[POSSIBILITIES AND LIMITATIONS OF SEXUAL ACTIVITY FOLLOWING TOTAL HIP REPLACEMENT].

Total hip replacement in patients with osteoarthritis significantly reduces pain and enhances the quality of life (QoL). Sexual activity is an important component of QoL about which doctors rarely discuss with patients even though it is a matter of concern to many patients. In fact, patients who have previously had impaired sexual function due to preoperative hip pain and/or stiffness find that after surgery their hips are pain free and have better motion. After total hip arthroplasty range of hip motions is usually limited by surgeon's reccomendation in order to prevent dislocation of prosthesis. This creates limitations in activities of daily living, sport activities and also sexual activities. The aim of this paper is to give guidelines for safe sexual intercourse to patients following total hip replacement. During rehabilitation, patients should be educated on what positions are and are not recommended in the context of sexual activity.

Influence of Fondaparinux Versus Nadroparin Calcium Thromboprophylaxis on Clinical Parameters Following Total Knee Arthroplasty

Fondaparinux has been shown to be as effective as low molecular weight heparin in orthopedic surgery, with no cases of heparin induced thrombocytopenia proven until today. The main goal of this prospective randomized controlled trial was to define whether thromboprophylaxis in patients with primary osteoarthritis of the knee undergoing total knee arthroplasty (TKA) influences clinical parameters in the same manner in patients receiving fondaparinux as in those receiving nadroparin during the first 7 postoperative days. Sixty patients with primary knee osteoarthritis underwent unilateral TKA performed by the same surgeon and were randomized into two groups of 30 patients receiving either fondaparinux or nadroparin thromboprophylaxis. Patients were compared according to the duration of operation, perioperative blood loss, laboratory results and clinical evaluation of the edema during the early postoperative period. No differences were found between the groups in the mean duration of surgery, perioperative blood loss, and most of laboratory results. The level of urea was significantly lower in the nadroparin group on the first and second postoperative day. No cases of heparin induced thrombocytopenia, deep vein thrombosis or pulmonary embolism were noted during the study. Study results showed both fondaparinux and nadroparin to have the same influence on clinical parameters during the first 7 postoperative days in patients undergoing TKA.

Pre-operative autologous blood donation versus no blood donation in total knee arthroplasty: a prospective randomised trial.

PURPOSE: During total knee arthroplasty (TKA) blood loss can be significant and in spite of all techniques for reducing blood loss there is still a significant possibility for blood transfusions. For blood loss management during TKA, pre-operative autologous blood donation (PABD) is still a standard of care. In this prospective randomised study we have evaluated the efficacy of PABD in patients undergoing TKA to answer the question whether there is any need for autologous blood donations during TKA and, if yes, for which group of patients. METHODS: Patients were randomised to three groups. In group 1 patients did not donate autologous blood, in group 2 patients donated 1 dose 72 hours prior to TKA and in group 3 patients donated autologous blood 14 days prior to TKA. In all patients haemoglobin, haematocrit, thrombocyte and reticulocyte values, iron concentrations (Fe, unsaturated iron binding capacity, total iron binding capacity), activated partial thromboplastin time, prothrombin time, and intra-operative and post-operative blood loss were measured and compared. RESULTS: With PABD there was no reduction in allogeneic blood transfusions and a large number of taken doses of autologous blood was discarded, which significantly increased the cost of treatment for these patients. For patients undergoing TKA, PABD can provoke iatrogenic anaemia and thereby increase the likelihood of the need for allogeneic blood transfusion. CONCLUSIONS: Results of our study showed that PABD in non-anaemic patients is not justified and is not economically feasible.

Failure of bulk bone grafts after total hip arthroplasty for hip dysplasia.

