Revealing the Effect of Spinopelvic Alignment on Hip Disorders.

Background: Hip osteoarthritis (HOA) is a growing burden and one of the leading causes of hip pain. The relationship between the HOA and the alignment of the spinopelvic region has been intensively studied, however the issue remains controversial. Spinopelvic imbalance, HOA, and dysplasia were investigated in relation to sagittal spinopelvic parameters in this study. Methods: We collected computerized tomography (CT) topograms of the pelvis or abdomen from 380 patients. In antero-posterior (AP) topograms, Tonnis grading, center-edge angle (CEA) and Sharp's acetabular angle (AA) measurements were performed on each patient. Lateral topograms were used to evaluate the following spinopelvic parameters for each patient: pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), sacral table angle (STA), lumbar lordosis (LL), proximal lumbar lordosis (PLL), distal lumbar lordosis (DLL), and PI-LL difference. Initially, the cohort was divided into two subgroups based on whether or not they had HOA. Then, they were divided into two subgroups based on whether or not they had dysplasia. Ultimately, it was divided in half based on the PI-LL imbalance. Statistical analyses were conducted to determine the likely correlations between the spinopelvic parameters of these subgroups. In addition, the correlations between spinopelvic parameters were investigated. Results: There were 380 patients evaluated. We found no association between HOA or dysplasia and spinopelvic parameters. In addition, there was no association between PI-LL imbalance and HOA or dysplasia. Conclusion: There was no difference in constant PI and STA angle, besides other variable parameters, between groups having HOA and dysplasia or not. PI-LL imbalance has no effect on HOA and dysplasia.

Plate fixation after lengthening with an external fixator in patients with achondroplasia : A comparative study between two centers.

BACKGROUND: This study compared internal fixation with a plate after lengthening (PAL) with an external fixator with the conventional method (CM) in terms of radiologic and clinical outcomes in the lower extremities of patients with achondroplasia. METHODS: In this study 20 patients (50 lower extremity long bones) who underwent PAL or CM were divided into 2 cohort groups. The amount of lengthening, percentage lengthening, external fixator index (EFI), external fixator time, Li regeneration index, complication rate, and knee range of motion (ROM) were compared between the groups. RESULTS: The median age was 9.4 years (range 6-16 years) in the PAL group and 12 years (range 9-16 years) in the CM group (p = 0.01). Males comprised 80% of the patients in the PAL group and 47% of the patients in the CM group (p = 0.02). The median amount of lengthening in the PAL and CM groups was 7.5 cm (range 5.5-9.5 cm) and 6.0 cm (range 5.5-9.0 cm), respectively (p < 0.01). The median percentage of lengthening in the PAL and CM groups was 44.6% (range 20.0-70.1%) and 43.0% (range 20.5-57.3%), respectively (p = 0.01). The median external fixator time in the PAL and CM groups was 127 days (range 94-185 days) and 180 days (range 105-355 days), respectively (p < 0.01). The median EFI in the PAL and CM groups was 21 days/cm (range 10-33 days/cm) and 27 days/cm (range 15-59 days/cm), respectively (p < 0.01). The Li regeneration index was 3 (interquartile range, IQR 2-4) in both groups (p = 0.2). The total complication rate was similar between the groups. CONCLUSION: In patients with achondroplasia, after lengthening with an external fixator, internal fixation with a plate can be a reliable alternative to the conventional method. LEVEL OF EVIDENCE: Level III therapeutic.

Does the technique of limb lengthening affect physeal growth in patient with achondroplasia? Comparison of the simultaneous and consecutive tibia and femur lengthening with external fixators.

We aimed to retrospectively investigate and compare patients who underwent bilateral simultaneous and consecutive lengthening surgery of the femur and tibia in terms of the effect on physeal growth. We hypothesize that compared with the sequential lengthening technique, simultaneous lengthening of the bilateral femur and tibia affects physeal growth to a greater extent. Twenty-six patients with achondroplasia who operated in our clinic between 1995 and 2015 for limb lengthening were included in the study. Fourteen patients with bilateral lengthening of the femur and tibia at the same time were named as simultaneous bilateral lengthening (SBL). Twelve patients with bilateral lengthening of the femur and then bilateral tibia lengthening in other sections or vice versa, at a different time was named consecutive bilateral lengthening (CBL). All patients were followed until at least 18 years old. The physeal arrest was measured with predicted final length at the first visit (investigated with the multiplier method), the total amount of lengthening, and final clinical, and radiological length. Mean limb lengthening was 145 mm (48.5%) and 151 mm (46.6%) for simultaneous and consecutive groups respectively. For lower extremity length, the first group reached 527.6 mm while the expected was 447.3 mm. Considering 151 mm lengthening, the mean growth disturbance for the SBL group was 70.7 mm and for the CBL group was 47.5 mm. For total height comparing between two groups, disturbance for height was 80.5 mm and 65.4 mm, respectively. Although there was no statistical difference, simultaneous bilateral femoral and tibial lengthening has more physiological physeal disturbance effects than consecutive lengthening in patients with achondroplasia.

