DIFFERENCE IN PATIENT QUALITY OF LIFE AFTER HIP ARTHROPLASTY WITH A MINIMALLY INVASIVE APPROACH OR CLASSIC APPROACH.

The increasing rate of orthopedic procedures, hip arthroplasty in particular, requires improvement of surgical techniques, as well as of the respective rehabilitation protocols. The aim of the study was to assess differences in the quality of life and incidence of limping eight years after total hip arthroplasty performed with a minimally invasive or classic approach. This cross-sectional study included 68 patients, i.e. 32 operated with classic approach and 36 with minimally invasive approach during 2011. The following parameters were observed: anthropometric measurements, history of comorbidity, subjective assessment of limping, and SF-36 questionnaire (Short Form Survey Instrument). SF-36 testing, which consists of 8 domains, showed that 5 domains of the quality of life were statistically significantly better in the minimally invasive group (level of significance p<0.05). These domains were role of limitation due to physical health (p=0.01), energy (p=0.02), social functioning (p=0.02), pain (p=0.02) and general health (p=0.00). The minimally invasive group had a statistically significantly lower incidence of limping (p=0.032). Quality of life after hip replacement could be a decisive factor when choosing the type of orthopedic procedure. The higher number of limping patients in the classic approach group may have contributed to differences in the quality of life. In conclusion, the minimally invasive approach enables higher long-term quality of life and functional recovery.

Chiari pelvic osteotomy does affect hip survival: a long-term follow-up study.

BACKGROUND: The modern indications for Chiari pelvic osteotomy (CPO) have narrowed and the number of such operations performed has diminished markedly. So far published long-term experience with CPO indicate the fact that in selected patients satisfactory functional results can be achieved. The aim of this study was to investigate the parameters which influence CPO survival and its conversion into total hip arthroplasty (THA). METHODS: This is a single-centre retrospective case-series study. In the period from 1976 to 2012, it included 172 CPO in 158 patients. Of those, in 43 patients (48 hips) the follow-up was discontinued, leaving 115 patients (124 hips) for final analyses. The median age at the time of the surgery was 34 years, and the mean duration of the follow-up was 19 years. RESULTS: In 115 patients (124 CPO) included in the study, a total of 51 THA was performed in 49 patients. The median period between CPO and THA was 14 years. CONCLUSION: Supporting our results, we suggest that CPO should still be indicated in a selected group of younger patients even with advanced stage of hip osteoarthritis who prefer a joint-conserving procedure and consent to a predicted less optimal outcome.

Functional recovery after muscle sparing total hip arthroplasty in comparison to classic lateral approach - A three years follow-up study.

BACKGROUND: The muscle sparing total hip arthroplasty had generated a distinguishable interest, in both the patients and the surgeons, but its benefits are still often questioned. The main idea of this study was to compare the functional clinical outcome of the patients operated by the anterolateral approach with a muscle-sparing technique (modified Watson-Jones approach), and the patients operated by modified direct lateral approach without the muscle-sparing technique (Bauer/Hardinge approach). METHODS: The patients (N = 130) were divided into two groups: 68 in a standard method group (STAND) and 62 patients in a muscle sparing surgery group (MSS). The hip flexibility, mobility, the strength of the hip abduction, the pain scale, Harris hip scores, the duration of the hospital stay and the overall satisfaction were measured seven days, three months, one year and three years (in 80 patients) after the surgery. There were no differences in any of the parameters between the groups prior to the procedure. RESULTS: The statistically significant differences in first three follow-ups (up to one year) were determined between the groups in passive and active hip flexion ability but the hip abduction strength, which is a crucial parameter for functional recovery, and 50 m walk test remained better in MSS group even after three years. Patients, who underwent MSS suffered also less pain, stayed in hospital shorter and were more satisfied with the operation outcome. CONCLUSIONS: The functional recovery in patients treated with muscle sparing method was faster than in patients operated with conventional lateral approach. Based on the results, we could recommend anterolateral muscle sparing approach for a total hip replacement for its faster and fuller functional recovery.

