The mid-term clinical outcomes of total knee arthroplasty in the management of end-stage hemophilic arthropathy

Objective:

This study aimed to evaluate the mid-term clinical outcomes of total knee arthroplasty (TKA) in the management of end-stage hemophilic arthropathy.

Methods:

Eleven patients (15 knees) undergoing TKA with stiff knees were retrospectively evaluated. TKA was performed in all patients without additional surgical interventions such as posterior capsular release, hamstring release, synovectomy, VY quadricepsplasty, or tibial tubercle osteotomy. All patients were evaluated for clinical and radiological results at follow-ups. Functional evaluation and pain status were assessed using the Knee Society Score and Visual Analogue Scale.

Results:

The mean age at the time of operation was 40.8 ± 11.8 years (range = 30–64 years). The mean follow-up was 51.2 ± 20.6 months (range = 24–95). The mean flexion contracture significantly decreased from 17.6 ± 11.3 to 1.7 ± 2.8 degrees, and the mean maximum flexion increased dramatically from 55.6 ± 20.5 to 109.2 ± 16.2 degrees (P < 0.001). Statistical significant improvement in flexion and flexion contracture degrees continued up to the postoperatively 18 months. The mean Knee Society Score increased from 22.7 ± 2.4 points preoperatively to 87.8 ± 3.8 points at the last follow-up (P < 0.001). The mean cost of coagulation factor consumption and blood transfusion accounted for 78% of the total cost.

Conclusion:

This study has shown that TKA is an effective treatment for relieving pain and improving both ranges of motion and quality of life in managing end-stage hemophilic arthropathy of the knee joint.

Level of Evidence: Level IV, Therapeutic Study

Triple pelvic osteotomy for the treatment of symptomatic acetabular dysplasia in adolescents and adults : A review of 42 hips

We treated 42 hips with symptomatic acetabular dysplasia using triple pelvic osteotomy. The mean age of the patients was 20.7 years (12-47). The median follow-up was 50.3 months. The average Harris hip score improved from 74 to 92 points. Significant improvement from the preoperative to the latest follow-up evaluation was seen radiologically with reference to the center-edge angle, the anterior center-edge angle, the acetabular index and the femoral head extrusion index. Shenton's line was intact in 9 hips before the operation and it was intact in 40 hips at the latest follow-up. The cross-over sign was present in 15 hips before the operation and it was present in one hip after the operation. The results of this study demonstrated that triple pelvic osteotomy provides improved radiographic results and good symptomatic relief in acetabular dysplasia.

Compartment syndrome, disseminated intravascular coagulation, pneumonia, and acute renal failure due to varicella in a previously healthy child

Varicella infections are usually considered to be benign. Although very rare, infection of an immunocompetent patient by this virus may result in a severe illness. We describe a case of varicella infection in a previously healthy, immunocompetent 5-y-old boy, complicated with compartment syndrome, disseminated intravascular coagulation (DIC), pneumonia, and acute renal failure. He was treated successfully with aciclovir and intravenous immunoglobulins for the varicella infection, a fasciotomy for compartment syndrome, and fresh frozen plasma for DIC.

The effects of spinal, inhalation, and total intravenous anesthetic techniques on ischemia-reperfusion injury in arthroscopic knee surgery

PURPOSE

To compare the effects of different anesthesia techniques on tourniquet-related ischemia-reperfusion by measuring the levels of malondialdehyde (MDA), ischemia-modified albumin (IMA) and neuromuscular side effects.

METHODS

Sixty ASAI-II patients undergoing arthroscopic knee surgery were randomised to three groups. In Group S, intrathecal anesthesia was administered using levobupivacaine. Anesthesia was induced and maintained with sevoflurane in Group I and TIVA with propofol in Group T. Blood samples were obtained before the induction of anesthesia (t1), 30 min after tourniquet inflation (t2), immediately before (t3), and 5 min (t4), 15 min (t5), 30 min (t 6), 1 h (t7), 2 h (t8), and 6 h (t9) after tourniquet release.