CORONAL PLANE GROWTH MODULATION FOR GENU VALGUM IN SKELETAL DYSPLASIA.

Objective: To investigate the efficiency and rates of correction by hemiepiphysiodesis using 8-plate to manage genu valgum deformity in children with skeletal dysplasia. Methods: Eleven children with skeletal dysplasia (three female, eight male; mean age = 10.5 years; age range = 7-13) who underwent temporary hemiepiphysiodesis using 8-plates for genu valgum deformity were retrospectively reviewed. There were nine bilateral cases and two unilateral cases. The mean follow-up time from the index surgery to the final follow-up was 45 (ranging from 24 to 72) months. Radiographical assessment including preoperative and final follow-up measurements of joint orientation angles and mechanical axis deviation (MAD) were conducted. Results: Deformities were completely corrected in nine lower extremities (45%) and partially corrected in seven extremities (35%). In four extremities of two children with Morquio syndrome, MAD worsened. The correction rate of MAD was 1.25 ± 1.62 mm/mo. Conclusion: Though hemiepiphysiodesis using 8-plate requires a longer treatment period, it seems to be an effective treatment for correction of genu valgum in children with skeletal dysplasia. Level of Evidence IV, Case Series.

Objetivo: Investigar a eficiência e as taxas de correção da hemiepifisiodese usando placa-8 no tratamento da deformidade de geno valgo em crianças com displasia esquelética. Métodos: Foram avaliadas retrospectivamente 11 crianças com displasia esquelética (três meninas e oito meninos; idade média = 10,5 anos; faixa etária = 7-13) que foram submetidas à hemiepifisiodese temporária com placa-8 devido à deformidade do geno valgo. Havia nove casos bilaterais e dois casos unilaterais. O acompanhamento médio desde a cirurgia de implante até o acompanhamento final foi de 45 (variação de 24 a 72) meses. Foi feita avaliação radiográfica incluindo medidas de acompanhamento pré e pós-operatórias dos ângulos de orientação da articulação e desvio mecânico do eixo (MAD). Resultados: As deformidades foram completamente corrigidas em nove extremidades inferiores (45%) e parcialmente corrigidas em sete (35%). Em quatro extremidades de duas crianças com síndrome de Morquio, o MAD piorou. A taxa de correção do MAD foi de 1,25 ± 1,62 mm/mês. Conclusão: Embora a hemiepifisiodese com placa-8 necessite de um período de tratamento mais longo, a técnica parece ser um tratamento eficaz para a correção do geno valgo em crianças com displasia esquelética. Nível de Evidência IV, Série de Casos.

The Relationship Between Limb Lengthening Rate and Callus Quality in Patients with Achondroplasia.

Objectives: This study investigated the effect of the femur, tibia, and humeral lengthening rate in patients with achondroplasia and regenerated bone quality. Methods: The records of the patients with achondroplasia who underwent limb lengthening surgery for both upper and lower extremities between 2002 and 2019 were retrospectively reviewed. Bone formation regeneration was evaluated in each segment at anteroposterior and lateral radiographs and the callus quality was determined at the first month of the consolidation period according to Li's classification system. Results: This study included 42 (28 females and 14 males), 38 (26 females and 12 males), and 17 (11 females and 6 males) patients with bilateral femoral, bilateral tibial, and bilateral humeral lengthening. The mean lengthening rate was 0.920 ± 0.23 (range, 0.53-1.67), 0.813 ± 0.17 (range, 0.51-1.26), and 1.02 ± 0.26 (range, 0.58-150) mm/day in the femoral, tibial, humeral groups, respectively. In the femoral group, 75% femur with good morphological quality, 56.6% good morphological quality in tibial group and 55.9% good morphological quality in humeral group. Statistically significant relationships were found between femoral lengthening rate and callus quality (p < 0.001; r = 0.454). However, no significant correlation was found in the humeral and tibial groups. Moreover, the sensitivity and specificity of the lengthening rate for obtaining good morphological quality callus were 72% and 80%, respectively, with an optimum diagnostic cutoff value of 0.976 mm/day for femoral lengthening. Conclusions: A higher-rate good morphological callus was obtained in femoral lengthening compared with tibia and humerus in patients with achondroplasia.

