Does Thoracic Kyphosis Have any Importance in Selective Versus Nonselective Fusion Preference in Patients with Lenke Type 5C Adolescent Idiopathic Scoliosis?

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.

Surgical Approach Algorithm in the Treatment of Lumbar and Thoracolumbar Pyogenic Spondylodiscitis.

AIM: To reveal the efficiency of our surgical approach algorithm in patients with thoracolumbar pyogenic spondylodiscitis based on the involvement of anatomical structure. MATERIAL AND METHODS: Data of patients who underwent debridement or stabilization surgery for thoracolumbar pyogenic spondylodiscitis from January 2012 to December 2018 were reviewed. Lumbar and thoracolumbar spondylodiscitis was classified into four stages based on anatomical involvement. Infection was limited in the disc space, which had not spread to the endplate in stage 1 and progressed as two-level corpus involvement of > 1/2 of vertebral corpus bony destruction or as failed treatment in stage 4. Neurological function was evaluated using Frankel's grading postoperatively. Functional outcomes were categorized according to the Kirkaldy-Willis criteria. RESULTS: The study included 39 patients, with a mean age of 58.2 years. Of these patients, 10, 12, 13, and 4 had stages 1, 2, 3, and 4 spondylodiscitis, respectively. The mean follow-up period was 60.2 (12-184) months. All patients with stages 1 and 2 spondylodiscitis had grade E injury; 2 and 10 patients with stage 3 had grades D and E injuries, respectively; two patients with stage 4 had grade D injury and two had grade E injury at the last follow-up. Moreover, 100%, 84.6%, and 50% of the patients with stages 1 and 2, 3, and 4 spondylodiscitis achieved good or excellent results, respectively. CONCLUSION: The choice of the surgical technique depends on the destruction severity at the adjacent vertebral corpus. Surgical staging system for spondylodiscitis is useful and reliable in choosing appropriate surgical techniques.

Direct vertebral rotation significantly decreases the pullout strength of the pedicle screw: a biomechanical study in adult cadavers.

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.

Posterior Approach Alone Versus Combined Anterior and Posterior Approach in the Management of Vertebral Tuberculosis.

AIM: To compare posterior surgery alone versus combined anterior and posterior surgery for the management of spinal tuberculosis. MATERIAL AND METHODS: Data from 31 consecutive patients who underwent surgery for spinal tuberculosis were analyzed retrospectively. Patients were divided into two groups as group A (posterior surgery alone) or group B (combined anterior and posterior surgery), and groups were compared in terms of invasiveness of the procedure, spinal deformity, fusion, neurological status, and postoperative complications. RESULTS: Group A included 16 patients (mean age: 56 years, range: 29-75) with a mean follow-up period of 29 months (range 12-60) while group B included 15 patients (mean age: 60 years, range: 35-73) with a mean follow-up period of 28 months (range 12-60). Procedurally, average operation time and mean length of hospitalization were shorter, and mean blood loss was lower in group A (p < 0.05) compared to group B. Postoperative bone fusion took significantly (p < 0.05) longer time in group A (10.5 ± 2.1 months)than in group B (9.3 ± 3.1 months), and all patients with a neurological deficit recovered completely during the postoperative period. No significant differences were observed between two groups with respect to postoperative complications (p > 0.05). CONCLUSION: Combined anterior-posterior surgery may not be required for treating vertebral tuberculosis as posterior surgery alone appears to be sufficient.

Postoperative mechanical alignment analysis of total knee replacement patients operated with 3D printed patient specific instruments: A Prospective Cohort Study.

OBJECTIVE: Total knee replacement (TKR) is a surgical treatment for final stage gonarthrosis. The lifespan of the prosthetic implants used in TKR surgery is a major interest for the orthopaedic research community.Previously, proper implant alignment of the implants has been advocated for longevity of the TKR surgery. Recently, patient-specific (PSI) instruments have been proposed to improve the mechanical alignment of the TKR by permitting better implant positioning over conventional TKR surgery. The aim of this study is to compare the mechanical alignment results of patients operated with PSIs and conventional instruments. METHODS: Two groups of 20 patients chosen in a quasi-random manner have been compared in this study. In the first group femoral distal and tibial osteotomies were made by a PSI which was produced by the patients' computed tomography scans. All osteotomies in the control group were made with the TKR set's routine instruments by conventional means. Patients' preoperative and postoperative mechanical femorotibal angles (mFTA), femoral coronal angles (FCA), tibial coronal angles (TCA) were measured and the number of outliers which showed more than 3° of malalignment were counted in both groups for comparison. RESULTS: The average postoperative mFTA was found to be 2.09° for the PSI group and in was found to be 2.84° for the control which was not statistically significant. The comparison of postoperative FCA and TCA also did not show significant difference between the groups. The number of outliers showing more than 3° of malalignment per group were found to be 1 out of 20 (5%) for the PSI group and 7 out of 20 (35%) for the control which was statistically significant. CONCLUSION: In this study patient-specific instrumentation provided significantly better mechanical alignment compared to conventional TKR for the frequency of outlier cases with malalignment beyond 3°. PSI proved no significant difference when the groups were compared for mFTA, FCA and TCA. Our findings support that PSI may improve TKR alignment by improving the ratio of the outlier patients with marked malalignment. LEVEL OF EVIDENCE: Level III, Therapeutic Study.

