Subvastus Approach Supporting Fast-Track Total Knee Arthroplasty Over the Medial Parapatellar Approach: A Systematic Review and Network Meta-Analysis.

BACKGROUND: Numerous surgical approaches are being used to perform total knee arthroplasty (TKA). This systematic review and network meta-analysis aimed to compare surgical approaches used in TKA regarding postoperative outcomesat different time points. METHODS: We performed a literature search from medical database inception until October 2, 2021. We searched for randomized controlled trials (RCTs) investigating patients undergoing TKA and comparing at least 2 surgical approaches regarding early postsurgical clinical outcomes (range of motion [ROM], pain on a visual analog scale, and Knee Society Score [KSS]). We included 33 RCTs in our networks. Using paired and network meta-analysis, we calculated pooled mean differences (MDs) with 95% CIs by comparing surgical approaches to the medial parapatellar method. RESULTS: The subvastus (SV) method performed the best on days 1 (MD = 6.99; CI: 1.08; 12.89), 3 (MD = 8.00; CI: 2.08; 13.92), 4 (MD = 27.01; CI: 18.09; 35.92), and 6 (MD = 27.22; CI: 18.38; 36.07) for ROM improvement. Regarding the decrease in pain, the mini SV approach offered significantly lower pain values on days 1 (MD = -1.98; CI: -2.93; -1.03), 3 (MD = -0.85; CI: -1.49; -0.22), and 7 (MD = -1.90; CI: -2.23; -1.57). The differences decreased as time passed. Furthermore, the SV and mini-SV methods performed the best regarding total, knee and function KSS. CONCLUSION: Quadriceps-sparing approaches, especially the SV and mini-SV, are superior to the other approaches in the early postsurgical period, but the differences decrease as time passes.

[Hungarian adaptation of the Caregiver Priorities and Child Health Index of Life with Disabilities questionnaire]. / Cerebralis paresisben szenvedo gyermekek egészségindexe.

INTRODUCTION: Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD) questionnaire is a measurement tool for assessing health status and wellbeing of disabled children, which evaluates children's quality of life from the caregiver point of view. OBJECTIVE: The aim of our work was the Hungarian translation and cultural adaptation of the questionnaire and also validation of the CPCHILD on Hungarian cerebral palsy patients. Further aim was to test the eligibility of the questionnaire for superficial assessment of caregiver's psychological attitudes. METHOD: Translation of the questionnaire was carried out according to the Beaton's guidelines. Test-retest, interrater reliability (ICC) and also internal consistency (Cronbach-alpha) were calculated for reliability. The importance of the questions was assessed for face validity and known group validity test was done to measure construct validity. For examining parental attitudes, the patients were divided into ambulatory and non-ambulatory groups and the 36 quality of life questions of the 7th domain were used to find relations. RESULTS: During test-retest reliability measurements, the ICC was 0.96 (95% CI: 0.88-0.98), and Cronbach-alpha exceeded the minimal expected value of 0.7 (0.74-0.97) except in the 5th domain (0.67), while measuring interrater reliability the ICC was 0.87 (95% CI 0.70-0.94). Face validity was above the 2.0 threshold in every question (2.6-4.5; mean: 3.4 ± 1.34) and the known group validity calculations showed significant differences between the CPCHILD scores of ambulatory and non-ambulatory groups. Examining parental attitudes, a significant difference was also shown among the parents of ambulatory and non-ambulatory children in assessing the importance of sitting in the quality of life of their children (2.89 ± 1.28 vs. 3.51 ± 0.82; p<0.01). CONCLUSION: The final outcome of our study is that CPCHILD questionnaire has become widely accessible in Hungarian language. Our result, that the answers referring to the sitting abilities and the activities should be carried out in sitting position, was significantly different among the caregivers of the ambulatory and non-ambulatory children, showing that the parents of the GMFCS IV and V category children evaluate the importance of sitting ability higher compared to those parents who care for GMFCS I, II and III category children. Furthermore, the results draw attention to the wellbeing and health of the children measurable with CPCHILD as well as that parental caregiver attitudes can be recognized which may give further help in finding the balance between expectations and possibilities during the rehabilitation of cerebral palsy children. Orv Hetil. 2023; 164(16): 610-617.