Temporary Epiphysiodesis Using the Eight-Plate in the Management of Children with Leg Length Discrepancy: A Retrospective Case Series.

Background: Although eight-plates have been shown to be effective in correcting angular deformities of the knee, the literature is scarce regarding the efficiency of this method in treatment of children with LLD. Objectives: The aim of this study was to determine the efficiency, rates of correction and complications of epiphysiodesis using eight-plate in the management of children with leg length discrepancy (LLD). Methods: Eleven consecutive patients with LLD (7 boys, median age = 9, age range 6-11 years) who were treated by temporary epiphysiodesis using eight-plates were retrospectively reviewed and included in the study. The main indication for temporary epiphysiodesis was an LLD between 2 and 5 cm in all patients. LLD and lower limb alignment were examined on lower extremity weight-bearing radiography preoperatively and at skeletal maturity. Longitudinal correction rate was calculated. The final LLD was categorized as ''good result'' (final LLD < 1.5 cm), ''fair result'' (1.5-2 cm), and ''poor result'' (> 2 cm). Results: The mean treatment period with the eight-plate was 44 (min to max = 32-72) months, and the mean follow-up from the index surgery to the final follow-up was 62 (min to max = 39-106) months. The mean LLD was significantly reduced from 39 (range 25-50) mm preoperatively to 22.40 (range 6-55) mm postoperatively (p = 0.006). The mean longitudinal correction rate was found to be 0.48 mm/mo. Radiographic evidence of lower limb deformity in frontal and sagittal planes was determined in neither preoperative nor postoperative deformity analysis. No major complications were recorded. Conclusion: For the management of children with LLD of 2-5 cm, temporary hemiepiphysiodesis using the eight-plate seems to be an effective treatment with low complication rates.

Effect of lengthening speed on the quality of callus and complications in patients with congenital pseudarthrosis of tibia.

PURPOSE: This study aims to evaluate the effect of lengthening speed on the quality of callus and complications during distraction osteogenesis and describe an optimal lengthening speed in patients with congenital pseudarthrosis of tibia (CPT). METHODS: Twenty-seven patients with CPT with a minimum follow-up of 36 months who underwent limb lengthening surgery between 1997 and 2016 with external fixator only were included in this study. All patients underwent lengthening procedures after achieving complete bone union in this study. Regenerate quality is evaluated according to the Li classification on the X-ray taken one month after the end of the distraction period. Complications were noted in post-operative follow-up period. Receiver operator characteristics (ROC) curve analysis was performed to obtain optimal lengthening speed for these patients. RESULT: The mean age at the time of surgery was 5.74 years. The mean lengthening speed was 0.596 mm/day. Follow-up period of 136.14 months with a mean lengthening period of 92.4 days. Mean amount of lengthening was 5.44 cm for patients with CPT. Total rate of callus with good morphological quality was calculated as 66%. According to ROC analysis, optimal cut-off values of lengthening speed for the obtaining good morphological quality callus was 0.564 mm/day for tibial lengthening in CPT. There was a significantly positive correlation between complication rate and lengthening speed for each group. CONCLUSION: We recommend a mean lengthening rate of 0.56mm/day for the lengthening procedures with external fixator in patients with CPT who had complete bone union at the area of pseudarthrosis.

The Effect of Intraarticular Insulin on Chondral Defect Repair.

