Zero surgical site infection in primary knee arthroplasty with multidisciplinary intervention: is it possible?

Surgical site infections (SSI) are among the most important complications in knee arthroplasty. In this article we aim to retrospectively evaluate effects of preoperative multidisciplinary assessment and treatment of focal infections in primary knee arthroplasty patients operated by a single surgeon in a single center. A total of 93 patients undergoing 120 primary knee arthroplasty operations were included in the study. In the preoperative assessment all patients were consulted by infectious diseases, otorhinolaryngology (ENT) and dentistry departments, and female patients additionally by gynecology departments to evaluate and treat possible focal infections. Decolonization protocols were implemented for the bacterial growths detected in nasal and urine cultures. Patients received one of four surgical interventions, namely unilateral total knee arthroplasty (TKA), unilateral robotic-assisted unicompartmental knee arthroplasty (RUKA), bilateral RUKA or unilateral TKA and unilateral RUKA. No patients received bilateral TKA in a single session. Out of 93 patients 70 (75.3%) were female, mean age was 67.7 ± 9.9 years, and American Society of Anesthesiologists (ASA) scores were < 3 for 93.5% of the study group. Fifty-two (55.9%) of the patients received RUKA. Mean value for the duration of operations was 150.7 ± 67 minutes, for hospitalization it was 5.9 ± 2.8 days, and postoperative follow-up was 25.7 ± 8.8 months. None of the patients developed SSI in the follow-up period. Many factors are associated with SSI after knee arthroplasty. Total absence of SSI in our study group may be attributable to meticulous patient selection, multidisciplinary preoperative assessment, and the performance of RUKA by a single surgeon in a single center.

A new arthroscopic technique for lateral parameniscal cyst decompression.

BACKGROUND: The purpose of this study was to describe an arthroscopic technique for lateral parameniscal cyst (LPC) decompression with preservation of meniscal substance and to report the short- to mid-term outcome of 20 patients. METHODS: All patients underwent a complete physical examination and magnetic resonance imaging (MRI) of the knee prior to surgery. After arthroscopic diagnosis of a LPC, partial lateral meniscectomy was performed via anterolateral (AL) and anteromedial (AM) portals. For LPC treatment, we used AL and superomedial (SM) portals. We describe a SM portal at the most proximal part of suprapatellar pouch, just medial to quadriceps tendon for the arthroscope. To decompress the cyst, an intra-articular (IA) portal was created with a shaver on the anterior synovial wall of the cyst from the AL portal. Decompression was performed via the AL portal and through the IA portal under the view of the arthroscope in the SM portal in SM portal. At the last follow-up, Lysholm score was used, and patients' clinical outcomes were classified into four categories: excellent, good, acceptable, and poor. Additionally, during the last control, patients underwent an MRI which was assessed for recurrence. RESULTS: Mean follow-up period was 37.5±18.8 months. Clinical outcomes were excellent in 15 patients, good in four, and fair in one. The mean Lysholm score was 96.2±7.59. No recurrence of the cyst was seen on control MRIs. CONCLUSIONS: Arthroscopic LPC decompression with superior and anterior portals is a novel, safe, and effective technique for experienced surgeons. It allows conservation of meniscal tissue, easier handling of instruments, and provides an excellent view of the cyst.

Cardiovascular effects of abduction shoulder sling in elderly patients; is it really safe?