The influence of ski helmets on sound perception and sound localisation on the ski slope.

OBJECTIVES: The aim of the study was to investigate whether a ski helmet interferes with the sound localization and the time of sound perception in the frontal plane. MATERIAL AND METHODS: Twenty-three participants (age 30.7±10.2) were tested on the slope in 2 conditions, with and without wearing the ski helmet, by 6 different spatially distributed sound stimuli per each condition. Each of the subjects had to react when hearing the sound as soon as possible and to signalize the correct side of the sound arrival. RESULTS: The results showed a significant difference in the ability to localize the specific ski sounds; 72.5±15.6% of correct answers without a helmet vs. 61.3±16.2% with a helmet (p < 0.01). However, the performance on this test did not depend on whether they were used to wearing a helmet (p = 0.89). In identifying the timing, at which the sound was firstly perceived, the results were also in favor of the subjects not wearing a helmet. The subjects reported hearing the ski sound clues at 73.4±5.56 m without a helmet vs. 60.29±6.34 m with a helmet (p < 0.001). In that case the results did depend on previously used helmets (p < 0.05), meaning that that regular usage of helmets might help to diminish the attenuation of the sound identification that occurs because of the helmets. CONCLUSIONS: Ski helmets might limit the ability of a skier to localize the direction of the sounds of danger and might interfere with the moment, in which the sound is firstly heard.

Physiological load and posture control thresholds.

The aim of the study was to evaluate the influence of the physiological load on postural control. Special attention was directed toward the identifying the intensity level in which the major deterioration in balance abilities occurs. Thirty subjects randomly divided into two groups performed multistage all-out exertion protocol on cycle-ergometer with measurements of ventilatory-metabolic and subjective parameters of exertion. Each stage lasted three minutes and was followed with three minute breaks during which the subjects underwent the static (keeping the cursor in the center of the screen) and the dynamic balance testing (following the cursor clockwise or counter clock wise by body movements) on balance platform. In a control group, the protocol encompassed only balance testing procedures followed by 3 min rest. After the completion of the testing procedures, the five intensity zones were determined according to the ventilatory-metabolic parameters. The significant differences in both static and dynamic balance tests were found between the test stages in exercising group. The post hoc analyses revealed the significant negative effect of exercise on the static balance with three visible "balance thresholds". The first threshold was at the rest to work transition, the second at the anaerobic threshold and the third at the maximal exertion level. The dynamic balance was also negatively affected with exercise, however no "balance thresholds" were clearly identified. No significant changes in neither static nor dynamic balance abilities were observed in the control group so the changes in the experimental group could have been attributed to the exercise intensity.

Ultrasound-assisted calcaneoplasty.

PURPOSE: The endoscopic technique for resection of a postero-superior part of calcaneus served as a golden standard during the last 10 years, and it has mostly replaced the open techniques. In an effort to reduce the morbidity and the recovery time, we had introduced the ultrasound-assisted technique. METHODS: In the period of 1 year, 15 patients with the prominent postero-superior part of calcaneus and retrocalcaneal bursitis were operated through the single skin incision using the ultrasound-assisted technique. The prominent part of calcaneus was resected with a bone abrader under the ultrasound control to the point when there was no impingement between Achilles tendon and calcaneus in maximal dorsal flexion. The patients were evaluated preoperatively and postoperatively with the AOFAS score and Ogilvie-Harris score. The strength test of the muscle triceps surae, as well as the proprioceptive test, was also undertaken. RESULTS: Initially, the follow-up was meant to last 6 months, but there were no differences in results between 6 weeks and 3 months postoperatively, so it was concluded that the 3-month follow-up is sufficient and relevant. All 15 patients were available for follow-up. All measured variables significantly improved (AOFAS, Ogilvie-Harris), and all the patients were satisfied with the postoperative result. Only one minor complication occurred: superficial infection. CONCLUSION: The ultrasound-assisted calcaneoplasty enables a precise resection of the postero-superior part of calcaneus and removal of the retrocalcaneal impingement. This method could become clinically relevant as it enables effective treatment of Haglund deformity, and results of this study presented rapid functional recovery. LEVEL OF EVIDENCE: Case series with no comparison group, Level IV.

