to Lower-end Vertebra?

BACKGROUND: The most appropriate fusion levels remains challenging, especially in Lenke type 5 curves. In Lenke 5 adolescent idiopathic scoliosis (AIS) generally fusion includes the lower end vertebra (LEV). This study determines whether it is appropriate to fuse mild to moderate Lenke 5 curves to LEV-1, if possible. MATERIALS AND METHODS: Forty-two patients with mild to moderate Lenke 5 AIS that underwent posterior fusion were retrospectively evaluated. The preoperative goal was to stop the instrumentation at LEV-1 in all patients if possible. However, the final decision was made intraoperatively according to the alignment of the disc below lowest instrumented vertebra (LIV). In 19 patients, this goal was achieved and LIV was LEV-1, whereas 23 patients were fused to LEV. Hence, two groups occurred and they were compared in terms of coronal, sagittal, and LIV related parameters at 1 year and 3 years postoperatively. Surgical times were also noted. Clinical outcomes were assessed using scoliosis research society (SRS-22) and Short Form-36 questionnaires. RESULTS: Two groups were well matched according to preoperative values. Postoperative radiographic results were also similar, except LIV disc angle and LIV translation, which were significantly higher in LEV-1 group at 1 and 3 years followup (P < 0.05). Surgical times were significantly longer in LEV group (P = 0.036). No significant correction loss was observed between 1 and 3 years followup. There were no significant differences regarding postoperative clinical outcomes except the activity domain of SRS-22, which was significantly higher in LEV-1 group, but the significance was weak (P = 0.045). CONCLUSIONS: Fusion to LEV-1was associated with the higher amount of LIV disc angle and LIV translation, which did not cause coronal and sagittal imbalance and decreased the quality of life scores. Hence, if intraoperatively a level disc below LIV can be achieved, fusion to LEV-1 may be an option in mild to moderate Lenke 5 curves, to save one more mobile segment.

Intraspinal Anomalies in Individuals with Scheuermann's Kyphosis: Is the Routine Use of Magnetic Resonance Imaging Necessary for Preoperative Evaluation?

STUDY DESIGN: Retrospective study. PURPOSE: This study aimed to determine the incidence of intraspinal pathologies (ISPs) in individuals with Scheuermann's kyphosis (SK) and to validate whether the routine use of magnetic resonance imaging (MRI) is necessary for preoperative evaluation. OVERVIEW OF LITERATURE: There are several studies on the necessity of routine MRI screening and prevalence of ISPs related to different types of scoliosis have been conducted. However, despite the well-established association between ISPs and a higher risk for neurological complications there is no any study on the scientific literature concerning the prevalence of ISPs in patients with SK has been conducted. METHODS: The database of the institution was retrospectively reviewed to identify all patients diagnosed with SK who underwent surgery between 2012 and 2015. Patients were excluded from the study if their hospital database records did not include spinal images, which are routinely collected before surgery. The presence or absence of ISPs, as indicated on magnetic resonance images, was evaluated by a radiologist. RESULTS: Of the 138 potential participants, 120 were included in the study. Of these, seven patients (5.8%) had ISPs, and all the cases involved syringomyelia. None of the seven patients with ISPs required additional neurosurgical procedures before corrective surgery. No complications were reported during the perioperative period, and none of the patients developed postoperative neurological deficits. CONCLUSIONS: According to this study, the incidence rate of ISPs in patients with SK was 5.8%, and we recommend that all patients with SK should be evaluated using MRI of the spine before corrective surgery.

Cervical Sagittal Alignment in Extensive Fusions for Lenke 3C and 6C Scoliosis: The Effect of Upper Instrumented Vertebra.