OBJECTIVE: The purpose of the prospective study is to investigate the cardiovascular effects of abduction shoulder sling (ASS) in elderly patients who underwent rotator cuff surgery. METHODS: The study included 49 consecutive patients older than 50 years (mean 59.3 ± 8.2 years) who underwent arthroscopic rotator cuff repair surgery and used ASS in postoperative period. All cases underwent Holter electrocardiographic monitoring before (24 h) and after (48 h) the operation. The Holter findings were read by an experienced cardiologist and a pause of longer than 3 s and heart rate of <40 bpm was evaluated as significant bradycardia. RESULTS: One patient (61-year-old male) described feeling faint (presyncope) which was confirmed with the Holter finding of a pause more than 3 s which occurred in the day time. Two other patients (52-year-old male, and 62-year-old female) reported severe dizziness (hypotensive attack) which required admission to a general practitioner. However, Holter findings were normal in these patients. These three cases were referred to cardiology department for evaluation of carotid hypersensitivity syndrome (CSH). CSH was confirmed with tests made with provocative maneuvers in a sitting position. CSH was defined as at least 3 s of asystole (cardio-inhibitor type) during carotid massage or systolic blood pressure falling below 50 mmHg (vaso-depressor type). All three patients were obese patients and BMI was higher than 30. CONCLUSIONS: ASS may trigger CSH in short necked and obese patients by exerting mechanical stimulation to the carotid sinus. These patients should be informed about symptoms and signs of CSH and educated on the proper use of ASS and correct positioning of shoulder strap. CSH should be kept in mind in patients who present with dizziness, presyncope and palpitation during the postoperative period.

Results of arthroscopic repair of partial- or full-thickness longitudinal medial meniscal tears by single or double vertical sutures using the inside-out technique.

BACKGROUND: Although numerous studies have assessed arthroscopic repair of meniscal tears, no study has described the repair of partial- or full-thickness longitudinal medial meniscal tears using single or double vertical sutures. PURPOSE: To present the intermediate-term results of medial meniscal tears repaired with single or double vertical sutures. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: The authors evaluated the results of 112 longitudinal medial meniscal tears treated with inside-out single or double vertical sutures, with or without anterior cruciate ligament (ACL) reconstruction, based on the clinical resolution of symptoms, the Lysholm knee scoring scale, and the Tegner activity scale. Re-examination was also performed by magnetic resonance imaging after the repair. The length of the tears was evaluated arthroscopically. Eighty-five tears of 112 were >2 cm in length, and 27 were tears ≤2 cm. Eighty-nine (79.4%) of the 112 repairs were performed in conjunction with ACL reconstructions, and the remaining 23 (20.6%) repairs were performed in ACL-intact knees. The tear type of the menisci in our study was full thickness in 66 (58.9%) cases and partial thickness in 46 (41.1%) cases. Double vertical sutures were used for full-thickness tears, and single vertical sutures were used for partial-thickness tears. RESULTS: The cases were evaluated after a mean follow-up duration of 49.3 months (range, 12-88 months). Clinical and radiological examination results determined that 99 (88.4%) meniscal repairs had healed, and the remaining 13 cases (10.6%) were considered to be failures. The healing rate of the full-thickness group was 80.3%, while in the partial-thickness group, the rate was 100%. The mean Lysholm score improved significantly from a preoperative value of 63.8 to a postoperative value of 89.5 (P < .001). The mean Tegner activity score was 3.3 preoperatively and 6.7 postoperatively (P < .001). Logistic regression analysis found that concurrent ACL reconstruction, tear length, and smoking as factors had a significant effect on meniscal healing. CONCLUSION: Single or double vertical sutures using the inside-out technique provide a high rate of healing in longitudinal medial meniscal tears.

No difference between knotless sutures and suture anchors in arthroscopic repair of Bankart lesions in collision athletes.

The purpose of this study was to compare the clinical results of knotless and knot-tying suture anchors in arthroscopic Bankart repair of collision athletes. Thirty-eight athletes underwent arthroscopic Bankart repairs. The mean age of the patients at the time of surgery was 23 years. Bio-Knot-tying anchors were used in 18 patients, and Bio-Knotless suture anchors were used in 20 patients. Preoperative and postoperative evaluations were performed by Rowe scores. At the end of 40 months follow-up, both the knot-tying and the knotless suture anchor groups had similar postoperative results. There were no differences between Knot-Tying and Knotless repair about late disengagement and re-dislocation in this patient group. Knotless repair provided secure and low-profile repair without introducing complexities to the procedure of arthroscopic knot tying one.

Arthroscopic inspection after the surgical treatment of patella fractures.