Effectiveness of posterior structures in the development of proximal junctional kyphosis following posterior instrumentation: A biomechanical study in a sheep spine model.

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 100 and at least 100 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.

Quantitative comparison of a laterally misplaced pedicle screw with a re-directed screw. How much pull-out strength is lost?

OBJECTIVE: Redirecting of a laterally misplaced pedicle screw into the accurate position decreases the pull-out strength due to the reinsertion, lateral wall cortical perforation and widening of the pedicle hole. Thus, this biomechanical study was performed to quantitatively analyze the pullout strength of a redirected laterally misplaced pedicle screw into the accurate position. METHODS: Thirty pedicules of 15 bovine vertebrae were separated to 3 groups, according to the screw placement method: 1) standard flawless trajectory; 2) trajectory with lateral pedicle wall perforation; 3) trajectory with lateral wall perforation redirected to the standard trajectory. Samples were placed on a universal testing machine and pullout loads were measured. Kruskal-Wallis test was utilized within 95% confidence interval and p value <0.05 to test for the statistical significance. RESULTS: The mean pullout strength was 2891±654,2 N(1383-3814,5) in Group 1; 817,8±227,6 N(308,6-1144,9) in Group 2 and 2081,1±487,7 N(1583,5-2962,5) in Group 3. The results found out to be statistically significant (p<0.05). Inter-group comparisons revealed that lateral pedicle wall perforation significantly decreases the pullout strength (p<0.05) and redirection of the screw increases the strength (p<0.05), however it was still weaker than the screws with flawless standard trajectory but this was not statistically significant (p>0.05). CONCLUSION: The results of this study confirm that pullout strength of pedicle screw decreases by approximately 71% when the lateral wall is perforated and decreases 28% after redirection to the accurate position.

Influence of Distal Fusion Level on Sagittal Spinopelvic and Spinal Parameters in the Surgical Management of Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Retrospective analysis of adolescent idiopathic scoliosis. PURPOSE: This study aimed to investigate the influence of distinct distal fusion levels on spinopelvic parameters in patients with adolescent idiopathic scoliosis (AIS) who underwent posterior instrumentation and fusion surgery. OVERVIEW OF LITERATURE: The distal fusion level selection in treatment of AIS is the one of milestone to effect on surgical outcome. Most of the paper focused on the coronal deformity correction and balance. The literature have lack of knowledge about spinopelvic changing after surgical treatment and the relation with distal fusion level. We evaluate the spinopelvic and pelvic parameter alteration after fusion surgery in treatment of AIS. METHODS: A total of 100 patients with AIS (88 females and 12 males) were retrospectively reviewed. Patients were assigned into the following three groups according to the distal fusion level: lumbar 2 (L2), lumbar 3 (L3), and lumbar 4 (L4). Using a lateral plane radiograph of the whole spine, spinopelvic angular parameters such as thoracic kyphosis (TK), lumbar lordosis (LL), pelvic incidence (PI), sacral slope (SS), and pelvic tilt (PT) were radiologically assessed. RESULTS: The mean age was 15±2.4 years, and the mean follow-up period was 24.27±11.69 months. Regarding the lowest instrumented vertebra, patients were categorized as follows: 30 patients in L2 (group 1), 40 patients in L3 (group 2), and 30 patients in L4 (group 3). TK decreased from 36.60±13.30 degrees preoperatively to 26.00±7.3 degrees postoperatively in each group (p=0.001). LL decreased from 52.8±9.4 degrees preoperatively to 44.30±7.50 degrees postoperatively (p=0.001). Although PI showed no difference preoperatively among the groups, it was statistically higher postoperatively in group 3 than in the other groups (p<0.05). In addition, in group 2, PI decreased from 50.60±8.74 degrees preoperatively to 48.00±6.84 degrees postoperatively (p=0.027). SS decreased from 35.20±6.40 degrees preoperatively to 33.40±5.80 degrees postoperatively (p=0.08, p>0.05). However, mean SS was significantly higher in group 3 (p=0.042, p<0.05). PT decreased from 15.50±7.90 degrees preoperatively to 15.2±7.10 degrees postoperatively. The positive relationship (28.5%) between LL and PI measurements was statistically significant (r=0.285; p=0.004, p<0.01). Furthermore, the positive relationship (36.5%) between LL and SS measurements was statistically significant (r=0.365; p=0.001, p<0.01). CONCLUSIONS: When the distal instrumentation level in AIS surgery is below L3, a significant change in PT and SS (pelvic parameters) is anticipated.