RESULTS

MDA and IMA levels increased significantly compared with baseline values in Group S at t2-t 9 and t2-t7. MDA levels in Group T and Group I were significantly lower than those in Group S at t2-t8 and t2-t9. IMA levels in Group T were significantly lower than those in Group S at t2-t7. Postoperatively, a temporary 1/5 loss of strength in dorsiflexion of the ankle was observed in 3 patients in Group S and 1 in Group I.

CONCLUSIONS

TIVA with propofol can make a positive contribution in tourniquet-related ischemia-reperfusion.

[The long-term results of brace treatment in Perthes disease]

OBJECTIVES

We evaluated the long-term radiological outcomes of the patients with Perthes disease who were conservatively treated with brace.

PATIENTS AND METHODS

Thirty-three hips of 27 skeletally mature patients (21 males, 6 females; mean age 25.2±3.4 years; range 20 to 32 years) treated with modified Thomas splint were included in this study. The results were evaluated according to the Stulberg classification.

RESULTS

The mean age of the patients was 6.3±2.2 (range 3-12) years at the onset of the disease and the mean follow-up was 18.6±3.2 (range 7.2-24.1) years. According to onset of the disease, good results were obtained for the patients who were less than six-years-old as 77.7%, between 6-9 years old as 84.2%, after nine years old as 40%. However, 100% of the Herring group A hips, 79.2% of the group B hips and 50% of the group C hips were healed with Stulberg class I or II results.

CONCLUSION

We obtained satisfactory results after conservative treatment with Thomas splint in patients who were between 6-9 years old at onset of the disease with Herring group B involvement. It is hard to say whether the good results were stemmed from having good prognosis of these patients, or stemmed from positive effect of using brace on treatment.

Treatment of capitellar osteochondritis dissecans with a tendon graft: a case report

A 14-year-old girl who was engaged in farming was admitted with the complaints of right elbow pain and limited range of motion in the elbow joint. Plain radiograph revealed capitellar osteochondritis dissecans. After the loose fragment was removed from the capitellum and the defect was curetted, a palmaris longus tendon graft harvested from the same hand was implanted into the capitellar defect. Elbow joint was immobilized for three weeks. Magnetic resonance imaging showed that tendon graft was successfully adapted into defect. The range of motion was preserved and she had no pain in the elbow joint. In conclusion, we suggest that tendon autograft can be used in the treatment of capitellar osteochondritis dissecans.

Comparison between conservative and surgical treatment in Perthes disease

INTRODUCTION

The purpose of this study was to compare the results of conservative and surgical treatment in a homogeneous group constituted by patients between 6 and 8 years of age at onset of the Perthes disease with Herring B involvement.

METHODS

Twenty-seven hips of 25 patients were evaluated radiologically and clinically. Patients were divided into two groups in terms of treatment type. In group I [16 hips of 14 patients], hips were treated conservatively using Thomas splints. The mean follow-up period was 21.5 (10-25) years. In group II [11 patients], hips were treated surgically using femoral osteotomy. The mean follow-up period was 14.3 (8-20) years.

RESULTS

There was no statistically significant difference between the groups in terms of Stulberg classification, but surgically treated patients had more varus angle, more shortening, and more trochanteric overgrowth compared with the braced group.

CONCLUSION

Non-surgical treatment with a brace is a reliable alternative to surgical treatment in Perthes disease between 6 and 8 years of age at onset with Herring B involvement. However, we could not know whether the good results were influenced by the brace or stemmed from having good prognosis of these patients.

[Effects of human amniotic fluid on posterolateral spinal fusion: an experimental preliminary study]

OBJECTIVES

In this study, the effects of human amniotic fluid on posterolateral spinal fusion were investigated in a rat model.

MATERIALS AND METHODS

Twenty-eight 20-week-old male Sprague Dawley rats were included in the study. The subjects were divided into two main groups as the control group and the amniotic fluid group. Posterolateral spinal fusion was performed by using autografts in all groups whereas 0.3 ml of centrifuged human amniotic fluid was added to the fusion area in amniotic fluid groups. Groups were further divided into subgroups each including seven rats and evaluated radiologically and histologically at the third and sixth weeks.