STUDY DESIGN: A retrospective analysis of cervical sagittal alignment (CSA) in Lenke 3C and 6C adolescent idiopathic scoliosis (AIS). OBJECTIVE: The aim of this study was to evaluate CSA according to upper instrumented vertebra (UIV) level. SUMMARY OF BACKGROUND DATA: Hypokyphotic effect of extensive fusions of Lenke 3C and 6C curves on thoracic spine leads to kyphotic changes in cervical region. No study has evaluated the CSA in these patients according to UIV level. METHODS: A total of 55 Lenke 3C and 6C AIS patients who underwent posterior fusion with pedicle screw instrumentation were recruited in this study. Patients were divided into three groups according to UIV level, which was determined preoperatively on the basis of shoulder balance. There were 22, 19, and 14 patients in T2, T3, and T4 groups, respectively. Three groups were similar according to demographic and preoperative coronal and sagittal alignment parameters. Patients were compared at two-year follow-up according to radiographic changes in coronal and sagittal planes. Main sagittal parameters were C2-C7 cervical lordosis (CL), T1 slope, T1-T5, and T5-T12 kyphosis. Clinical outcomes were assessed using scoliosis research society (SRS)-22 and short form (SF)-36 questionnaires. RESULTS: In all patients, C2-C7 CL, T5-T12 kyphosis, and T1 slope significantly decreased postoperatively (P < 0.05). The amount of decrease was similar between groups. T1-T5 kyphosis did not change significantly in all groups. Twenty-seven patients had postoperative cervical kyphosis (CK). Thirteen of them had preoperative CL and 14 had CK. Twenty-eight of 41 patients with preoperative CL remained in lordotic CSA postoperatively. SRS-22 and SF-36 scores did not change significantly after the surgery. CONCLUSION: In Lenke 3C and 6C AIS, postoperative CSA is independent from UIV level. Decreased CL is mainly caused by T5-T12 and T1 slope decrease. In order to achieve level shoulders, fusion can be extended to appropriate upper level, without increased risk of CK. LEVEL OF EVIDENCE: 4.

Three-Dimensional Correction in Patients With Lenke 1 Adolescent Idiopathic Scoliosis: Comparison of Consecutive Versus Interval Pedicle Screw Instrumentation.

STUDY DESIGN: A retrospective-matched cohort study. OBJECTIVE: To assess the correction of the adolescent idiopathic scoliosis (AIS) deformity in three dimensions, comparing consecutive and interval pedicle screw (PS) instrumentation techniques. SUMMARY OF BACKGROUND DATA: The number of the sites that should be implanted with pedicle screws in AIS surgery is controversial. Coronal and sagittal planes have been investigated thoroughly but there are very little data about transverse plane correction according to PS density. METHODS: A total of 76 AIS patients who underwent posterior fusion with PS instrumentation were recruited in this study. Patients were divided into two groups according to PS density with 38 patients in each group. In group 1, consecutive PS instrumentation was used (CPS group), and in group 2 interval pedicle screw instrumentation (IPS group). Two groups were matched according to similar patient age, fusion levels, curve magnitude and flexibility, identical Lenke curve type, and identical operative methods. Patients were compared at 1-year follow-up according to radiographic changes in coronal, sagittal, and transverse planes. Clinical outcomes were assessed using Scoliosis Research Society-22 and spinal appearance questionnaires. RESULTS: The two cohorts were well matched. At 1-year follow-up, major coronal Cobb angle changes were 45.4° in CPS group and 38.9° in IPS group (P = 0.049). T5-T12 sagittal Cobb angle changes were 5.1° and 5.9° in CPS and IPS groups, respectively (P = 0.897). Apical vertebral rotation changes were measured as 12.0° in CPS group and as 3.6° in IPS group, which demonstrated a significant difference (P = 0.001). Scoliosis Research Society-22 scores were similar in both groups, whereas spinal appearance questionnaire appearance domain was significantly better in CPS group at 1-year follow-up (P = 0.035). CONCLUSION: CPS provides better deformity correction in AIS surgery in all three planes, compared with IPS. Improved deformity correction results in better appearance outcomes. LEVEL OF EVIDENCE: 3.

Effect of Calcium ß-Hydroxy-ß-Methylbutyrate (CaHMB), Vitamin D, and Protein Supplementation on Postoperative Immobilization in Malnourished Older Adult Patients With Hip Fracture: A Randomized Controlled Study.