Bilateral First-Ray Amputation of the Foot Due to Severe Tophaceous Gout Complicated by Infection and Discharged Sinus A Case Report.

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.

Does pedicle screw density matter in Lenke type 5 adolescent idiopathic scoliosis?

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.

The effect of tourniquet usage on cement penetration in total knee arthroplasty: A prospective randomized study of 3 methods.

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.

Selection of distal fusion level in terms of distal junctional kyphosis in Scheuermann kyphosis. A comparison of 3 methods.

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.

Comparison of spinal sagittal parameters by time of day in a healthy working population: Do we bend during the day?

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.

Investigation of efficacy of treatment in spinal cord injury: Erythropoietin versus methylprednisolone.

BACKGROUND: Investigation of the expression of platelet-derived growth factor (PDGF)-ß 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-ß- 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-ß- 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-ß expression on the locomotor function, we determined that PDGF-ß 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-ß, thus produce better results in locomotor functions when compared to MP.

Aarskog-Scott syndrome: An unusual cause of scoliosis.

A 16-year-old boy who had been diagnosed previously as Aarskog-Scott syndrome (AAS), referred to our clinic with shoulder asymmetry for 1 year. Results of spine examination showed a 52° right thoracic curve at T3-T11. Surgery was planned, and T1-L1 posterior instrumentation and fusion were performed. After surgery, satisfactory correction was achieved, and during 10 years follow-up, the patient had no complaints. AAS is a X-linked genetic disorder with facial, genital, and skeletal manifestations. Scoliosis is not reported as a typical finding of AAS, and there is no reported case in the English literature. Due to mutation affecting the developing skeleton tissue, spinal deformities may develop. In our case, concave side fusion was seen at the deformity. Although we do not know any specific pattern of the scoliotic deformity of this syndrome, surgical correction of the deformity can be difficult because of the premature fusion at these levels.

Analysing the change of sagittal balance in patients with Lenke 5 idiopathic scoliosis.

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.

Effects of NSAIDs and hydroxyapatite coating on osseointegration.

PURPOSE: The aim of our study is to investigate the bone ongrowth of two different alternative surfaces and the effect of nonsteroidal anti-inflammatory drugs (NSAIDs) on osseointegration. METHODS: Hips of 40 New Zealand white rabbits were operated bilaterally. Hydroxyapatite (HA)-coated titanium rods were implanted into the right femur, and grit-blasted titanium rods were implanted into the left femur. They were divided into three groups. At the end of 8 weeks, both femora of the rabbits were removed and investigated biomechanically and histologically. RESULTS: HA-coated implants had a significantly better failure load and "percentage of bone-implant contact" than grit-blasted implants. There was no significant difference between the medication groups as a result of the biomechanical and histologic investigations. CONCLUSIONS: Our results indicate that NSAIDs did not have any negative effect on the osseointegration. HA-coated implants may provide more tensile strength and greater bone-implant contact rate in comparison with grit-blasted implants.

Esophageal Perforation Caused by a Posterior Pedicle Screw: A Case Report.

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.

Health related quality of life and perception of deformity in patients with adolescent idiopathic scoliosis.

BACKGROUND: Quality of life and cosmethic appearance have gained importance as outcomes in AIS treatment. Improving aesthetic appearance and quality of life are defined as the primary aims of scoliosis treatment by health professionals. Studies that assess and compare the different treatment results in the field of quality of life and cosmethics are some what limited. OBJECTIVE: A cross-sectional study was designed to compare quality of life and deformity perception in patients with adolescent idiopathic scoliosis (AIS) received conservative (exercise or exercise + brace) or surgical treatment. METHODS: A total of 68 (58 females) patients aged 10-18 years with AIS received conservative (exercise or exercise+brace) or surgical treatment were invited to participate in the study. Quality of life (Scoliosis Research Society-23 (SRS-23)) and perception of deformity (Walter Reed Visual Assessment (WRVAS)) were assessed. RESULTS: Conservatively treated patients had significantly superior scores in function domain of SRS-23 than surgically treated patients (exercise/surgery, exercise+brace/surgery; p= 0.009, 0.004). Otherwise, surgically treated patients had significantly superior scores in self-image (p= 0.000, 0.000), and satisfaction with management (p= 0.001, 0.006) domains of SRS-23, and WRVAS (p= 0.000, 0.000) than conservative groups. CONCLUSION: In addition to radiographic assessments, quality of life, aesthetic perception, functionality, satisfaction with management, psycho-social status should carefully be taken into consideration by health professionals in the teratment of AIS.

Postoperative changes in sacropelvic junction in short-segment angular kyphosis versus Scheuermann kyphosis.

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.