RESULTS

The radiological fusion observed in the amniotic fluid group was significant at the sixth week when compared to that in the control group. The histological fusion quality was significant in the amniotic fluid groups both at the third and sixth weeks when compared to the control groups.

CONCLUSION

We conclude that human amniotic fluid enhances posterolateral spinal fusion. We believe that the growth factors and hyaluronic acid present in the amniotic fluid played a role in this result.

Radiological evaluation of combined valgus extension osteotomy and tectoplasty for the treatment of Herring group C Perthes patients

OBJECTIVES

In this study we evaluated the results of combined proximal femoral valgus extension osteotomy and tectoplasty in the treatment of Herring group C Perthes disease with hinge abduction.

PATIENTS AND METHODS

This study was carried out in 11 male patients who underwent combined proximal femoral valgus extension osteotomy and tectoplasty for hinge abduction related to Perthes disease between January 2002 and February 2009. All patients were assessed as group C according to the Herring lateral pillar classification. The mean age at the time of surgery was nine years and one month with an age range of six years to 11 years and two months. All patients had pain and hinge abduction preoperatively.

RESULTS

The mean follow-up was 65 months (range 26 to 111 months). In the patients who received a proximal valgus extension osteotomy and tectoplasty, the postoperative femoral head containment was significantly increased radiographically. The postoperative femoral head containment was evaluated on radiographs which were taken one and three months after the surgery. After healing of the osteotomy, one-year and final control graphies were evaluated. We carried out a comprehensive evaluation of preoperative and postoperative radiographs that included measuring; subluxation ratio, femoral head coverage ratio, femoral head size ratio, Sharp's angle, CE (center-edge) angle, neck-shaft angle, caput index and acetabular depth index. Consequently there were significant radiographic healing and improvements from time of initial follow-up to final follow-up.

CONCLUSION

This study has shown that, in the short-term, combined valgus extension osteotomy and tectoplasty relived pain and corrected deformity in patients with hinge abduction. As growth continues the remodelling of hip joint is influenced in a positive way.

Magnetic resonance imagination of the peroneus longus tendon after anterior cruciate ligament reconstruction

Several studies report that tendons can regenerate after harvesting. These studies have been performed especially in patellar and hamstring tendons. At our institution, 10 cm length of full thickness peroneus longus tendon has been harvested to reconstruct torn anterior cruciate ligament since 1997 as a different graft source. The aim of this study was to investigate whether the peroneus longus tendon used the anterior cruciate ligament reconstruction has a regeneration potential or not. Twelve patients, who had originally undergone harvesting of the peroneus longus tendon for the primary surgery of the anterior cruciate ligament reconstruction, underwent magnetic resonance imaging (MRI). Images of both legs were acquired simultaneously with the use of the scanner's extremity coil, as we aimed to compare harvested peroneus longus tendon with the other leg's peroneus longus tendon (healthy side) for evaluation of the regeneration potential. The average age of the patients was 31 years. There were eight right and four left legs. The average time interval was 52 months between ligament surgery and MRI. In all patients, a varying amount of the regeneration of the peroneus longus tendon was seen on the MRI images. Although the extent of PLT regeneration in proximal sections seemed better than in mid- and distal sections, there was no statistical difference between sections (P = 0.130). These data show that the peroneus longus tendon has a regeneration potential after harvesting for anterior cruciate ligament reconstruction.

[The effect of tibiofemoral angle changes on the results of dome osteotomy]

OBJECTIVES

We investigated the effect of tibiofemoral angle changes on the results of dome osteotomy in patients with medial compartment osteoarthritis of the knee.

METHODS

The study included 23 knees of 22 patients (15 women, 7 men; mean age 60 years; range 37 to 73 years) who underwent high tibial dome osteotomy for medial compartment osteoarthritis. A simple modified Charnley external fixator was used for stabilization of the osteotomy. Based on the Ahlback classification, 15 knees had grade I, six knees had grade II, and two knees had grade III osteoarthritis. The patients were evaluated in three groups based on the postoperative tibiofemoral angles obtained; hence, a valgus angle of less than 8 degrees (4 knees), 8 degrees to 12 degrees (10 knees), and greater than 12 degrees (9 knees). Clinical evaluations were made using the American Knee Society scoring system. The mean follow-up period was 5.4 years (range 1 to 10 years).

