The Short-Term Efficacy of Integrating the Easy-Flex Device with Inpatient Rehabilitation in Total Knee Arthroplasty Patients: Insights from a Single-Blind Randomized Controlled Trial.

OBJECTIVE: To determine the effect of Easy-Flex as an adjunct to standard inpatient rehabilitation on clinical and functional outcomes. DESIGN: Prospective randomized controlled trial SETTING: Outpatient clinic and research laboratory PARTICIPANTS: A total of 44 patients were randomized to the Easy-Flex Group (EFG) or Control Group (CG). INTERVENTION: A rehabilitation program averaging 50-60 minutes per day was implemented for the CG patients. In the EFG, in addition to 30-40 minutes of exercise with the Easy-Flex, the rehabilitation program applied to the CG was integrated with reduced sets and repetitions, with an average duration of 20 minutes. All interventions were performed under the supervision of a physiotherapist during hospitalization. After discharge, both groups received the same home exercise program. OUTCOME MEASUREMENTS: The primary outcome is the flexion and extension range of motion (ROM). The secondary outcomes include the Numeric Pain Rating Scale (NPRS), Western Ontario and McMaster University Osteoarthritis Index (WOMAC), Five Times Sit-to-Stand Test (5TSST), 10-Meter Walking Test (10MWT), Short Form-12v2, and Global Rating of Change score (GRCS). RESULTS: After 6 weeks, the overall group-by-time interaction for the 2 × 3 mixed-model ANOVA was found to be significant for flexion ROM (p=0.005), NPRS-rest (p=0.04), NPRS-activity (p=0.01), 10-MWT (p=0.003), WOMAC (p=0.021) and SF-12-PCS (p=0.032) in favor of EFG exercising with Easy-Flex in addition to standard rehabilitation. The between-group differences in favor of the EFG were -8.0° knee ROM, 1.35 to 1.5 points for pain intensity, and 0.12 m/sec for gait speed. Furthermore, differences favouring EFG in NPRS-rest,10-MWT speed, and SF-12 PCS were greater than the reported MCID. CONCLUSIONS: Incorporating Easy-Flex into standard physical therapy can be a beneficial, safe, and effective approach in clinical practice, as patients undergoing TKA typically prioritize improving their quality of life by reducing pain and increasing ROM.

Symptomatic osteonecrosis of the hip and knee in patients with systemic lupus erythematosus: Prevalence, pattern, and comparison of natural course.

OBJECTIVE: Osteonecrosis (ON), also known as avascular necrosis, is characterized by the collapse of the architectural bone structure secondary to the death of the bone marrow and trabecular bone. Osteonecrosis may accompany many conditions, especially rheumatic diseases. Among rheumatic diseases, osteonecrosis is most commonly associated with systemic lupus erythematosus (SLE). We assessed prevalence and distribution pattern of symptomatic ON in patients with SLE and compare the natural courses of hip and knee ON. METHODS: 912 SLE patients admitted between 1981 and 2012 were reviewed. SLE patients with symptomatic ON were retrospectively identified both from the existing SLE/APS database. The prevalence of symptomatic ON was calculated; with ON, the joint involvement pattern was determined by examining the distribution of the joints involved, and then the data about the hip and knee joints were entered in the Kaplan-Meier analysis. Kaplan-Meier methods were used to calculate 5- and 10-year rates of ON-related hip (the hip group) and knee survival (the knee group). RESULTS: Symptomatic ON developed in various joints in 97 of 912 patients with SLE, and the overall prevalence of ON was detected as 10.6%. The mean age at the time of SLE and ON diagnoses were 27.9 ± 9.9 (14-53) and 34.2 ± 11.3 (16-62) years, respectively. The mean duration from diagnosis of SLE to the first development of ON was 70.7± 60.2 (range = 0-216) months. The most common site for symptomatic ON was the hips (68%, n=66), followed by the knees (38%, n = 37). According to Kaplan-Meier analysis, hip and knee joint survival rates associated with 5-year ON were 51% and 88%, and 10-year survival rates were 43% and 84%, respectively. CONCLUSION: We observed that the prevalence of symptomatic ON in patients with SLE was 10.6%. With the estimated 10-year survival rates of 40% versus 84% for the hip and knee joints, respectively, hip involvement may demonstrate a more aggressive course to end-stage osteoarthritis than the knee involvement.

The Impact of the Ligamentous Injury Pattern and Associated Neurovascular Injury on Ultimate Knee Function in Patients with Traumatic Knee Dislocations.