OBJECTIVE: The aim of this study is to evaluate the effects of intraarticular insulin on the treatment of chondral defects. DESIGN: Twenty-four mature New Zealand rabbits were randomly divided into 3 groups as control (Group 1), microfracture (Group 2), and microfracture and insulin (Group 3). Four-millimeter full-thickness cartilage defects were created to the weight-bearing surface on the medial femoral condyles of each rabbit. In the first group, any additional interventions were not performed. Microfracture was performed on defects in groups 2 and 3. Additionally, 10 IU of insulin glargine was administrated into the knee joints of the third group. Three months after surgery, the knee joints were harvested and cartilage quality was assessed according to Wakitani and ICRS (International Cartilage Repair Society) scores histopathologically. Insulin injections were performed into the knees of 2 additional rabbits without creating a cartilage defect to evaluate the potential adverse effects of insulin on healthy cartilage (Group 4). RESULTS: The total ICRS and Wakitani scores of the insulin group were found to be significantly lower than the microfracture group but similar to the control group. No negative effects of insulin on healthy cartilage were detected. Intraarticular insulin after surgery has led to a statistically significant decrease in systemic blood sugar levels whereas the decrease observed after administration to intact tissues was not statistically significant. CONCLUSIONS: Insulin had a negative influence on the quality of cartilage regeneration and had no effect on healthy cartilage. Intraarticular insulin administration does not cause significant systemic effects in intact tissue.

Quality of Life Evaluation Following Limb Lengthening Surgery in Patients with Achondroplasia.

BACKGROUND: The primary objective of this study was to evaluate the quality of life following limb lengthening surgery in patients with achondroplasia. The complications and different lengthening techniques have and effects on mid-term results were also investigated. METHODS: We performed a retrospective, multicenter study by evaluating the records of patients with achondroplasia operated in our clinic between 1999 and 2014 for limb lengthening with a minimum follow-up of 3 years. Forty nine patients were underwent bilateral lower limb lengthening surgery and 21 of 49 patients underwent bilateral humerus lengthening surgery. Patients were evaluated by the Pediatric Quality of Life Inventory (PedsQL) 4.0 Generic Core Scales to assess the health-related quality of life (HRQOL) of children. Twenty patients with achondroplasia who had no lengthening surgery history were also evaluated with the PedsQL score as the control group. RESULTS: The average age at the time of first surgery was 6.17 years. The average follow-up period was 100.2 months. The average age at the time of study 14.70 ± 2.44 (11-18) years. There were significant differences between the patients with humeral lengthening and patients who did not undergo humeral lengthening in all scores. Transient complications had minimal effects on scores. Although all scores in the operated group were higher than non-operated patients with achondroplasia, there were no significant differences. CONCLUSION: Quality of life was significantly improved as a result of humerus lengthening surgery of patients with achondroplasia, despite minor complications compared with Lower limb lengthening surgery. LEVEL OF EVIDENCE: Level III, case control study.

Combined Technique for the Treatment of Infected Nonunions of the Distal Femur With Bone Loss: Short Supracondylar Nail-Augmented Acute Shortening/Lengthening.

OBJECTIVE: To evaluate a combined technique for treating distal femoral bone defects after debridement of osteomyelitis, using an external fixator together with a short supracondylar nail. DESIGN: Retrospective study. SETTING: Single tertiary referral center. METHODS: Between 2003 and 2018, 23 patients with a mean age of 37.2 years (26-56) underwent surgery with the same technique to manage postdebridement defects in the distal femur due to osteomyelitis. This involved acute shortening and intramedullary fixation of the defect site, together with relengthening from a proximal osteotomy using simultaneous external fixation. Radiographic union, range of motion of the hip and knee, external fixation time and external fixation index, and limb length discrepancy were assessed. RESULTS: The mean follow-up was 51 months (18-192). Union was achieved in all patients without recurrence of infection during this follow-up period. The mean knee flexion was 120 degrees, and the mean extension deficit was 5 degrees at final follow-up. The mean limb length discrepancy improved from 5.5 cm (3-7) to 0.5 cm (0-2). The mean external fixation index was 29.2 d/cm (20-50), and the mean external fixation time was 115 days (90-150). Radiographic scores were excellent in 15 cases, good in 6, and fair in 2. Functional scores were excellent in 14 cases, good in 7, and fair in 2. CONCLUSION: This combined strategy was an effective method for treating distal femoral segmental bone defects after debridement of osteomyelitis, with a high rate of union and acceptable complication rates. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Outcomes of salvage total hip arthroplasty after failed osteosynthesis for collum femoris fractures.