One-stage bilateral hip arthroplasty / Egy ülésben végzett kétoldali csípoprotézis-beültetés

Introduction: The unilateral total hip arthroplasty is a routine surgical intervention, but in the mean time in several institutions over the world, they perform also bilateral total hip arthroplasty as a one-stage surgery, with different indications. Objective: The aim of this study is to present through our cases and through the international literature the indication criteria, the absolute and relative contraindications, and the potential difficulties of one-stage bilateral hip arthroplasty, showing also the real state of this intervention in our healthcare and financial situation. Method: In this publication, we review - in relation to our five cases - the possibilities of bilateral total hip arthroplasty, their indications and differences compared to the unilateral intervention, and also its financial background. Results: We had neither surgical nor internal medicine complications. Comparing to unilateral hip arthroplasty, patients needed no higher quantity of blood transfusion, but the hospitalization period was 1,5-2 times longer in our cases. Difficulties of mobilization were according more to their internal medical status. Conclusion: According to our experience, the one-stage bilateral hip arthroplasty, with well considered indication range, can be performed safely in adequate internal medicine state of the patient, involving the cardiology and reumatology specialist, with careful anesthesia preparation. The financial side of this intervention is not yet solved at the National Health Insurance Fund of Hungary.

Effect of the surgical exposure on the early postoperative period after total knee arthroplasty / A feltárás módjának hatása a közvetlen posztoperatív idoszakra teljes felszínpótló térdprotézis beültetése esetén

INTRODUCTION: Total knee arthroplasty has become one of the most successful and safest surgical procedures in orthopedic surgery. Of the many different types of surgical exposure, the most common, so-called medial parapatellar (MP) incision is the cut of the quadriceps tendon, which impairs extensor function. In contrast, subvastus (S) exposure, which spares the extensor apparatus, may promise better healing. AIM: The purpose of our prospective observational study at the Orthopedic Clinic of Semmelweis University is to compare the effects of the MP and the S excision on the early postoperative period. METHOD: The 60 patients enrolled were randomly assigned to two different groups according to the type of intervention. In the study, we measured the effects of the two different methods of surgical exposure on homogeneous patient groups in the early postoperative period based on international literature and the parameters we defined. RESULTS: Visual analog scale (VAS) measured resting and active pain levels for the first 10 days, suggesting a more pronounced difference in active VAS values for the S group. In the case of active VAS, patients in the S group also had significantly less pain on days 2, 3, and 10 than in the MP group. Taking into account the results of the other days, it is in favour of preserving the integrity of the extensor apparatus for improved postoperative functionality. Patients' knee joint range of motion was also measured. On day 1, those in the S group were significantly larger. As the days progress, MP group members catch up with S group during their rehabilitation. Group S patients had an average of 1.944 days to extended leg elevation, which is nearly two days shorter compared to the MP group (p<0.0001). CONCLUSIONS: After statistical analysis of data, subvastus exposure appears to be more beneficial in the rehabilitation of the early postoperative period. However, large-scale, multicentre observational studies are required to establish evidence. Orv Hetil. 2020; 161(29): 1208-1214.

[Prevalence of blood transfusion after primary total hip arthroplasty]. / A vértranszfúzió gyakorisága primer csípoprotézis-beültetés után.

Introduction: Total hip arthroplasty is one of the most common surgical procedures that requires blood transfusion, with the possible risk of significant complications. Aim: A retrospective study was performed to analyze the predictors of blood transfusion after primary total hip arthroplasty. Method: We collected the data of 210 consecutive patients undergoing total hip arthroplasty. Patient's data, preoperative hemoglobin and hematocrit level, the type of the prosthesis, the use of a suction drain, tranexamic acid or anticoagulants and the type and amount of blood transfusion were recorded. Results: A total of 41% of our patients required transfusion, 8.6% receiving allogenic blood. Significant predictors of allogenic blood transfusion were preoperative hemoglobin and hematocrit levels, the type of prosthesis, the use of suction drainage and the use of tranexamic acid. Patients with pre-donated autologous blood did not require allogenic blood transfusion. Conclusion: Based on our study, total hip arthroplasty necessitates allogenic blood transfusion in 8.6%. Major predictors associated with the need for transfusion are preoperative hemoglobin and hematocrit levels, the type of prosthesis, the use of suction drainage and the use of tranexamic acid. Pre-donated autologous blood helps to reduce allogenic transfusion rate. Orv Hetil. 2020; 161(8): 290-294.

[Biomechanical and functional comparison of kayaking by abled-disabled athletes]. / Ép és mozgásukban korlátozott kajakos sportolók biomechanikai mozgáselemzése és összehasonlító vizsgálata.