BACKGROUND: Nutrition support in orthopedic patients with malnutrition shortens the immobilization period. The efficacy of calcium ß-hydroxy-ß-methylbutyrate (CaHMB), vitamin D, and protein intake on bone structure is studied and well known; however, there is no evidence supporting the effect of combined use in orthopedic conditions. We investigated the effects of CaHMB, vitamin D, and protein supplementation on wound healing, immobilization period, muscle strength, and laboratory parameters. MATERIALS AND METHODS: This randomized controlled study included 75 older female patients with a hip fracture admitted to orthopedic clinics. The control group received standard postoperative nutrition. The study group received an enteral product containing 3 g CaHMB, 1000 IU vitamin D, and 36 g protein, in addition to standard postoperative nutrition. Anthropometric, laboratory, wound-healing, immobilization period, and muscle strength assessments were evaluated preoperatively and on postoperative days 15 and 30. RESULTS: Wound-healing period was significantly shorter in the CaHMB/vitamin D/protein group than in the control group ( P < .05). The number of patients in the CaHMB/vitamin D/protein group who were mobile on days 15 and 30 (81.3%) was significantly higher than patients in the control group, who were mobile on days 15 and 30 (26.7%) ( P = .001). Muscle strength on day 30 was significantly higher in the CaHMB/vitamin D/protein group vs the control group. CONCLUSION: Nutrition of elderly patients with a CaHMB/vitamin D/protein combination led to acceleration of wound healing, shortening of immobilization period, and increased muscle strength without changing body mass index. It also reduced dependence to bed and related complications after an orthopedic operation.

Wound management with vacuum-assisted closure in postoperative infections after surgery for spinal stenosis.

OBJECTIVE: To evaluate the results of negative-pressure wound therapy (NPWT) in the treatment of surgical spinal site infections. MATERIALS AND METHODS: The use of NPWT in postoperative infections after dorsal spinal surgery (transforaminal lumbar interbody fusion plus posterior instrumentation) was studied retrospectively. From February 2011 to January 2012, six patients (females) out of 317 (209 females; 108 males) were readmitted to our clinic with surgical site infections on postoperative day 14 (range 9-19) and were treated with debridement, NPWT, and antibiotics. We evaluated the clinical and laboratory data, including the ability to retain the spinal hardware and recurrent infections. RESULTS: The incidence of deep postoperative surgical site infection was six (1.89%) patients (females) out of 317 patients (209 females; 108 males) at 1 year. All patients completed their wound NPWT regimen successfully. An average of 5.1 (range 3-8) irrigation and debridement sessions was performed before definitive wound closure. The mean follow-up period was 13 (range 12-16) months. No patient had a persistent infection requiring partial or total hardware removal. The hospital stay infection parameters normalized within an average of 4.6 weeks. CONCLUSION: The study illustrates the usefulness of NPWT as an effective adjuvant treatment option for managing complicated deep spinal surgical wound infections.

Hydatid cyst of biceps brachii associated with peripheral neuropathy.

INTRODUCTION: Hydatidosis represents the most significant parasitic disorder in the Mediterranean countries and leads to major problems through unfavorable effects on the public health and national economy. Localization of the primary cyst hydatid infection in the extremity is rare and biceps brachii localization is also rarely reported in the literature. PRESENTATION OF CASE: A 43-year-old woman, who presented with the complaints of mass and pain in the left arm and numbness of the hand. Laboratory investigations, X-ray and magnetic resonance (MRI) findings revealed hydatid cyst of the biceps brachi muscle. The mass was totally excised and the diagnosis was confirmed by the macroscopic images of the mass and the pathologic results. After the surgery, the patient had an improvement in the nerve compression findings including numbness of the hand and the upper extremity and pain. DISCUSSION: Localization of a primary cyst hydatid infection in the upper extremity is rare and there are no reports of peripheral neuropathy secondary to mass effect. Even if the pre-surgical electromyelography performed for the nerve conduction study reveals a normal result, the potential for the hydatid cysts to cause nerve compression should be taken into consideration in such patients. CONCLUSION: Cases of concomitant neurologic findings and complaints secondary to peripheral nerve compression are very rare. The clinical findings should not be ruled out even if the EMG result is negative.