BACKGROUND: This study is an investigation of the outcomes of salvage total hip arthroplasty (THA) to treat collum femoris fractures that resulted in complications or failure after osteosynthesis. METHODS: Twenty patients (6 male, 14 female; mean age: 56.7 years) who underwent salvage total hip arthroplasty (THA) between 1988 and 2012 due to failure developing after closed reposition and osteosynthesis in the treatment of collum femoris fractures were included in the study. The type of osteosynthesis, and the length of time until failure and before THA application after collum femoris fracture were recorded. Cementless acetabular and femoral components were used in all of the patients. Complications were defined as those occurring during and after surgery. The clinical results were assessed with the Harris Hip Score (HHS) and the presence of loosening was assessed with radiological evaluation in follow-up. RESULTS: The mean length of the follow-up period was 59.4 months (range: 15-178 months). The collum femoris fractures of the 20 patients were classified as: 5 Garden type II, 13 type III, 2 type IV, and 3 Pauwels type I, 8 type II, and 9 type III. Cannulated screws were used in 13 patients (65%) and dynamic hip screw (DHS) fixation was used in 7 patients (35%). Complications observed after osteosynthesis were nonunion in 4 cases (20%), malunion in 2 (10%), avascular necrosis in 10 (50%), and implant failure in 4 (20%). A mean of 9.66 months (range: 3-54 months) elapsed before osteosynthesis failure and the mean length of time until THA was 31.6+-51.7 months. There was no statistically significant difference between cannulated screw and DHS fixation in the development of complications (p=0.084). Early dislocation (5%), periprosthetic fracture (5%) and acetabular protrusion (5%) were recorded as complications. A revision was made upon determination of loosening in the 10th year in the patient who developed early dislocation. While the mean HHS was 54.05+-8.22 before THA, it was evaluated to be 86.45+-8.73 at the last follow-up, which was a statistically significant difference (p<0.0001). CONCLUSION: The study findings demonstrated that THA applied with suitable surgical technique is a safe and successful method that may be used after failed osteosynthesis in cases of collum femoris fracture.

A Minimally Invasive Technique Using a Modified Stoppa Approach for Periacetabular Osteotomy: A Preliminary Cadaveric Study.

BACKGROUND: Developmental hip dysplasia is diagnosed when the femoral head is not sufficiently covered by the acetabulum. Anterior and lateral cover deficiency is seen, as a result a dysplastic hip joint. Various incision modifications have been developed because of the muscle dissection and wide wound scar in Smith-Peterson incision, which was originally used in Bernese osteotomy. This study evaluates applicability of the modified Stoppa approach in the performance of Bernese periacetabular osteotomy (PAO). MATERIALS AND METHODS: Ten hemipelvises of five donor cadavers were used. The transverse Stoppa incision was made 2 cm over the symphysis pubis for quadrilateral surface exposure and pubic and ischial bone osteotomies. The second skin incision, a few centimeters lateral to the original incision, was made along the tensor fascia lata. Iliac bone osteotomy was performed starting just above the rectus femoris insertion. The displacement of the osteotomy was measured clinically and radiographically. RESULTS: The mean anterior coverage calculated with center-edge angle was improved from 22.8° ±2.8 (range 20° min-28° max) preoperatively to 44.1° ± 3.7 (range 36° min-48° max). The displacement of the osteotomy at the iliopectineal line calculated on the iliac inlet view radiographs was 22.1 ± 3.4 mm (range 15 mm min-26 mm max). The clinical amount of the anterior displacement on the cadavers was 17.8 ± 3.35 mm (range 11 mm-21 mm) and lateral displacement was 20.3 ± 3.23 mm (range 15 mm-24 mm). The amount of the posterior intact bone enlargement at the quadrilateral surface was 5.3 ± 0.48 mm. CONCLUSION: This less traumatic two-incision exposure is an adequate technique for Bernese PAO, allowing the bone to be cut under direct visual observation and reducing the need to use fluoroscopy.

Long-term results and comparison of the three different high tibial osteotomy and fixation techniques in medial compartment arthrosis.

