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. ER - Keywords Scheuermann kyphosis Distal junctional kyphosis Sagittal stable vertebra First lordotic vertebra Lower end vertebra

Background: Accurate deformity classification and fusion-level planning are essential in adolescent idiopathic scoliosis (AIS) surgery and are traditionally guided by Cobb angle measurement and the Lenke system. Multimodal large language models (LLMs) (e.g., ChatGPT-4.0; Claude 3.7 Sonnet, Gemini 2.5 Pro, DeepSeek-R1-0528 Chat) are increasingly used for image interpretation despite limited validation for radiographic decision-making. This study evaluated the agreement and reproducibility of contemporary multimodal LLMs for AIS assessment compared with expert spine surgeons. Methods: This single-center retrospective study included 125 AIS patients (94 females, 31 males; mean age 14.8 ± 1.9 years) who underwent posterior instrumentation (2020–2024). Two experienced spine surgeons independently performed Lenke classification (including lumbar and sagittal modifiers) and selected fusion levels (UIV–LIV) on standing AP, lateral, and side-bending radiographs; discrepancies were resolved by consensus to establish the reference standard. The same radiographs were analyzed by four paid multimodal LLMs using standardized zero-shot prompts. Because LLMs showed inconsistent end-vertebra selection, LLM-derived Cobb angles lacked a common anatomical reference frame and were excluded from quantitative analysis. Agreement with expert consensus and test–retest reproducibility (repeat analyses one week apart) were assessed using Cohen’s κ. Evaluation times were recorded. Results: Surgeon agreement was high for Lenke classification (92.0%, κ = 0.913) and fusion-level selection (88.8%, κ = 0.879). All LLMs demonstrated chance-level test–retest reproducibility and very low agreement with expert consensus (Lenke: 1.6–10.2%, κ = 0.001–0.036; fusion: 0.8–12.0%, κ = 0.003–0.053). Claude produced missing outputs in 17 Lenke and 29 fusion-level cases. Although LLMs completed assessments far faster than surgeons (seconds vs. ~11–12 min), speed did not translate into clinically acceptable reliability. Conclusions: Current general-purpose multimodal LLMs do not provide reliable Lenke classification or fusion-level planning in AIS. Their poor agreement with expert surgeons and marked internal inconsistency indicate that LLM-generated interpretations should not be used for surgical decision-making or patient self-assessment without task-specific validation.

Complex tibial plateau fractures present significant challenges due to severe articular comminution and soft tissue complications. There is still no consensus in the current literature regarding the optimal treatment for these fractures. This study aims to evaluate the clinical and radiological outcomes of complex tibial plateau fractures treated with Ilizarov external fixation with or without minimal internal fixation. This retrospective study analyzed 62 patients with Schatzker type V or VI tibial plateau fractures, with a minimum follow-up duration of three years. Patients were divided into two groups: one treated with circular external fixation (Ilizarov method) combined with minimal internal fixation and the other treated with circular external fixation alone. Clinical, functional, and radiological outcomes were assessed, including knee range of motion (ROM), Knee Society Score (KSS), Kujala Score, and Visual Analog Scale (VAS) score. At the latest follow-up, Group 1 demonstrated better functional and clinical outcomes compared to Group 2. The mean knee range of motion in Group 1 was 116.56° versus 97.83° in Group 2 (p<0.05). Group 1 also had higher KSS scores (92.43 vs. 79.06) and Kujala Scores (94.75 vs. 90.6) and lower VAS scores (1.13 vs. 3.33) (all p<0.05). Flexion contracture and extension lag were significantly less prevalent in Group 1, with fewer cases and lower severity. Circular external fixators were removed earlier in Group 1 (120.43 days) compared to Group 2 (157.06 days) (p<0.05), with a lower incidence of delayed union in Group 1. Varus malalignment was also less frequent and less severe in Group 1. No major complications, such as neurovascular injuries, septic nonunion, or deep venous thrombosis, were reported in either group. Both groups exhibited similar rates of minor complications, primarily pin tract infections, which resolved with appropriate treatment. Ilizarov external fixation, with or without minimal internal fixation, is an effective treatment method for complex tibial plateau fractures. However, patients in whom the joint was anatomically reduced demonstrated better anatomical reduction, improved range of motion, earlier weight-bearing, and enhanced functional recovery, highlighting the superiority of this approach. These findings support the recommendation of this combined technique as the preferred treatment for such challenging fractures.

Objective: This study aimed to examine the relationship between lumbosacral transitional vertebra (LSTV), classified by Castellvi’s system, and lumbar disc degeneration, graded using Pfirrmann’s classification, based on radiological assessment. Methods: This retrospective study analyzed 2516 patients (1548 females and 968 males) with a mean age of 51.83 ± 15.6 years withchronic low back pain who underwent lumbosacral magnetic resonance imaging and computed tomography scans at a single centerbetween January 2018 and January 2021. Pfirrmann grading was used to assess L4-L5 intervertebral disc degeneration, and Castellviclassification determined the anatomical type of LSTV. Correlation analysis was performed to evaluate the association between LSTVpresence and disc degeneration. Additionally, a proportional-odds ordinal logistic regression model was used to examine the relationship between Pfirrmann grade and patient-specific factors (age, gender, and LSTV presence). Results: According to Pfirrmann classification, 113 patients were grade I, 402 were grade II, 877 were grade III, 861 were grade IV, and 263 were grade V. A total of 771 patients (30.6%) did not have LSTV, while the remaining 1745 patients (69.4%) had LSTV. A statistically significant association was found between LSTV presence and Pfirrmann grade (P < .001, r=.200). Patients with LSTV had 0.75 times higher probability (95% CI: 0.58–0.90, P < .001) of exhibiting a higher Pfirrmann grade compared to those without LSTV. However, no significant correlation was observed between LSTV subtypes classified by Castellvi and Pfirrmann grade (P=.379). Additionally, age was significantly correlated with Pfirrmann classification, LSTV presence, and Castellvi classification (P < .001). Female patients had 1.34 times higher likelihood (95% CI: 1.19–1.49, P < .001) of exhibiting a higher Pfirrmann grade compared to male patients. Conclusions: This study highlights the significant association between LSTV and advanced disc degeneration, establishing LSTV as apotential risk factor for progressive spinal changes. It emphasizes the importance of early detection and targeted management, particularly for older adults and females who are more susceptible to severe degenerative changes. Cite this article as: Bayram S, Altin YF, Kahraman A, Ya!ci TF, Korkmaz M, Akgül T. Presence of sacralized lumbar vertebra predisposes to adjacent level lumbar disc degeneration: A cross-sectional study. Acta Orthop Traumatol Turc., 2025;59(2):117-121.

EFFECTIVENESS OF HALO TRACTION IN THE TREATMENT OF PATIENTS WITH SEVERE RIGID SCOLIOSIS - The Journal of Turkish Spinal Surgery