The "cello technique": a new technique for ultrasound-assisted calcaneoplasty.

The "cello technique" is a new calcaneoplasty technique for the treatment of Haglund disease. It is an ultrasound-assisted technique for resection of the posterosuperior part of the calcaneus. It is possible to resect the posterosuperior part of the calcaneus under direct ultrasound control with the patient in the prone position, with a dorsally positioned ultrasound probe, in line with the Achilles tendon fibers (sagittal line), and with the abrader in the posteromedial working portal. We describe in detail the technique for this new procedure in foot and ankle surgery. This innovative technique offers the possibility of expanding the indications for ultrasound-guided surgery in other fields of orthopaedic surgery.

Risk-taking behavior in skiing among helmet wearers and nonwearers.

OBJECTIVE: To examine differences in on-the-snow ski behavior between helmet wearers and nonwearers. METHODS: The data were collected using a survey. Several tourist agencies helped in administrating the survey to the skiers during the 2008-2009 and 2009-2010 seasons. The survey consisted of multiple-choice questions. The subjects were asked to choose answers most suitable for their skiing style and preferred skiing technique, volume of off-piste skiing, readiness to use time measuring systems on the slopes, and group-skiing preferences, such as leading the group, beside the group, away from the group, etc. The Risk Index was then calculated for each subject. RESULTS: The answers of 710 skiers (mean age 35.5, range 16-81 years) were analyzed. The predictive power for risk-taking behavior was tested for gender, age, educational level, level of skiing, years of skiing, and helmet usage. Younger age, male gender, higher skiing level, and helmet usage were used as independent predictors for the overall Risk Index (Power [1-ß err prob] = 0.942). Significantly higher risk was assessed for the male helmet wearers while the results were not significant for the female helmet wearers. The male occasional helmet wearers were found to be the most prone to risky behavior. In female nonhelmet wearers, there was a significant decrease in risk-taking behavior with age but this was not true for female helmet wearers. CONCLUSIONS: For males under 35 years of age, helmet use is one of the factors influencing risk-taking on the slopes. This is demonstrated for occasional helmet wearers in particular.

New "L value" parameter simplifies and enhances hip ultrasound interpretation in the detection of developmental dysplasia of the hip.

PURPOSE: The purpose of this study was to simplify and enhance the ultrasound (US) analysis of the infant's hip by introducing a novel parameter named "L value" into the widely used Graf method. METHODS: We analysed 508 ultrasonographic images of the hips in infants aged three months. The images were first evaluated using the Graf measurements. On the same images, two additional measurements were performed in order to define the new parameter that was named L value. The threshold values of the new L value were identified based on the highest specificity as well as sensitivity for discrimination between the Graf groups. Those values were then used in order to reclassify the hips into three simplified groups. Inter-observer agreement was estimated by Cohen's kappa coefficient. RESULTS: The threshold values for the L value between Graf groups Ia and Ib was 0.46, between Ib and IIb was 0.68 and between IIb and IIc was 0.92. Correlation analysis between Graf's classification and the values of the L value was performed and was proved to be statistically significant, r = 0.49; p < 0.001. After simplifying the classification into three newly defined groups of patients depending on the degree of hip development, the correlation coefficient was much higher, r = 0.94, r (2) = 0.88 for p < 0.001. Inter-observer agreement for the L value was substantial. CONCLUSIONS: The new L value parameter in Graf's ultrasound hip evaluation enables a faster, simpler, more reliable and more unbiased classification for developmental dysplasia of the hip as the L value changes proportionally with the hip maturity.

Long-term results of anterior cruciate ligament reconstruction: a comparison with non-operative treatment with a follow-up of 17-20 years.