BACKGROUND: The purpose of this study is to report and analyze the long-term outcomes of the patients who underwent high tibial osteotomy (HTO) with three different techniques for the treatment of medial compartment arthrosis. METHODS: A total of 187 patients (195 knees) who underwent HTO between 1990 and 2010 were retrospectively evaluated. Eighty-eight knees, opening-wedge osteotomy with Puddu plate (group A); 51 knees, transverse osteotomy below the tubercle with external fixator (group B); and 29 knees, closing-wedge osteotomy with staple fixation (group C) were included in the study. The patients (mean age 44.9 ± 10.6 years, mean follow-up of 12.4 ± 3.2 years) were called for final controls and survival rates of the knees, and functional evaluations of the patients were performed using Knee Society Score (KSS) and Hospital for Special Surgery (HSS) knee score assessments. RESULTS: In the comparison of the three groups, there were no differences regarding the mean age, preoperative arthrosis levels, or preoperative deformity analyses (n.s.). The main finding of these comparisons showed that the closing-wedge osteotomy has the greatest lateralization effect on mechanical axis deviation (MAD) (p = 0.024), the greatest valgization effect on medial proximal tibial angles (MPTA) (p = 0.026), and the lowest posterior tibial slope (PTS) angles (p = 0.032) in comparison to the other groups. There were no functional differences between the three groups in the long-term assessment of patients with KSS and HSS knee scores. According to the Kaplan-Meier survival analysis, the probability of the survival of the native knee joint after HTO was 93.4% in 5 years and 71.2% in 10 years in our study group. During the follow-up of the 168 knees, revision surgery with total knee replacement was needed in 27 knees (16%). The mean time from HTO to total knee replacement was 8.9 years in these patients. CONCLUSIONS: HTO has acceptable long-term clinical and functional results that should not be underestimated by orthopedic surgeons under pressure to perform arthroplasty operations.

Mid-Term Results of Minimally Invasive Plate Osteosynthesis and Circular External Fixation in the Treatment of Complex Distal Tibia Fractures.

BACKGROUND: The treatment of pilon tibia fractures is challenging. Anatomical reduction of the joint surface is essential. Excessive soft-tissue dissection may interfere with the blood supply and can result in nonunion. We sought to compare the outcomes of distal tibia fractures treated with medial locking plates versus circular external fixators. METHODS: We retrospectively evaluated 41 consecutive patients with closed pilon tibia fractures treated with either minimally invasive locking plate osteosynthesis (n = 21) or external fixation (EF) (n = 20). According to the Ruedi and Allgower classification, 23 fractures were type B and 18 were type C. Soft-tissue injury was evaluated according to the Oestern and Tscherne classification. Time to fracture union, complications, and functional outcomes were assessed annually for 3 years with the American Orthopaedic Foot and Ankle Society (AOFAS) ankle score. RESULTS: Mean ± SD values in the plate group were as follows: age, 42.4 ± 14 years; union time, 19.4 ± 2.89 weeks (range, 12-26 weeks); and AOFAS ankle scores, 86.4 ± 2.06, 79.5 ± 1.03, and 77.9 ± 0.80 at 1, 2, and 3 years, respectively. Four patients in the plate group needed secondary bone grafting during follow-up. In the EF group (mean ± SD age, 40.7 ± 12.3 years), all of the patients achieved union without secondary bone grafting at a mean ± SD of 22.1 ± 1.7 weeks (range, 18-24 weeks). In the EF group, mean ± SD AOFAS ankle scores were 86.6 ± 1.69, 82.1 ± 0.77, and 79.7 ± 1.06 at 1, 2, and 3 years, respectively. There were no major complications. However, there were soft-tissue infections over the medial malleolus in five patients in the plate group and grade 1-2 pin-tract infections in 13 patients and grade 3 pin-tract infections in one patient in the EF group. Post-traumatic arthritis was detected in eight plate group patients and seven EF group patients. CONCLUSIONS: Minimally invasive plating and circular EF methods have favorable union rates with fewer complications.

Double intertrochanteric osteotomy for trochanteric overgrowth and a short femoral neck in adolescents.

PURPOSE: To review the outcome of Wagner double intertrochanteric osteotomy for trochanteric overgrowth and a short femoral neck in 7 adolescents. METHODS: Records of one male and 6 females aged 15 to 20 years who underwent modified Wagner osteotomy for trochanteric overgrowth and a short femoral neck by a single senior surgeon were reviewed. The diagnoses were coxa vara (n=2), developmental dysplasia of the hip (n=3), Leg-Calve-Perthes (n=1), and proximal femoral focal deficiency (n=1). Radiological indication for double intertrochanteric osteotomy included a neck-shaft angle (NSA) <120º or a centre trochanter distance (CTD) <28 mm. Function was evaluated using the Children's Hospital Oakland Hip Evaluation Scale (CHOHES). The articulotrochanteric distance (ATD), CTD, NSA, and the distance between the centre of the femoral head and the centre of the acetabulum (MZ) were measured on radiographs. RESULTS: The mean follow-up duration was 61 (range, 28-86) months. The ATD improved from 16±11.5 mm to -6.3±10.2 mm (p=0.018), the CTD from 27.9±3.5 mm to 36.4±7.1 mm (p=0.018), the NSA from 112º±24.4º to 131º±16º (p=0.028), the MZ from 12.7±6.5 mm to 7.7±4.2 mm (p=0.028), and the CHOHES score from 62.1±8.7 to 84±9.6 (p=0.017). One patient had delayed union. Two patients had persistent Trendelenburg gait. Two patients declined second-stage surgery for acetabular dysplasia after solving the femoral side problems at the first stage. One of them developed hip arthrosis. CONCLUSION: Double intertrochanteric osteotomy is a viable treatment option for adolescents with trochanteric overgrowth and a short femoral neck.