INTRODUCTION: Bulk bone grafts are used in total hip arthroplasty (THA) when adequate acetabular cup coverage cannot be achieved. Data from literature show mainly good short-term and mid-term results with contradictory long-term results. The aim of this study was to investigate acetabular cup stability and graft integrity after dysplastic adult hip reconstruction with total hip endoprosthesis and bulk bone graft for acetabular deficiency. METHODS: Seventy-two hips in 64 patients that underwent THA with bone autograft or allograft were assessed immediately after operation, 6 months and 1, 2, 3 and 10 years after operation. Acetabular angle, acetabular cup coverage, bone graft width, and bone graft height were measured and questionnaire was designed to determine acetabular cup stability and grade graft integrity. Four investigators graded grafts and inter-rater and intra-rater reliability of the questionnaire was tested. RESULTS: All measured parameters in all patients and in patients with autograft and those with allograft separately showed significant changes consistent with graft failure and acetabular cup instability when level of significance was set at p < 0.05. CONCLUSIONS: Results of this study show significant decrease in acetabular cup stability when either autograft or allograft is used for cemented acetabular reconstruction of dysplastic hip. Further, allografts showed twice as rapid failure as autografts. Although these results contradict both good short-term and long-term results in published literature, they present warning for future use of free bulk bone grafts in reconstructive hip surgery.

Treatment of postoperative pain after total hip arthroplasty: comparison between metamizol and paracetamol as adjunctive to opioid analgesics-prospective, double-blind, randomised study.

INTRODUCTION: Metamizole use has been limited because of its risk of agranulocytosis. However, more recent literature seems to support its safety. This prospective, randomised, double-blind study was conducted to compare the analgesic effects of intravenous metamizole or intravenous paracetamol in combination with morphine PCA during the first 24 h following total hip arthroplasty. MATERIALS AND METHODS: One hundred ten consecutive patients were selected for study. The two study groups were (A) metamizole, (B) paracetamol. Postoperative pain therapy was provided by Morphine PCA pump. In the first treatment group (A group), all patients received intravenous metamizole 1.5 g every 8 h during the first 24 postoperative hours. In the second treatment group (B group), all patients received intravenous paracetamol 1 g every 8 h during the first 24 postoperative hours. Postoperative pain intensity was measured 1, 2, 3, 4, 6, 8, 10, 14, 18, 22 h after the end of surgery by a VAS. RESULTS: Statistically significant differences in VAS pain values favoring metamizole were reported at 6-h (p = 0.038), 8-h (p = 0.036), 14-h (p = 0.011), 18-h (p < 0.001) and 22-h (p = 0.025) post-baseline. Mean cumulative pain values were 17.9 for metamizole and 30.6 for paracetamol. CONCLUSIONS: In this study, we have also shown excellent efficacy of paracetamol and metamizole combined with opioids, but metamizole proved to be a better analgesic than paracetamol. It is also necessary to mention the financial aspect considering that intravenous paracetamol is about ten times more expensive than an equivalent analgesic doses of intravenous metamizole.

Patient satisfaction after revision hip arthroplasty or resection hip arthroplasty due to periprosthetic infection.

In this retrospective study we have analysed 10-year period results of all type periprosthetic hip joint infection treatments at our Department. Data for 73 patients were analysed and functional status for 41 patients evaluated. A smaller proportion of patients (45%) with resection arthroplasty as the definitive solution were satisfied. These were mostly females with numerous comorbidities and lower functional demands. Much better results were achieved in 2-stage revision arthroplasty group. In conclusion whenever possible revision arthroplasty should be done because probability of re-infection is much lower than was previously believed, and the functional status of patients and their general life satisfaction is much higher.

Measurement of safe acetabular medial wall defect size in revision hip arthroplasty with a porous cup.

INTRODUCTION: The majority of acetabular revisions can be performed with an uncemented, porous acetabular component with or without bone grafting. These are contained acetabular defects, with an intact acetabular rim (Paprosky type I and II). As defects of the medial wall of the acetabulum are a challenge situation revision surgery, we performed this biomechanical study on a pig pelvis model with contained acetabular defects to determine the size of medial wall defect at which the acetabular cup will have sufficient primary stability. MATERIALS AND METHODS: In 24 pig pelvis models, different diameter of medial wall defects were created, followed by acetabular component placement. The acetabulum externally loaded, and the force at a level in which the acetabular component remains stable for each diameter of defect, or at which point the acetabular cup moves into the pelvis for >2 mm. RESULTS: In the models with acetabular medial wall defects of 10 and 20 mm, 2 mm acetabular displacement occurred under a force between 1000 and 1500 N. In those with a medial wall defect of 25 mm, the force that caused acetabular instability was between 700 and 1000 N. In the models with 30 mm of medial wall defect all acetabular components were unstable under a force of 700 N. CONCLUSIONS: According to our results, acetabular component should be stable if the defect of the medial wall of the acetabulum is less than 68% of the diameter of the acetabular component or if the uncovered surface area of the acetabular component is not greater than 27%, and the force <700 N. For a load of 1000 N, the medial wall defect should not exceed 45% of acetabular component diameter or 18% of uncovered acetabular component surface.