The present study aims to investigate whether there is a relationship between the ligamentous injury pattern and concomitant neurovascular injury with long-term functional outcomes in patients with traumatic knee dislocations (TKDs). A total of 42 patients with TKDs were categorized according to the Schenck's classification based on the pattern of ligamentous injury. Concomitant vascular and neural injuries were recorded. Long-term functional outcomes were assessed using several objective and subjective outcome measures. This retrospective study was conducted in two phases: (1) to analyze the impact of ligamentous injury pattern on functional outcomes of patients with TKDs in the overall study population, by comparing all the variables among Schenck's grades; (2) to determine the impact of concomitant vascular and neural injury on ultimate knee function based on the subgroup analyses. In the overall study statistical differences were determined among each pattern of ligamentous injury in the total range of motion (ROM) and scoring systems (chi-squared test, p = 0.254). The overall rates of vascular and neural injury were 26 and 28%, respectively. In subgroup analyses, 40 patients were divided into three subgroups: group A (isolated concomitant neural injury), group B (isolated concomitant vascular injury), group C (without concomitant major vascular or neural injury). The analysis revealed a significant difference in the total ROM (p = 0.005), flexion measurements (p = 0.004), and the loss of extension (p = 0.003). Group A had the lowest total knee ROM and the mean flexion degrees, as well as the highest loss of extension. Concerning functional scoring systems including the combined Knee Society Score (knee score + function score), Lysholm knee scoring scale, and International Knee Documentation Committee score, subgroup analyses revealed significant differences among the groups (p = 0.001, p < 0.01 for all scores). All the scores were found to be lowest in group A. Evidence from the current study showed that the ligamentous pattern and concomitant neurovascular injury both may have a significant impact on ultimate knee function in patients with TKDs. This is a Level III-retrospective comparative study.

The Combination of Exercise and Manual Therapy Versus Exercise Alone in Total Knee Arthroplasty Rehabilitation: A Randomized Controlled Clinical Trial.

BACKGROUND: Total knee arthroplasty (TKA) is one of the most commonly performed orthopedic surgeries in the lower extremity. However, patient dissatisfaction and functional disability are mostly experienced because of pain and limited range of motion (ROM). Although manual therapy is commonly implemented to improve ROM and modulate pain in the management of musculoskeletal disorders, there is a lack of evidence about its clinical effectiveness on postoperative TKA rehabilitation. OBJECTIVE: To investigate the effectiveness of an exercise program combined with manual therapy compared with an exercise program only for pain, ROM, function, quality of life, and patient satisfaction outcomes. DESIGN: A randomized controlled clinical trial. SETTING: Rehabilitation unit of a university hospital. PARTICIPANTS: Forty-two patients (68.45 ± 6.3 years) scheduled for unilateral TKA as a treatment of severe osteoarthritis. INTERVENTIONS: Joint and soft tissue mobilizations in addition to exercise therapy were provided to the mobilization group (n = 21) while the control group received exercise therapy only (n = 21). MAIN OUTCOME MEASURES: The outcome measures were numeric pain-rating scale, knee ROMs, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, 10-meter walk test (10MWT), 5-times sit to stand test (5SST), and Short Form-12 (SF-12). RESULTS: Improvements in pain outcomes were significantly higher in the mobilization group than in the control group (P = .001, F [3, 33] = 7.06) and the between-group difference in change score was 1.3 points (P = .001). Although the between-group difference in change score was 12.8° for knee flexion at 2 months (P = .001), the overall group-by-time interactions were not significant for flexion and extension ROMs (P = .175, F [3, 33] = 1.75 and P = .57, F [2, 34] = 0.56, respectively). Additionally, there were statistically meaningful group-by-time interactions on total WOMAC score (P = .006, F [2, 34] = 5.29), 10MWT (P = .002, F [3, 33] = 5.98), and SF-12 mental component summary (P = .01, F [2, 34] = 4.92) favoring the mobilization group. Also, patient satisfaction was higher in the mobilization group (P = .02). CONCLUSIONS: A structured exercise program combined with manual therapy can be more beneficial in improving pain, function, and patient satisfaction compared to exercise program alone for postoperative TKA patients.

New trends in the orthopaedic management of diabetic foot.

Although there are various types of therapeutic footwear currently used to treat diabetic foot ulcers (DFUs), recent literature has enforced the concept that total-contact casts are the benchmark.Besides conventional clinical tests and imaging modalities, advanced MRI techniques and high-sensitivity nuclear medicine modalities present several advantages for the investigation of diabetic foot problems.The currently accepted principles of DFU care are rigorous debridement followed by modern wound dressings to provide a moist wound environment. Recently, hyperbaric oxygen and negative pressure wound therapy have aroused increasing attention as an adjunctive treatment for patients with DFUs.For DFU, various surgical treatments are currently available, including resection arthroplasty, metatarsal osteotomies and metatarsal head resections.In the modern management of the Charcot foot, surgery in the acute phase remains controversial and under investigation. While conventional fixation techniques are frequently insufficient to keep alignment postoperatively, superconstruct techniques could provide a successful fixation.Retrograde intramedullary nailing has been a generally accepted method of achieving stability. The midfoot fusion bolt is a current treatment device that maintains the longitudinal columns of the foot. Also, Achilles tendon lengthening remains a popular method in the management of Charcot foot. Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170073.