Efficacy of preoperative administration of single high dose intravenous tranexamic acid in reducing blood loss in total knee arthroplasty: A prospective clinical study.

OBJECTIVE: The aim of this study was to analyse the effectiveness of single dose of 20 mg/kg intravenous tranexamic acid (TXA), in reducing the blood loss in patients undergoing total knee arthroplasty (TKA). MATERIAL AND METHOD: 70 patients (65.5 ± 8.1 years old) that have undergone TKA were divided in two groups. The 20 mg/kg IV TXA was given before the skin incision to one group (study group). On the control group, TKA was performed without TXA. The demographic data, body mass index, amount of bleeding and erythrocyte infusion during the operation, hemoglobin and hematocrit values (preoperative and 48th hour), the amount of drainage after the operation were compared between the groups. RESULTS: The total amount of bleeding in the study group was 634.03 ± 182.88 ml and 1166.42 ± 295.92 ml in the control group (p < 0.001). Perioperative bleeding was 252.01 ± 144.13 ml in the study group and 431.33 ± 209.10 ml in the control group (p = 0.018). The drainage after the operation was 311.11 ± 141.64 ml at the 24th hour in the study group, 640.74 ± 279.43 ml at the 24th hour in the control group (p < 0.001). The drainage after 24th hour was 97.96 ± 115.86 ml in the study group and 112.96 ± 64.43 ml in the control group (p = 0.584). CONCLUSION: A high, single dose of TXA intravenously given to the patient prior to the TKA significantly reduces the bleeding during the operation and within the postoperative 24 h. There is no significant change in the bleeding amount after the 24th hour following the operation.

Acetabuloplasty at the anatomic centre for treating Crowe class III and IV developmental hip dysplasia: a case series.

INTRODUCTION: Total hip replacement in patients with developmental dysplasia of the hip (DDH) is a difficult technical procedure for surgeons to perform because of the potential for these patients to have severe anomalies in their bones and soft tissues. MATERIALS AND METHODS: We performed acetabuloplasty in 54 hips from 44 patients by reaming the posterior wall of the native acetabulum and medialising the acetabular component to restore the anatomic centre of hip rotation using a small cup without bone grafting. Median time to post-surgery follow-up was 5 (range 2-14) years. RESULTS: Prosthetic survival rates in patients after 2 and 5 years post hip replacement were 93% (50/54) and 89% (48/54), respectively. 4 patients required early revision because of malposition and instability of the acetabular cup. 3 patients with Crowe type IV dislocations had transient sciatic nerve palsy and 3 had deep vein thrombosis. CONCLUSIONS: Placement of the acetabular shell using posterior bone stock to provide normal hip rotation is a successful alternative technique for acetabuloplasty in patients with DDH.

Can chondral healing be improved following microfracture? The effect of adipocyte tissue derived stem cell therapy.

BACKGROUND: We aimed to investigate the effect of adipose tissue-derived mesenchymal stem cells (ADSCs) on chondral healing using the microfracture (MF) technique. METHODS: Thirty male rabbits were randomly divided into three groups. Standard cylindrical osteochondral defects (OCDs) were created in the weight-bearing areas of the medial condyles of all the right knees; the defects were four millimeters in diameter and two millimeters in depth. The control group (group A) was restricted to spontaneous healing. For group B, we performed MF with a 1.5-mm drill. For group C, we applied MF using the same method and then applied 3×10(6) ADSCs to the defect area. At eight weeks post-operation, the subjects were sacrificed, and the distal femoral joint surfaces were evaluated histopathologically for chondral healing. The samples were scored according to the International Cartilage Repair Society (ICRS) scale. RESULTS: The results for group C were significantly better than those for group A in terms of the surface properties (p=0.003). The matrix evaluation was better for group A than for group C (p=0.01). The cell distribution, cell viability and subchondral bone parameters were similar between the groups (p=0.198, p=0.387 and p=0.699). The cartilage mineralization parameter was better for group C than for group A (p=0.001). The signs of healing were better for group C than for group B, but the differences were not significant (p=0.185). CONCLUSIONS: Improvements with additional ADSC treatments were not statistically significant in cases in which ADSC treatment was compared with isolated MF treatment. CLINICAL RELEVANCE: Additional ADSCs treatment may have positive effect on chondral healing but it doesn't seem significant.