After the treatment of patella fractures the only way to evaluate healing at the articular surface before implant removal is through arthroscopy. The purpose of this study was to examine the healing potential of the cartilage. Arthroscopy was performed in 18 patients at the time of implant removal. The mean age of the patients was 42.1 years. The time elapsed from the index surgery to the arthroscopy and implant removal surgery was 12.9 months. During the arthroscopy, we inspected articular step-off, cartilage loss, and joint surface irregularities. Cartilage irregularities were observed in 13 of the 18 patients. Five patients had well-healed cartilage at the patellar surface. Although none of the patients had displacement at final follow-up X-rays, step-off was detected in two patients during arthroscopy. Our observation showed that cartilage lesions did not correlate with clinical and radiological evaluation. Despite good knee scores, we observed surface irregularities, chondral lesions, and fibrillation in most of the cases implicating subsequent patellofemoral arthritis.

Arthroscopic repair of radial lateral meniscus [corrected] tear by double horizontal sutures with inside-outside technique.

The purpose of this prospective study is to report the outcome of arthroscopic repair of radial lateral meniscus tears at the junction of the anterior horn and body. Five patients with an average age of 27 years were treated. The repair was performed with double horizontal sutures by inside-out technique, using zone-specific, curved cannulae with no enhancement technique. A mean of 2.4 superior and 2.8 inferior stitches were performed. Reduction was obtained in all cases. Patients were evaluated using Lysholm functional knee scores. All patients were clinically and radiologically examined using MRI to assess meniscus integrity at the repair site, over an average follow-up period of 31 months. All patients were able to return to their former level of activity. In all cases, MRI showed a fully healed meniscus at the repair sites, with no further disruption of the debrided area. The mean Lysholm scores improved from 62 preoperatively to 94 postoperatively. The difference between preoperative and postoperative values was found to be statistically significant (p=0.029). No cases of postoperative extra or intra-articular complications were encountered. We found that repairing rather than resecting radial lateral meniscus tears that extend into capsular zone, improves activity level.

[Surgical treatment of acute coronoid process fractures]. / Akut koronoid kiriklarinin cerrahi tedavisi.

OBJECTIVES: This study was designed to assess the results of surgical treatment for type 2-3 coronoid process fractures and to identify factors that might influence the outcome. METHODS: Thirteen male patients (mean age 35 years; range 17 to 53 years) were treated with open reduction and internal fixation for displaced coronoid fractures. According to the Regan-Morrey classification, the fractures were type 2 in nine patients (69.2%), and type 3 in four patients (30.8%). Nine patients had associated injuries (elbow dislocation, radial head or olecranon fractures, and/or ligamentous injuries). The mean duration to treatment was 2.3 days (range 1 to 7 days). Functional results were assessed according to the Mayo elbow performance score (MEPS), and signs of arthritis were assessed according to the Broberg-Morrey criteria. The mean follow-up was 41.1 months (range 12 to 96 months). RESULTS: A functional range of motion of the elbow joint was achieved in 10 patients (76.9%). The mean elbow range of motion was 110.7 degrees (range 85 degrees to 130 degrees ) and the mean forearm rotation was 134.2 degrees (range 120 degrees to 155 degrees ). Three patients who had comminuted fractures and associated elbow injuries had decreased range of motion. None of the patients exhibited signs of instability. The mean MEPS was 86.5 (range 75 to 100). The results were excellent in four patients (30.8%; the mean MEPS 98.8) having isolated or noncomminuted coronoid fractures, and good in nine patients (69.2%) with comminuted fractures and/or associated bone or ligament injuries. Post-traumatic arthritis was detected in seven patients (53.9%) whose mean MEPS was 81.4. Patients with an excellent functional result did not develop arthritis. All the patients returned to preinjury activity levels. CONCLUSION: Coronoid fractures are the most important component of complex elbow injuries. The presence of comminuted fractures, associated bone and ligament injuries, and post-traumatic arthritis affect the outcome adversely.

The effect of overlapping on the primary stability of osteochondral grafts in mosaicplasty.