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.

The cementless fibre mesh coated anatomic femoral stem: 12 to 23 years clinical and radiological outcome study.

INTRODUCTION: The aim of this study was to assess the long-term clinical and radiographic results, and possible reasons for failure of two versions of the cementless fibre-metal coated anatomical femoral component. METHODS: 99 patients (119 hips) were evaluated at an average of 16.7 years (range, 12 to 23 years) following primary THA. Developmental dysplasia of the hip (DDH) was the most common pathology (n = 37 hips). Structural femoral head autografts were used to increase cup coverage in 23 hips. Vertical and horizontal migration of acetabular and femoral components and osteolysis around the components were assessed using conventional radiolography. For clinical evaluation, the Harris Hip Score and Merle D'Aubigne scale were used preoperatively and at final follow up. Implant survival was calculated according to the Kaplan-Meier survivorship analysis and failure was defined as component's revision for any reason. RESULTS: The cumulative survival rate of the anatomical femoral stem was 64.2% at 19.8 years, with a worst-case scenario of 41%. The cumulative survival rate of the total hip arthroplasty was 51% at 19.8 years, with a worse case scenario of 38%. The mean preoperative Harris Hip Score of 42 points improved to 88 postoperatively. The mean preoperative Merle D'Aubigne functional score of 3.5 improved to 5.2 points at the time of final follow-up. In 36 hips (41.6%) osteolysis was found in Gruen zone 1, proximal to the ingrowth surface. CONCLUSIONS: The cementless fibre-metal coated anatomical femoral component showed favourable long-term clinical and radiological results. Proximal coating seems to protect bone implant interface from wear debris induced osteolysis during the second decade.

Biomechanical comparison of oblique and step-cut osteotomies used in total hip arthroplasty with femoral shortening.

BACKGROUND: Various types of shortening osteotomies and prosthesis are used for femoral reconstruction in total hip arthroplasty of the high hip dislocation. This biomechanical study investigates whether step-cut osteotomies result in better stability than oblique osteotomies and cylindrical femoral stems enhance stability of the osteotomy more than conical stems, and which osteotomy and prosthesis type maintain the stability better after cyclical loading. METHODS: Oblique and step-cut shortening osteotomies were compared under axial and rotational forces, using synthetic femur models and conical or cylindrical femoral prostheses. The models underwent cyclic loading for 10,000 cycles at 3 Hz (100-1000 N axial bending or 0.5-10 Nm torque). After the completion of cyclic loading, the models were loaded until failure. Stiffness values before and after cyclical loading, and failure loads were the outcome parameters. Relative displacements at the osteotomy sites were also measured using 3-Dimensions Digital Imaging Correlation System. RESULTS: The mean failure load was significantly higher in conical prosthesis groups under axial forces. In torsion tests, the mean stiffness of conical prosthesis groups after cyclical loading was higher in oblique osteotomies. The other parameters were similar between the groups. CONCLUSIONS: According to the results of the study, although some individual statistically significant parameters were obtained, step-cut osteotomies, which are technically challenging procedures, were not found biomechanically superior to oblique osteotomies, with neither conical nor cylindrical prostheses.

Cementless total hip arthroplasty with modified oblique femoral shortening osteotomy in Crowe type IV congenital hip dislocation.

Midterm results of cementless total hip arthroplasty in patients with Crowe type IV congenital dislocation of the hip were evaluated. A modified oblique subtrochanteric shortening osteotomy was used in all patients. A cylindrical femoral stem was used in all patients to stabilize the osteotomy. Mean follow-up was 82 months in 20 hips of 16 patients. Mean Merle D'Aubigné pain score increased from 2.52 to 5.65 points, function score improved from 4.0 to 5.3 points, and mobility score improved from 3.95 to 5.35. Mean greater trochanter height relative to the estimated hip center was 6.8 ± 2.0 cm preoperatively and -1 ± 0.2 cm postoperatively. Complications were dislocations in 3 patients, which were successfully managed without redislocation and fracture of greater trochanter in 3 patients, which healed uneventfully in 2 but with residual Trendelenburg gait in one. Total hip arthroplasty with modified oblique subtrochanteric shortening osteotomy is an effective technique for the treatment for Crowe type IV hip dislocation.