PURPOSE: The aim of our study was to review the clinical and radiological outcome of patients who had undergone anterior cruciate ligament (ACL) reconstruction in comparison to a group of non-operatively treated patients. METHODS: In a retrospective study we compared ACL reconstruction using a bone-patellar tendon-bone graft with a non-operatively treated group of patients 17-20 years later. Fifty-four patients that met the inclusion criteria, with arthroscopically proven ACL rupture, were treated between 1989 and 1991. Thirty-three patients underwent ACL reconstruction, forming group one. Eighteen non-reconstructed patients continued with rehabilitation and modification of activities (group two). The International Knee Documentation Committee (IKDC) subjective and objective evaluation forms and the Lysholm and Tegner scale were used to assess the knees at follow-up. Radiographic assessment was performed using the IKDC grading scale. RESULTS: Follow-up results showed that 83% of reconstructed patients had stable knees and normal or nearly normal IKDC grade. Patients in the non-reconstructed group had unstable knees with 84% having abnormal or severe laxity. The subjective IKDC score was significantly in favour of group one: 83.15 compared to 64.6 in group two. The Lysholm and Tegner score was also significantly better in group one. Conservatively treated patients all had unstable knees and worse scores. The rate of osteoarthritis showed more severe changes in non-reconstructed patients with additional meniscus injury. CONCLUSIONS: We can conclude that 94% of patients who underwent ACL reconstruction had stable knees after 15-20 years and there was a significantly lower percentage of osteoarthritis in comparison to conservatively treated patients.

Electromyographic analysis of the knee using fixed-activation threshold after anterior cruciate ligament reconstruction.

The aim of this study was to establish whether there are any electromyographic (EMG) differences after two different surgical techniques in two years follow-up after anterior cruciate ligament (ACL) reconstruction. Study participants were divided into three groups. The control group included healthy athletes (C), the first study group (E1) consisted of injured athletes who were treated by ACL reconstruction using patellar tendon graft and the second study group (E2) comprised injured athletes treated by gracilis and semitendinosus tendon graft. The threshold of muscle activity was defined as 30% of maximum amplitude of EMG signal medial envelope of individual muscles in the control group. Two years after reconstruction, the E2 group achieved the maximum amplitude of biceps femoris muscle signal in the takeoff phase statistically significantly later than the E1 group (0.0166, p = 0.05 and 0.015152, p = 0.05/3 = 0.016), whereas the rectus femoris muscle in the flight phase in the E2 group improved statistically significantly earlier than in the C group (0.0393, p = 0.05 and 0.025974, p = 0.05/3 = 0.016). The results of this study show particularly statistically significant differences between observed surgery techniques, which led to the change of the neuromuscular pathway during simple and controlled knee movements even two years after ACL reconstructions in athletes who returned to active training. These disturbances of muscle work coordinations in the knee joint could be tied to the function and location from which the graft was taken rather than the quality of the transplant itself. This may result in an increased risk of repeated knee injury, including potential permanent health consequences in athletes. Based on the results of this research, we were unable to establish which of the presented ACL reconstruction techniques is more appropriate. This study may be useful for athletes and their coaches, who could plan, programme and adequately adjust their training process, thereby improving knee function in the best possible way, which in turn would maintain and extend athletes' respective sports careers.

Postoperative blood loss management in total knee arthroplasty: a comparison of four different methods.

PURPOSE: As the blood loss after the total knee arthroplasty (TKA) is not only a potentially serious medical problem but also an economical concern, the purpose of the study was to investigate the effectiveness of different combinations of knee positioning and the applied wound dressings on blood saving after TKA. METHODS: A randomized controlled trial including 147 TKA-operated patients was conducted. The subjects were assigned to one of the four groups; Group 1-controls, Group 2-flexion, Group 3-flexion and compression, Group 4-compression. The main outcome measures of the study were the blood loss volumes during the procedure and in the intensive care rooms and the decreases in haemoglobin, haemotocrit and red blood cells on the first and the second postoperative day. RESULTS: The MANOVA results showed no differences between the groups in any of the observed parameters. The post-hoc comparisons of the each group to the control group also revealed no influence of any of the proposed blood saving techniques on the actual blood loss. CONCLUSION: No significant differences among the four proposed blood saving methods were determined.