Our goal was to determine the primary stability of overlapping osteochondral grafts used in mosaicplasty by studying the effect of overlapping in an ex vivo model. Osteochondral grafts, 10 mm in diameter, were transplanted from the trochlea of cow femurs to the weight-bearing area of the lateral femoral condyle with 0, 15, or 30% overlap. The grafts were pushed in with a probe at a rate of 2 mm/min, and load (N)-displacement (mm) curves were recorded. In Group I (control, 0% overlap), insertion 1 and 2 mm below the cartilage level could be reached at 572.3 +/- 273.6 and 999.3 +/- 427.6 N, respectively. In Group II (15% overlap), insertion 1 and 2 mm below the cartilage level could be reached at 263.6 +/- 91.7 and 746.6 +/- 88.0 N, respectively. In Group III (30% overlap), insertion 1 and 2 mm below the cartilage level could be reached at 179.4 +/- 31.2 and 657.0 +/- 106.5 N, respectively. The loads that were necessary to produce a 1-mm dent in the grafts were significantly different between Groups I and II and Groups I and III (p < 0.05). These results suggest that stability may be reduced by graft overlapping in mosaicplasty surgery. The results of this ex vivo animal study contribute to a more complete understanding of the primary stability of osteochondral grafts in an overlapping position as well as postoperative protocols.

[Mosaicplasty technique in the treatment of osteochondral lesions of the knee]. / Diz eklemi osteokondral lezyonlarinin tedavisinde mozaikplasti teknigi.

OBJECTIVES: We evaluated early results of patients undergoing mosaicplasty for full-thickness cartilage lesions of the knee. METHODS: The study included 24 patients (8 females, 16 males; mean age 39 years; range 17 to 52 years) with full-thickness cartilage lesions on the weight-bearing surface of the lateral (n=6) and medial (n=8) femoral condyles. Mosaicplasty was performed with open surgery. All grafts were harvested from the ipsilateral femoral condyle at the level of the sulcus terminalis and transplanted with the mosaicplasty technique to the defect area. The mean defect diameter was 13.5 mm (range 8 to 27 mm), and the mean number of grafts used was 1.5 (range 1 to 4). Final clinical assessments were made using the Lysholm and ICRS (International Cartilage Repair Society) scoring systems. Radiological evaluations were made according to the Kellgren-Lawrence criteria. Donor-site morbidity was evaluated according to the Bandi scoring system. The mean follow-up was 30.5 months (range 13 to 47 months). RESULTS: The mean pre- and postoperative Lysholm knee scores were 46 (range 28 to 64) and 86 (range 76 to 100), respectively. ICRS scores were grade I in 16 patients (66.7%), grade II in six patients (25%), and grade III in two patients (8.3%). Five patients (20.8%) had slight donor-site disturbance which regressed within six months to a level that did not restrict daily physical activities. All the patients returned to preinjury activity levels. Postoperative magnetic resonance imaging showed no signs of graft loosening or collapse. According to the Kellgren-Lawrence criteria, 20 patients (83.3%) were free from any signs of osteoarthritis, whereas four patients (16.7%) exhibited early osteoarthritic changes. CONCLUSION: Mosaicplasty is a reliable procedure in the treatment of full-thickness chondral lesions because it is minimally invasive, can be performed at a single session, and has a low complication rate and low cost.

Elution characteristics and mechanical properties of calcium sulfate-loaded bone cement containing teicoplanin.

