Expression Pattern of iNOS, BCL-2 and MMP-9 in the Hip Synovium Tissue of Patients with Osteoarthritis.

Hip osteoarthritis (HOA) is characterized by degradation of the cartilage and synovitis. However, the pathohistological effects of synovial tissue inflammation on HOA are not clear. The aim of this study was to evaluate the expression of iNOS, BCL-2 and MMP-9 markers in different synovial cell populations. A total of 32 patients were evaluated retrospectively. Age, sex, height, weight, body mass index were recorded and lymphocyte, fibrocytes and macrophages were analysed in tissue sections. Osteoarthritis cartilage histopathology assessment system (OARSI), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Krenn score, Harris Hip Score (HHS) and Kellgren-Lawrence (K-L) grading of the hip joints were performed. Total hip arthroplasty was performed on 32 patients and controls. Patients were divided into two groups according to their disease severity. The tissues were immunohistochemically analysed. K-L grade and Krenn score differ between all three groups, but also between moderate and severe OA. Synovial lining cell layer, resident cells in stroma and especially inflammatory infiltration were increasing with severity of OA. iNOS expression in both intima and subintima was positively correlated with Krenn score in moderate and severe osteoarthritis (OA) groups. Expression of BCL-2 in intima of severe OA patients was positively correlated with Krenn score. In conclusion, iNOS, BCL-2 and MMP-9 are involved in the regulation of HOA. Our study indicates a relationship between the pathohistological features, the synovial inflammation and the cartilage condition at the time of hip replacement due to OA or femoral neck fracture.

Postoperative Regional Analgesia Is Effective in Preserving Perforin-Expressing Lymphocytes in Patients After Total Knee Replacement.

BACKGROUND Pain and surgical stress cause a pro-inflammatory response followed by downregulation of the immune response, which can increase the incidence of postoperative complications, such as infections or prolonged wound healing. T lymphocytes and natural killer (NK) cells have cytotoxic potential and are crucial components of cellular immunity, which is important for maintenance of immune balance. The aim of this study was to analyze the effects of 3 types of postoperative analgesia on the preservation and cytotoxic potential of T lymphocytes, NK cells, and their subpopulations, as well as NKT cells, in patients after total knee replacement (TKR) to find the most effective analgesic technique for mitigating immune suppression. MATERIAL AND METHODS Forty-eight patients scheduled for TKR were randomly allocated to Group 1 (patients received epidural analgesia), Group 2 (patients received sciatic and femoral nerve block), or Group 3 (patients received multimodal systemic analgesia). Pain intensity was assessed at rest and on movement before, immediately after, and at 24 and 72 h after surgery. Blood samples were collected at the same time points and peripheral blood mononuclear cells were isolated. The frequencies of T lymphocytes, NK cells, and NKT cells, as well as their perforin expression, were simultaneously detected and analyzed by flow cytometry. RESULTS Patients in Group 1 and Group 2 experienced less severe pain than those in Group 3. The frequencies and perforin levels of T lymphocytes, their subsets, and NKT cells were significantly lower in Group 3 than in Group 1 and Group 2. CONCLUSIONS The present study confirmed that regional analgesia is more effective in maintaining cell-mediated immunity and perforin expression in peripheral blood lymphocytes in patients after TKR.

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.

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.

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.

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

Bilateral congenital dislocation of the knee with ipsilateral developmental dysplasia of the hip--report of three patients.

Congenital dislocation of the knee (CDK) is a very rare condition. Here we report our strategy and results in treatment of three children with CDK. All three patients were treated with conservative method, and only one had underwent a surgical procedure on one knee. Of the remaining, we recorded a good outcome with conservative treatment in three knees, while two had poorer outcome as a result of musculoskeletal anomalies. We also present here a unique case of a child born without cruciate ligaments and patellas on both sides. We performed the operative procedure by Z-plasty of the extensor apparatus on one left knee according to Niebauer and King on one child. The clinical result of this procedure was very good. Five years after the operation we decided to perform an MRI examination to assess the postoperative status of the operated knee, especially the position and the shape of left patella. We found the asymmetry and high position of the operated patella resulting in patella alta. Compared to the initial clinical presentation, we consider all patients to have good clinical presentation nowdays.

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.

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.

Synovial chondromatosis of the pisotriquetral joint with secondary osteoarthritis: case report.

There are only a few reported cases of synovial chondromatosis affecting pisotriquetral joint (PT). Osteoarthritis of the PT is also rare and can be as disabling as osteoarthritis of any other joint. We report this to be the unique case of synovial chondromatosis of the PT joint with secondary osteoarthritis.

The rational strategies for detecting developmental dysplasia of the hip at the age of 4-6 months old infants: a prospective study.

Using ultrasound in evaluation of infant's hip development can reduce surgical procedures, hospitalization and late presentation of developmental dysplasia of the hip (DDH). The increasing incidence of DDH after ultrasound examination is observed and published by many authors. In a prospective study, radiograph of every single ultrasonographic positive hip in infants older than three months, was taken and analyzed in order to see whether it affects infants splintage rate in treating DDH. In a period of 30 months, clinical and simple static ultrasonographic examinations according to Graf were performed on 1430 consecutive infant hips in patients aged between 4 and 6 months. Sonographic positive hips were radiographed and acetabular index (AI) values on simple AP radiographs were analyzed. The sonographic DDH incidence was 51.75 per 1000 hips (51.75 per thousand). After X-ray examination of all 74 ultrasonographic positive hips, only 44 remained abnormal and required treatment indicating a true DDH incidence of 30.77 per 1000 hips (30.77 per thousand). The difference in incidence per ultrasonographic and X-ray positive hips is statistically significant p < 0.01 (t = 5,536). The rational approach in detection of DDH in a child more than 3 months old is to do radiographic assessment of every sonographic positive hip.

Complications in leg lengthening using an Ilizarov external fixator and intramedullary alignment in children: comparative study during a fourteen-year period.

BACKGROUND: The purpose of this retrospective study was to evaluate the complications associated with leg lengthening in children treated with the Ilizarov external fixator (IEF) and compare them between two groups of patients: one group was treated using an IEF alone and the other group was treated using an IEF in association with intramedullary alignment (IA). PATIENTS AND METHODS: The study was performed at the University Children's Hospital in Belgrade, Serbia during a fourteen-year period (from 2000 to 2014). Complications occurred in 73 paediatric patients who underwent the leg lengthening procedure. Complications were classified according to the Caton classification and compared between two groups. Group I comprised 39 patients who underwent the limb lengthening procedure using IEF alone. Group II consisted of 34 patients who were treated with the combination of IEF and IA using two Kirschner wires (K-wires) or Titanium Elastic Nails (TEN). The duration of hospital treatment was also compared between the two groups and the impact of the type of IA on the occurrence of complications was assessed. RESULTS: There was a high rate of complications in patients treated using an IEF compared with those treated using the combination of IEF and IA, but there was no statistically significant difference between the two groups. There was a statistically significant difference in the duration of initial hospitalisation between the two groups, particularly when comparing TEN usage in IA. A comparison of the group of patients treated using an IEF in association with K-wires and patients treated using IEF and TEN showed there was no statistically significant difference in complication rate and duration of initial hospitalisation. CONCLUSION: IA has multiple advantages as a method of treatment of leg length inequality. The major effect of applying IA in association with a circular IEF is significantly reduced complication rate and duration of initial hospitalisation, particularly when using TEN as a method of IA. This method of treatment also decreases hospital costs.

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.

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.