Ski helmets could attenuate the sounds of danger.

OBJECTIVE: To determine whether a ski helmet reduces skiers' hearing particularly sounds that can warn skiers of potentially dangerous situations. DESIGN: Randomized repeated measures (first part), environmental field measurements (second part). SETTING: Audiology Centre of Rijeka Medical School, ski slopes at Platak resort. PARTICIPANTS: Thirty healthy subjects not used to wearing a helmet each served as their own control. INTERVENTION: Ski cap, ski helmet, and no intervention in randomized order. MAIN OUTCOME MEASUREMENTS: Laboratory open-field audiometric testing: bareheaded, ski cap, and ski helmet (0.125-8 kHz protocol), and environmental A-weighted sound measurements on the slope for potentially dangerous situations like snowboarder breaking or skier passing by. In both parts of the study, the sound pressure levels (dB) and sound spectrum frequencies were analyzed. RESULTS: First part-No differences were found between bare head and wearing only a ski cap. Significant sound attenuation characteristics of the helmet were determined for frequencies 2, 4, and 8 kHz (P < 0.001). Second part-High sound pressure levels were found for all the danger sounds measured on the slope, especially at frequencies that were most affected by helmet sound attenuation (2-8 kHz) in previously conducted laboratory tests. CONCLUSIONS: Helmets could influence the level of the hearing threshold in frequencies between 2 and 8 KHz. The spectrum of danger sounds on the slope has high pressure levels at frequencies that were most affected by helmet sound attenuation characteristics (2-8 kHz), so the helmet wearers might misinterpret the sounds of potentially dangerous situations because the sound might be distorted.

The influence of test repetition on bipodal visually controlled static and dynamic balance.

This study explores the influence of test repetition on bipodal visually controlled balance, both static and dynamic. Our goal was to get an insight into the pattern of changes in posture maintenance results during repeated balance tests. Fifteen young, healthy male recreational athletes were tested for static and for dynamic balance using KAT 2000 balance platform. The subjects first performed three trial tests of static and dynamic balance to get used to the platform followed by seven repetitions of static as well as dynamic test which were recorded. During the repeated tests we could not determine any significant improvements of static balance test resulting from number of test repetitions neither in static nor in dynamic balance (Friedman ANOVA: Static balance p = 0.497, Dynamic balance p = 0.393). Correlating static and dynamic balance results we found that only one third of the dynamic balance was related to static balance abilities (r2 = 0.36). Possible patterns in front-back and left-right directions were analyzed as well, however, none of these balance scores were found to be related to the number of repetitions. In conclusion, this study found no significant influence of limited number of repetitions (seven) on test results in static and dynamic posture. However, as large number of repetitions might still influence test results we discourage the use of KAT 2000 as a training tool in patients in which it will be used as an instrument to validate postoperative rehabilitation or investigation results.

Unrecognized fracture of the posteromedial process of the talus--a case report and review of literature.

In this report, we present a rare case of an initially unrecognized fracture of the posteromedial process of the talus sustained in a seldom reported position of dorsiflexion and supination of the foot. Fractures of the posteromedial process of the talus are very rare and represent an important diagnostic problem. Difficult x-ray visualization makes these fractures often misdiagnosed as ankle sprains. Complications due to this kind of fractures can include serious consequences such as avascular osteonecrosis, tarsal tunnel syndrome, post-traumatic osteoarthritis, or chronic pain. Timely diagnosis represents an important factor in the development of these conditions. A heightened awareness in examining ankle traumas with specific patient history details is of great importance. The most common mechanism of injury includes dorsiflexion and pronation of the foot. However, in an increasing number of cases alternative mechanisms have been described, all including high-energy impacts. Our patient sustained a fracture of the posteromedial process of the talus in dorsiflexion and supination with high-energy impact due to a 3-m fall. The patient was treated with excision of the fragment six months after the injury, and 18 months after the surgery the patient returned to his normal daily activities with significantly less pain in the posteromedial part of the ankle.