BACKGROUND: Acrylic bone cement is the most widely used drug delivery system clinically. It has already been shown that antibiotic release is significantly increased when calcium sulfate-loaded acrylic bone cement is used. However, there is no information yet about the mechanical responses of these composite materials. Thus, the purpose of this study was to investigate the effect of calcium sulfate on the elution characteristics and mechanical behavior of teicoplanin-loaded acrylic bone cement. METHODS: Four groups of acrylic bone cements (GI, GII, GIII, GIV) were prepared using the same liquid/powder ratios. After mixing, the bone cement and additive mixtures were packed into different-type molds to prepare the specimens for the elution and mechanical tests. All of the specimens were tested for two conditions (dry and human plasma solution). The mechanical tests included the setting time (hardness) and tensile, bending, and compression strengths. The fracture surfaces of the failed samples were also examined by scanning electron microscopy. RESULTS: Teicoplanin release in the calcium sulfate powder added groups (GIII and GIV) was higher than that of GII. When the calcium sulfate and teicoplanin were added on acrylic bone cement, the compressive, bending and tensile strength, hardness values, and elastic modulus decreased. Also, further reductions were evident in human plasma solution. CONCLUSIONS: Although mechanical properties of tested specimens decreased, all of the results obtained were higher than those required by the American Society for Testing and Materials Standards, but further investigations are necessary before making definitive statements for clinical applications.

Oxygen radicals and nitric oxide levels in chondral or meniscal lesions or both.

The pathophysiologic mechanism of osteoarthritis is not well known. The importance of reactive oxygen species and nitric oxide in the pathogenesis of osteoarthritis in patients with chondral or meniscal lesions or both and a search for their source were investigated. Synovial fluid samples obtained from 44 patients with osteoarthritis (16 had meniscal lesions, 12 had chondral lesions, and 16 had meniscal plus chondral lesions) were analyzed. Ten control subjects also were included. Reactive species, nitric oxide, and peroxynitrite were measured by the chemiluminescence technique. Patients with chondral lesions had significantly increased levels of O when compared with patients with meniscal lesions and the control group. However, patients with chondral or meniscal plus chondral lesions had significantly higher levels of other reactive oxygen species when compared with the control group. For the patients with meniscal plus chondral lesions, the contribution of nitrogen containing reactive species was evident. Although patients with chondral lesions had a significant increase in nitric oxide, the increase in patients with meniscal plus chondral lesions was more pronounced in peroxynitrite concentration. These reactive species will lead to tissue damage along with the mechanical damage caused by meniscal or chondral lesions or both.(2-)

[Intramedullary nailing of adult femoral fractures]. / Eriskin femur cisim kiriklarinin intramedüller çivilerle tedavisi.

OBJECTIVES: We evaluated the results of treatment of adult femoral fractures treated by intramedullary nails. METHODS: Sixty-two patients (15 females, 48 males; mean age 29 years; range 16 to 62 years) with 64 femoral fractures were treated by intramedullary nailing. Eighty-three percent of the fractures was closed and 17% was open. According to the Winquist (W) classification, there were 16 (25%) W0, 22 (34%) W1, nine (14%) W2, nine (14%) W3, and eight (13%) W4 fractures. The mean duration between trauma and surgery was 18 days (range 4 to 130 days), and the mean hospital stay was 25 days (range 11 to 142 days). Open and closed techniques were employed in 62 (97%) and two (3%) fractures, respectively. Nine fractures were unlocked; dynamic and static locking were performed in 39 and 16 fractures, respectively. In the open technique, secondary procedures involved grafting in 14 cases, cerclage in eight cases, grafting and cerclage in 10 cases, and grafting and screw fixation in one case. The results were assessed according to the criteria by Thoresen et al. The mean follow-up was 28 months (range 7 to 62 months). RESULTS: Fifty-one patients (80%) had satisfactory, 13 patients (20%) had poor outcome. All proximal locking screws (n=20) were successfully inserted, whereas 23 (24%) of 95 distal screws missed the nail holes. Complications included superficial infection (n=3), osteomyelitis (n=4), trochanteric bursitis (n=1), irritation of the skin by the distal screws (n=4), heterotopic ossification (n=6), shortening more than 1 cm (n=8), rotational malalignment greater than 10 degrees (n=2), migration of the nail through the knee joint (n=2), drill breakage while preparing the distal holes (n=2), knee range of motion below 100 degrees (n=6), and delayed union (n=2). CONCLUSION: Intramedullary nailing should be the primary indication for stable and unstable femoral fractures.