Introduction: During kayaking, the whole body works in a perfect harmony. While the trunk is doing a rotation, flexion-extension helps to the upper limb to create a special cyclic paddle. The purpose of this study was to gain a better understanding of the physical disabled (later disabled) person's kayaking motions and to probe whether there were any significant differences between disabled and non-disabled kayakers with special focus on the use of footrest. We hypothesised significantly different ranges of motion and muscle activity in lower limbs but no significant differences in those of the upper limbs. Aim: Our goal was to know more about the abled and disbled kayaking and compare the athlete's kayaking movements. Method: Thirteen (n = 13) elite disabled athletes (age range: 18-40 years, height range: 164-194 cm, body mass range:74-93 kg), eleven (n = 11) elite non-disabled athletes (age range: 18-40 years, height range:172-197 cm, body mass range: 72-96 kg) and nine (n = 9) athletes whose movements were artificially limited to imitate disabled conditions("imitation disabled" group) (age range: 18-40 years, height range: 172-197 cm, body mass range: 72-96 kg) were measured. Weba sport kayak ergometer, surface electromyography (EMG), and a 3-dimensional Vicon (MX T40) camera system were used to record the data, and a combined Matlab and MS Excel system was used to analyse the results. Results: In line with our basic assumption, range of motion of the upper limbs was not significantly different between disabled athletes and non-disabled athletes (p ≥ 0.05). However, muscle activities were significantly different in the disabled group compared to the non-disabled group (p ≤ 0.05). In the disabled group the knee joint and trunk motions and muscle activities were also significantly different compared to those in the non-disabled group (p ≤ 0.05). The differences in performance force applied to both footrests and force were significant (p ≤ 0.05). Discussion: The assumption that shoulder and elbow ranges of motion were not significantly different in disabled athletes compared to non-disabled athletes was proven. However, muscle activities were significantly different in the disabled group. In the disabled group, knee and trunk motions and muscle activities were also significantly different compared to the non-disabled group. Significant differences were found in performance, force and footrest use. Our results proved our assumption that motions and muscle activities of disabled and non-disabled athletes were significantly different. Orv Hetil. 2019; 160(52): 2061-2066.

[The role of multimodal postoperative analgesia after primary hip arthroplasty]. / A multimodális posztoperatív fájdalomcsillapítás szerepe primer csípoízületi arthroplasticában.

Introduction: Due to the increasing number of arthroplasties, the number of post-operative hospital days was reduced and the rate of rehabilitation accelerated. For this, proper postoperative analgesia is essential and the multimodal pain relief is an excellent tool. Aim: The aim of our study was to compare postoperative functional results, postoperative pain levels, and opioid analgesic needs of patients who received conventional and novel analgesic treatments. Method: In our prospective study, 81 patients were enrolled who underwent primary hip prosthesis surgery in our institution between February 2017 and January 2018. Of the randomized patients, 38 were in the control group and 43 in the multimodal pain group. We have tested their analgesic needs and the subjective pain levels of patients with the help of the visual analog scale (VAS). Results: Patients receiving multimodal pain relief had significantly lower opioid analgesic requirements and significantly lower VAS values assessed at 6 hours, and 3 and 4 days postoperatively. In addition, the patients in this group stayed in the hospital for a significantly shorter time after surgery. Conclusions: Based on our experience, multimodal pain relief in one-sided primary hip joint arthroplasty significantly reduced the patients' postoperative subjective pain sensation and pain killer consumptions. Orv Hetil. 2019; 160(52): 2054-2060.

[Periprosthetic joint infection caused by Rhodococcus equi. Case report]. / Rhodococcus equi által okozott nagyízületi endoprotézis körül kialakult fertozés.

Rhodococcus equi is a rare pathogen in humans causing infections mostly in immunocompromised hosts. We present the first case of periprosthetic joint infection caused by Rhodococcus equi. An 88-year-old male patient was referred to our clinic with a history of fever and right hip pain. The patient had multiple hip surgeries including total joint arthroplasty and revision for aseptic loosening on the right side. He was immunocompetent, but his additional medical history was remarkable for diabetes mellitus, diabetic nephropathy and stroke with hemiplegia resulting in immobilization. Radiography showed stable components, joint aspirate yielded Rhodococcus equi. Irrigation and debridement was proposed, but the patient refused any surgical intervention. Therefore antibiotic therapy was administered. At the last follow-up the patient is free of complaints but the C-reactive protein level is still elevated. This case illustrates the possible role of Rhodococcus equi in medical device-associated infections. Orv Hetil. 2017; 158(27): 1071-1074.

[Is suction drainage necessary in elective total hip arthroplasty?]. / Szükség van szívódrénre elektív csípoprotézis-mutétek során?