Bone allograft provides bone healing in the medial opening high tibial osteotomy.

Various materials are used to fill osteotomy defects created in the medial opening wedge high tibial osteotomy (MOWHTO). Our hypothesis was that a bone allograft would provide the osteotomy site bone healing within the expected time. We performed the MOWHTO using a cancellous bone allograft in 310 knees in 284 patients between 2000 and 2005. Internal fixation was achieved with a T-profile AO plate. Preoperative and postoperative radiographic measurements were taken and statistically processed. All patients were followed up for a period ranging from three to eight years, or 5.9 years on average. Implanted cancellous bone allografts

Microfracture technique in combination with intraarticular hyaluronic acid injection in articular cartilage defect regeneration in rabbit model.

Although articular hyaline cartilage typically has low potential for regeneration, numerous methods and techniques have been proposed to induce the reparation process. In our work, we used microfracture techniques in combination with intraarticular application of hyaluronic acid in rabbit knee articular cartilage defect. In comparison with the control group, after 6 and 10 weeks we observed a higher potential of healing in the experimental group, with thicker and more organized repair tissue filling the defect. In conclusion, a combination of the microfracture technique and application of hyaluronic acid might be potentially beneficial in inducing articular cartilage defect reparation.

A new tibial torsiometer applicable to clinical practice.

This study evaluated a new tibial torsiometer that is universally applicable to all limb sizes and requires no special training, jigs, or radiographic equipment. To compare the reliability of measurements obtained with the torsiometer, 160 tibias were evaluated with both the torsiometer and computed tomography. Results for both methods were identical in 51 tibias, within 1 degrees in 66 tibias, and within 2 degrees in 43 tibias. The difference between the two methods was not significantly different. No significant differences were found among examiners. This device should prove to be useful for the quantification of tibial torsion.

Limb salvage surgery in Enneking's stage III a--a case of leiomyosarcoma.

Limb saving surgery is today's tendency in treating the musculoskeletal tumours. Preserving the limb should not only pursue a good oncological and functional result but also aim at good psychological outcome. Our aim was to treat a very rare case of proximal femoral leiomyosarcoma with present solitary lung metastasis by conservative operative procedures.

Flat-footedness is not a disadvantage for athletic performance in children aged 11 to 15 years.

OBJECTIVE: Because the controversy about the relation of foot morphology and foot function is still present, we find it surprising that there are no studies published dealing with motor skills and athletic performance in flat-footed school children. Our aim in this study was to determine if there is an association between the degree of foot flatness and several motor skills that are necessary for sport performance. METHODS: The feet of 218 children aged 11 to 15 years were scanned, and the arch index was determined. The value of the arch index was corrected for the influence of age, and then the entire sample was categorized into 4 groups according to the flatness of their feet. The children were tested for eccentric-concentric contraction and hopping on a Kistler force platform, speed-coordination polygon (Newtest system), balance (3 tests), toe flexion (textile crunching), tiptoe standing angle, and repetitive leg movements. Altogether, 17 measures of athletic performance were measured. RESULTS: No significant correlations between the arch height and 17 motor skills were found. Categorizing the sample into 4 groups did not reveal any differences between the groups in athletic performance. Also, several multivariate analysis of variance sets of multiple independent variables referring to a particular motor ability were not found to be significant. The differences were not found even after comparing only the 2 extreme groups, meaning children with very low and children with very high arches. CONCLUSIONS: No disadvantages in sport performance originating from flat-footedness were confirmed. Children with flat and children with "normal" feet were equally successful at accomplishing all motor tests; thus, we suggest that there is no need for treatment of flexible flat feet with the sole purpose of improving athletic performance, as traditionally advised by many.