Two different dosing regimens of human recombinant erythropoietin beta during preoperative autologous blood donation in patients having hip arthroplasty.

PURPOSE: Our aim was to evaluate the effectiveness of two different dosing regimens of human recombinant erythropoietin (rHu-EPO) for preoperative autologous blood collection in patients undergoing total hip arthroplasty (THA). METHODS: Prospective randomised trials in which erythropoietin 15,000 IU was administered intravenously twice a week or 30,000 IU once a week (total 90,000 IU) combined with ferrous II sulphate (Ferro-Gradumet 2) orally and compared with Ferro-Gradumet 2 alone. RESULTS: Although different dosing regimens of rHu-EPO administration during preoperative autologous blood donation have similar effects on the collection of two units of autologous blood, preoperative haemoglobin level and perioperative allogenic blood transfusion, a once weekly dose regimen of rHu-EPO was more convenient (although not statistically significantly) for patients. CONCLUSION: We recommend the more practical and comfortable but yet highly effective therapeutic regimen with a single weekly intravenous administration of rHu-EPO for patients scheduled for THA.

[Surgical treatment of hallux valgus with new method: operative technique and review of 100 cases]. / Kirursko lijecenje haluksa valgusa vlastitom metodom: operacijska tehnika i prikaz 100 bolesnika.

We present the operative technique and treatment results for a new three-dimensional method for hallux valgus correction. Lucijanic procedure was developed at the Department of Orthopaedic Surgery, General Hospital Karlovac, where patients enrolled in this study were treated from 2001 to 2008. Clinical and radiological evaluation was performed in 100 cases with a mean follow-up of 4.5 years. Mean American Orthopaedic Foot and Ankle Society score improved from 48.56 preoperatively to 92.34 points postoperatively. Average recovery time and return to work was 7.7 weeks. Result was excellent or good in 93%, fair in 5% and poor in 2% of feet. On the average hallux valgus angle decreased from 29.7 degrees to 9.3 degrees and on the average intermetatarsal angle decreased from 12.5 degrees to 5.2 degrees. First metatarsal inclination angle on average increased 5.3 degrees. First metatarsophalangeal joint congruence and tibial sesamoid position were corrected. The new method allows for correction of hallux valgus deformity in all three planes and for metatarsalgia attenuation.

Revision of Acetabular Component with a Debonded Porous Coating in an Elderly Patient.

Debonding of the porous coating from the acetabular component of a total hip endoprosthesis is a rare complication. Revision total hip arthroplasty for an unstable acetabular component with a debonded porous coating strongly fixed to the bone can be challenging, especially in elderly patients of poor overall health. In such patients, revision procedures should be as simple and safe as possible. We present our technique of solving that problem in a case of an 82-year-old female with bad general condition and unstable acetabular component of hip endoprosthesis. Because of extremely deficient bone stock, a well-fixed porous coating was left in acetabulum to serve as a "cage", allowing cemented acetabular component placement. This procedure can reduce the risk of intraoperative bone fracture, blood loss, and duration of surgery, which is important in elderly patients with poor overall health.

Influence of the acetabular cup position on hip load during arthroplasty in hip dysplasia.

Placement of the acetabular cup during total hip arthroplasty is of great importance because usually every deviation from the ideal centre of rotation negatively influences endoprosthesis survival, polyethylene wear and hip load. Here we present hip load change in respect to various acetabular cup positions in female patients who underwent total hip replacement surgery due to hip dysplasia. The calculation suggests that, in the majority of cases, for every millimeter of lateral displacement of the acetabular cup (relative to the ideal centre of rotation) an increase of 0.7% in hip load should be expected and for every millimeter of proximal displacement an increase of 0.1% in hip load should be expected (or decreased if displacement is medial or distal). Also, for every millimeter of neck length increase, 1% decrease is expected and for every millimeter of lateral offset, 0.8% decrease is expected. Altogether, hip load decreases when the cup is placed more medially or distally and when the femoral neck is longer or lateral offset is used.