INTRODUCTION: Several studies have been published which questioned the use of suction drain during elective hip arthroplasty. AIM: In this prospective study the authors examined how the use of suction drainage affected complications related to perioperative blood loss and hemorrhage in patients undergoing elective hip arthroplasty. METHOD: Eighty-six patients undergoing elective hip arthroplasty were divided into two groups. In 54 patients ("drain" group) suction drains were used during operation, whereas in 32 patients no suction drain was applied. Perioperative blood loss, use of tranexamic acid, method of thrombosis prophylaxis, transfusion requirement, incidental postoperative hemorrhage, septic complications, and all other postoperative complications were recorded. RESULTS: Perioperative blood loss was affected with the use of tranexamic acid but not with the use of drainage (p = 0.94). Patients without the use of drain showed a tendency of lower transfusion requirement (p = 0.08). There was no correlation between any complications and the use of drainage. CONCLUSION: In accordance with published results the authors conclude that the routine use of suction drainage during elective hip arthroplasty is not definitely necessary. Orv. Hetil., 2016, 157(29), 1171-1176.

The effect of knee arthroplasty on balancing ability in response to sudden unidirectional perturbation in the early postoperative period.

INTRODUCTION AND OBJECTIVE: Total knee arthroplasty (TKA) affects 1-3% of the entire population. The effectiveness of surgery and rehabilitation are of great significance. The goal of this study was to determine how different surgical methods (i.e., conventional and minimally invasive) influence balancing ability in response to sudden unidirectional perturbation during the first 12 weeks of the postoperative period. MATERIALS AND METHODS: The balancing capacity after sudden unidirectional (horizontal) perturbation of 10 patients who had undergone TKA operations via the conventional method and 10 patients who had undergone TKA operations via the minimally invasive method were examined before and six and 12 weeks after TKA. Forty-five health age-matched participants composed the control group. The balancing capacities following unidirectional perturbation were characterised by the Lehr's damping ratio, which was calculated based on the results of the provocation tests that were performed with the patients standing on both the affected and non-affected limbs. RESULTS: In both patient groups, the Lehr's damping ratios increased during the postoperative period. However, in both patient groups, the Lehr's damping ratios calculated from the results of all three of the testing methods decreased compared to values obtained from the controls even at 12 weeks postoperatively. Six and 12 weeks after TKA, the Lehr's damping ratios of the patients who underwent operations utilising the minimally invasive exposure method were significantly higher than the values obtained from the patients who underwent operations by conventional exposure. DISCUSSION AND CONCLUSIONS: In both patient groups, the balancing capacities continuously improved over the first 12 weeks of the postoperative period, but the dynamic balancing capacities while standing on both limbs, on the affected limb and on the non-affected limb significantly differed from those of the controls. The balancing capacities of the patients who underwent the minimally invasive exposure procedures improved more rapidly than did the capacities of the patients who underwent operations utilising the conventional exposure method. This reduced balancing capacity should be considered when developing dynamic balancing abilities and abandoning therapeutic aids, and the difference in dynamic balancing abilities between the two patient groups should also be considered.

Variability of gait parameters in patients with total knee arthroplasty.

PURPOSE: Gait analysis has provided important information about the variability of gait for patients prior to and after total knee arthroplasty (TKA). The objective of this research was to clarify how the different surgical techniques influence gait variability. METHODS: Gait analysis was performed at 0.8, 1.0, and 1.2 m/s in three groups of patients (operated on using the conventional technique, conventional technique combined with computer-assisted navigation, and the minimally invasive technique combined with computer-assisted navigation; n = 15 each) and a control group (n = 15; healthy, age, body mass, and body height matched). Gait analysis was performed preoperatively and 6 and 12 months after the surgery. Gait parameter variability was characterized by the coefficient of variance of spatio-temporal parameters and by the mean coefficient of variance of angular parameters. RESULTS: One year after surgery, the variability of spatio-temporal parameters recovered to normal in patients operated on using the conventional technique; however, the variability of articular motion of the affected side decreased and the variability of articular motion of the non-affected side and pelvis increased compared to the control group. In patients operated on using the minimally invasive technique, the variability of spatio-temporal and angular parameters was similar to that of the control group. CONCLUSION: The type of surgical technique significantly influences the variability and stability of gait. Difference in the variability of angular parameters predicts gait instability and increased risk of falling after TKA with the conventional surgical technique. The minimally invasive technique ensures a recovery of gait variability and stability. Thus, particular attention must be paid to improving gait stability during postoperative rehabilitation. LEVEL OF EVIDENCE: II.