Knee Arthrodesis in Persistently Infected Total Knee Arthroplasty.

The reported incidence of infection in total knee arthroplasty (TKA) varies from 0.5 to 15%. The most common indication for knee arthrodesis is persistent infection after repeated staged knee replacement. The purpose of this study is to investigate the success of fusion with monoplanar fixators and eradication rates of infection, and to evaluate the satisfaction of patients who underwent a last-resort TKA due to infection.This is a retrospective review of infected knee arthroplasties that were treated with knee arthrodesis using unilateral external fixators at a single institution from 1999 through 2012. The patients' charts were analyzed for demographics, types of external fixators used, infection parameters, external fixator indexes, complications, positions of fusion, and leg length discrepancies (LLDs). Patients were called back to return for additional follow-up. A self-administered general health status questionnaire (SF-36) was assessed to evaluate life quality.There were 14 women and 3 men with an average age of 67 ± 16.6 years. Antibiotic-loaded acrylic cements were used as a spacer for an average of 3.4 ± 1.2 months in all patients. Monoplanar type of external fixator was used in all 17 patients. Fusions were achieved in all but one patient. The mean duration of fusion was 6.8 ± 2.2 months and external fixator duration was 7.6 ± 2.4 months. Average LLD was 2.9 ± 1.7 cm. The mean coronal alignment of fusion was 6.8 degrees (± 3.3 degrees, range 4-15 degrees) valgus and mean flexion was 11.3 degrees (± 6.5 degrees, range 3-30 degrees). Compared with the healthy controls, the SF-36 scores were significantly lower in patients with knee arthrodesis (physical component score [PCS]-arthrodesis: 39.3 vs. PCS- healthy controls: 47.9, p < 0.05; mental component score [MCS]-arthrodesis: 38.6 versus MCS-healthy controls: 47.7, p < 0.05).Use of monoplanar fixators for arthrodesis in infected TKA can achieve high fusion rates with the control of infection. If fusion can be achieved, the patient satisfaction is low with acceptable pain relief and functionality. We observed that monoplanar external fixators increased patients' comfort levels compared with circular external fixators. Further studies are needed to compare different arthrodesis modalities in patients with infected TKA.

Preliminary report on amputation versus reconstruction in treatment of tibial hemimelia.

OBJECTIVE: Tibial hemimelia is a rare disorder characterized by the absence or hypoplasia of the tibia with associated rigidity. The aim of this study was to retrospectively evaluate the affectivity of reconstructive surgeries including centralization of the knee-ankle joints and lengthening with Ilizarov principles, as well as physical and functional results of amputation and reconstruction. METHODS: This is an IRB-approved retrospective review of all patients diagnosed with tibial hemimelia who required surgery at a single institution between 1998 and 2011. Charts were analyzed for clinical and radiographical findings. At final follow-up, patients underwent physical and radiographic examination. Patients and their parents were asked to complete the SF-10™ health survey (QualityMetric Inc., Lincoln, RI, USA). RESULTS: Twenty-one patients (12 male, 9 female) with 30 affected extremities were included. Mean age was 4.8±3.1 years at initial surgery. Knee level disarticulation was performed in 6 extremities of 4 patients. One patient with type III underwent transtibial amputation. Mean number of surgeries for each patient was 6.4±3.3, and mean duration of external fixator and casting was 17±6 months. Mean lengthening was 4.9±1.3 cm, and mean limb length discrepancy was 3.1±1.7 cm at 5.8±3.7 years at follow-up. SF-10™ scores were similar in disarticulated and reconstructed patients (p=0.63). All scores were significantly higher when disarticulation was performed in cases of knee instability (p<0.01). CONCLUSION: When stability of the knee joint is present, treatment modality should be chosen according to the existence of the proximal tibia. Amputation should be preferred in cases of knee joint instability.