Treatment of hallux valgus with three-dimensional modification of Mitchell's osteotomy: technique and results.

Mitchell's osteotomy gives very good results but there are still some cases where the original method, as well as its modification, cannot address all aspects of deformity. We modified the original Mitchell's method to address pronation and plantar displacement of the first metatarsal. Modification includes formation of lateral and plantar spur with metatarsal displacement and derotation of distal metatarsal fragment in the frontal and horizontal planes with stable screw fixation. We present midterm results of the first 60 patients compared to the original Mitchell method (30 patients). Differences between the groups postoperatively were in declination angle, postoperative metatarsalgia rate, and first metatarsal pronation angle. The technique described eliminated many of the disadvantages of Mitchell's method.

Bifocal stress fracture of pubic Rami after contralateral total hip arthroplasty and longstanding ipsilateral hip fusion.

In this case report we present a patient with bifocal pubic rami stress fractures after contralateral total hip arthroplasty for congenital hip dysplasia and longstanding ipsilateral hip fusion. Treatment protocol for patients with various degrees of hip arthritis on one side and contralateral longstanding hip fusion are proposed based on the literature and our and previously published cases.

Femoral shortening during hip arthroplasty through a modified lateral approach.

UNLABELLED: We describe a modification of the direct lateral approach to the hip that provides excellent femoral and acetabular exposure and an easy way to shorten the proximal femur and equalize leg length. The approach also is useful for lower extremity elongation while preserving muscle continuity and minimizing postoperative complications. The exact amount of shortening can be calculated and planned preoperatively and measured and corrected intraoperatively if necessary. It avoids the necessity for osteotomies of the trochanter and transverse cuts or detachment of abductor muscles. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Arthroscopic transosseous suture anchor technique for rotator cuff repairs.

The skin is incised 1 to 2 cm distal to the lateral portal. A transosseous tunnel is created through the greater tuberosity by a sharp penetrator, entering 1.5 to 2 cm distal to the top of the greater tuberosity. The penetrator exits medially, between the tip of the greater tuberosity and the articular surface of the humeral head, in the middle of the footprint. The first anchor, a 5-mm Spiralok (DePuy Mitek, Norwood, MA) is placed at the penetrator's exit site on the footprint. Using a specially designed suture leader, the lateral limb of the suture in the anchor, which passes through the previously created transosseous tunnel, is taken from the anchor and pulled out. The other suture end is passed through the supraspinatus tendon. The second suture, placed superficially in the anchor, is passed from the anchor through the supraspinatus tendon, as a mattress suture. If more anchors are required, the procedure should be repeated. The transosseous suture limb and the suture limb that is passed through the supraspinatus tendon are tied through the lateral portal. The knot tying is then performed with a sliding Delimar knot. The mattress suture, passing through the supraspinatus tendon, is tied through the anterior lateral portal. The knot tying procedure is repeated depending on the number of anchors.

Elevated CRP level could herald less efficient autologous conditioned serum (ACS) treatment.

Autologous conditioned serum (ACS) is a biologically based local treatment aiming to influence the cytokine imbalance and is used in a variety of orthopedic diseases and conditions. The ACS contains elevated levels of various anti-inflammatory cytokines, such as IL-1 RA (receptor antagonist), IL-4 and IL-10 and several growth factors. It contains a combination of cytokines and growth factors, and their specific contribution to clinical effects have yet to be determined. Serum conditioned in that specific way does not always have the same content and concentration of the anti-inflammatory cytokines and growth factors. We hypothesize that ACS should not be prepared and administered if elevated C-reactive protein (CRP) levels are present at the moment of obtaining the patient's blood because of the potential detrimental effect of elevated pro-inflammatory cytokines in the same blood, namely IL-1 and TNF. We propose introduction of CRP measuring before any ACS treatment. The cut off value would be set at 5mg/dL as an usual value suggesting inflammation. Avoidance of collecting and administering ACS if elevated CRP is present would potentially eliminate low quality ACS.