Gait analysis following TKA: comparison of conventional technique, computer-assisted navigation and minimally invasive technique combined with computer-assisted navigation.

PURPOSE: there are questions concerning the influence of computer-assisted surgery and the minimal invasive surgical technique on the outcome of total knee arthroplasty. The authors followed up the rehabilitation of patients during the first postoperative year. METHODS: the ZEBRIS gait analysis system was used to obtain numerical data of kinetic and kinematic gait parameters. There were three groups of patients: patients operated by the conventional technique (Group I), patients operated on using computer-assisted surgery (Group II), and patients who underwent the surgical procedure by a minimally invasive technique and computer-assisted surgery (Group III). Both groups consisted of 15 patients. Gait analysis was performed preoperatively and 3, 6, 9, and 12 months after the surgery. The range of motion of the pelvis, the hip and the knee, the step width and the stride length were measured during walking. RESULTS: results were compared with the parameters measured in a group of healthy subjects of the same age (control group). The value of the measured parameters in Group I and in Group II reached the value of the control group 6 months after surgery. In Group III, this occurred 3 months after surgery. CONCLUSIONS: the results of the study confirm that navigation does not influence the length of rehabilitation. However, in case of minimal invasive surgery, rehabilitation is faster than in Groups I and II.

Experiences with computer navigated total knee arthroplasty.

The successful outcome of total knee arthroplasty (TKA) is very much dependent on precise positioning of the components. Inaccuracy may result in complaints as well as in early mechanical failure. Between March 2003 and September 2005, 69 TKA procedures were performed by the computer navigated technique. The postoperative outcome of this cohort was compared with the same number of TKAs done by the traditional technique. The lower limb anatomical axis was determined in all cases pre- and postoperatively by weight-bearing anteroposterior (AP) and lateral full length X-rays. The positions of femoral and tibial components were recorded. Comparing the data in the navigation group on the AP view, 96.6% of femoral and 96.9% of tibial components and on the lateral view in 95.4% of femoral and in 95.4% of tibial components, the overall postoperative axis in 95.4% fell in the range considered in the literature as optimal. In the traditional group on the AP view, 75.7% of femoral and 68.1% of tibial components and on the lateral view 81.8% of femoral and 63.6% of tibial components, the overall postoperative axis in 60.6% fell between the values considered optimal in the literature. It seems to be proven that the computer navigated total knee arthroplasty technique ensures positioning of components significantly more precisely compared with the traditional surgical method. Accuracy of navigation depends on the software used, on the correct detection of anatomical reference points, and on a potentially uneven thickness of the cement layer during final insertion of the components. The computer navigated technique does not substitute professional skill and experience, since it merely transmits information for the surgeon. The decision is in the hands of the doctor during the entire procedure. The real benefits of the computer navigated technique require further research and can be determined only after long-term analyses.

The influence of walking speed on gait parameters in healthy people and in patients with osteoarthritis.

It is difficult to identify objective parameters for assessing the joint function when evaluating the outcome of orthopaedic procedures, especially endoprosthetic replacement. Spatial and temporal parameters of gait have clinical relevance in the assessment of motor pathologies, particularly in orthopaedics. However, the influence of gait speed on these biomechanical parameters has been difficult to be taken into consideration so far. The objective of the present study was to analyse the impact of gait speed on gait parameters and to set a standard walking speed for patients with osteoarthritis by means of a special treadmill control mechanism. The second objective is to compare the gait patterns in patients with unilateral osteoarthritis of the hip joint or of the knee joint to the gait pattern of healthy control subjects. A total of 20 patients with severe unilateral osteoarthritis of the hip, 20 patients with severe unilateral osteoarthritis of the knee and 20 healthy elderly subjects without any history of lower extremity joint pathology were investigated at four different gait speeds. The gait analysis equipment used consisted of an infinitely adjustable force-instrumented treadmill and an ultrasound-based motion analyser system with electromyography. Our data suggest that most of the biomechanical parameters depend on gait speed. The highest gait speed that all our patients with severe osteoarthritis were suitable with, without pain and loss of coordination, was 2.00 km/h. Our findings indicate that the changes in gait parameters may occur in patients with unilateral osteoarthritis of the hip joint or the knee joint compared to the gait pattern of healthy control subjects. Hip joint or knee joint degeneration was compensated for in part by the pelvis and other joints in the lower limb. Reduced motion of the hip joint or knee joint leads to an increased pelvic motion, which should affect the natural mobility of the lumbar spine and cause pain in the lumbar region of the spine because of their kinematic interaction.