RESULTS

The mean tibiofemoral angle was 4.4+/-2.9 degrees of varus (range 0 degrees to 10 degrees ) preoperatively, and 11+/-3.8 degrees of valgus (range 5 degrees to 18 degrees ) postoperatively. The mean correction loss at final evaluations was 2.7 degrees . The mean preoperative and postoperative knee scores were 37.7+/-15.8 (range 19 to 77) and 80.2+/-9.2 (range 51 to 93), respectively (p<0.001). The mean functional score increased from 52.3+/-18.8 (range 10 to 80) to 75.6+/-18.5 (range 35 to 100) at final analysis (p<0.001). The knee and functional scores did not differ significantly between three groups of patients having a different range of postoperative tibiofemoral angle (p>0.05).

CONCLUSION

Our results show that the alignment obtained after high tibial osteotomy does not influence knee and functional scores provided that it is within an acceptable range.

Necrotizing fasciitis with ruminococcus

Necrotizing fasciitis is a life- and limb-threatening soft tissue infection. Due to its underlying predisposition and rapid progression, treatment should be started quickly using antibiotherapy and surgical intervention. Although necrotizing fasciitis is mainly caused by streptococci and staphylococci, it may also be polymicrobial. Other peptostreptococci have been reported as necrotizing fasciitis agents in the literature, though we encountered no cases of necrotizing fasciitis caused by Ruminococcus productus. Here, we describe a case of necrotizing fasciitis caused by R. productus, a Gram-positive, obligatory anaerobe.

Bucket-handle tear of medial plica

Plicae are synovial folds, classified according to their anatomical relationship to the patella. The medial patellar plica is normally asymptomatic, but it may cause symptoms when it becomes thickened and fibrotic. We describe three cases of bucket-handle tear of the medial patellar plica. They all suffered from anterior knee pain and clicking. Our cases' symptoms began when they incurred twisting injuries to the knee; therefore, we think that they had an asymptomatic plica first. Pain and clicking began because of the bucket-handle portion rubbed over the medial femoral condyle with knee flexion, and they improved after resection of the bucket-handle portion. Consequently, we think that medial patellar plica can be symptomatic not only when it becomes thickened or fibrotic but also when a bucket handle tear occurs.

Tendon regeneration: an anatomical and histological study in sheep

Utilization of the hamstring tendon in reconstruction of the anterior cruciate ligament (ACL) has become common in recent years. In MRI studies regeneration potential in harvested tendon has been observed. In the present study, 20 legs from ten sheep, which underwent 10 cm segment resection of tendon of musculus extensor digitalis lateralis (MEDL) were used. The sheep were killed 6 months after the operation and regenerated tendons were examined macroscopically and histologically. Dissection was performed in the tendon resection area and specimens were reharvested for histological examination. Regeneration of the tendon with normal anatomical topographies was found in all legs. Regeneration occurred on both sides of the resected tendon simultaneously. Regeneration was muscle-like in the proximal side but it was tendon-like in the distal side. The developed tendon was fused to the joint capsule and to the fascia at the joint line in all specimens. This study indicates that tendon has a potential for regeneration.

Initial fixation strength of interference nail fixation for anterior cruciate ligament reconstruction with patellar tendon graft (experimental study)

The objective of this study was to evaluate initial fixation strength of a new interference nail fixation in anterior cruciate ligament reconstruction using bone-patellar tendon-bone graft. Human cadaver knees were used. Fixation strengths ranged from 500 N to 600 N (mean 550 N). This corresponds to loads in the graft during aggressive rehabilitation. No slippage occurred at fixation site of specimens. Most of the failures appeared from the femoral side with tendon ruptures. With respect to primary fixation strength, interference nail fixation is a reasonable alternative for anterior cruciate ligament reconstruction with bone-patellar tendon-bone graft.