Anatomical risk factors for aseptic loosening of full hinge knee prosthesis in primary and revision TKAs.

INTRODUCTION: Risk factors (RF) associated with aseptic loosening (AL) in total knee arthroplasty (TKA) are poorly understood. Therefore, the aim of this study was to investigate the anatomical shape variations in relation to the inner-diameter of the femur and the tibia as prognostic RF for AL of full hinge prosthesis (FHP) in primary and revision TKA. MATERIALS AND METHODS: We retrospectively examined all patients, who underwent revision surgery (2003-2018) due to AL of the FHP in primary (n = 38) and revision TKA (n = 46). Diagnosis-appropriate controls without AL at minimum follow-up of 24 months were randomly collected for each group. Besides other risk factors, we also measured the inner diameter of the femur according to the Citak classification and of the tibia on anteroposterior radiographies. RESULTS: RF for AL are younger age in primary and revision as well as > 1 previous surgeries in revision TKA. The femoral index was shown to be a RF for AL in revision TKA (p = 0.001), but not in primary TKA. The novel tibial index was associated with AL in primary with AUC 0.776 (95% CI 0.67, 0.88), 65.8% sensitivity, 86.6% specificity and in revision TKA with AUC 0.817 (95% CI 0.73, 0.91), 82.6% sensitivity and 71.7% specificity. CONCLUSION: This is the first study to calculate the tibial measurements and the tibial index according to Citak et al. and to identify them as prognostic RF for AL of the full hinge knee prosthesis in TKA and confirm the femoral index as a RF for AL also in revision full hinge knee prosthesis. Therefore, the preoperative radiological evaluation should include the analysis of the anatomical shape variants in order to select the appropriate prosthesis design with a possibly enhanced prognosis.

Tranexamic acid is safe and effective in patients with heterozygous factor V Leiden mutation during total joint arthroplasty.

INTRODUCTION: Patients with an inherent hypercoagulable state are at a higher risk of venous thromboembolism (VTE) following total joint arthroplasty (TJA). Further administration of tranexamic acid (TXA) during TJA may increase the risk of VTE in these high-risk patients. There is no study that specifically analyzes the safety and efficacy of TXA during TJA in patients with factor V Leiden (FVL) mutation; therefore, the purpose of this study was to evaluate the safety and efficacy of TXA use on the risk of VTE and bleeding in patients carrying FVL mutation. MATERIALS AND METHODS: A total of 42 patients with FVL mutation (22 hips, 20 knees) and 40 control patients (20 hips, 20 knees) who underwent TJA were retrospectively reviewed. All patients received 1 g TXA intravenously 15 min before the skin incision and 2 g of TXA was administered locally at the surgical site as a periarticular injection. Pharmacological thromboprophylaxis (low-molecular-weight heparin) was administered to all patients. Estimated blood loss and in-hospital thromboembolic complications were compared between the groups. RESULTS: In both total knee arthroplasty (TKA) and total hip arthroplasty (THA) patients, there was no significant difference in the amount of estimated blood loss among the groups (p = 0.980, and p = 0963, respectively). None of the patients in the THA group received a blood transfusion. The transfusion rate was similar in the TKA group (p = 0.756, one patient in each group). No VTE, myocardial infarction, or any other complications related to TXA use were observed in any of the patients. CONCLUSIONS: The combined local and systemic administration of TXA could be safely used in patients with heterozygous FVL mutation receiving pharmacological thromboprophylaxis during TJA without increasing the risk of VTE.

Effects of knee prosthetic surgery on overactive bladder symptoms and incontinence in women.

INTRODUCTION AND HYPOTHESIS: Urinary incontinence (UI) and overactive bladder (OAB) are common conditions worldwide. These conditions significantly affect the quality of life (QoL) of patients with limited mobility. Total knee arthroplasty (TKA) is one of the most commonly performed orthopedic procedures, resulting in pain relief, as well as improved function and QoL. This study was aimed at evaluating changes in patients' mobility as a result of TKA surgery and the effect of these changes on their OAB and UI symptoms. METHODS: A total of 49 female patients with stage IV osteoarthrosis were included in the study. The International Consultation on Incontinence Question-Short Form (ICIQ-SF), Overactive Bladder-Validated 8 (OAB-V8), Visual Analog Scale (VAS), and Oxford Knee Score (OKS) forms were completed pre-operatively and at the 6th post-operative month. Both knee flexion angles were measured, and the post-void residual urine volume (PVR) was recorded. RESULTS: A statistically significant (p<0.001) decrease was observed in the ICIQ-SF, VAS, OKS, and OAB-V8 scores in the post-operative period compared with the pre-operative values. No statistically significant change was detected in PVR (p=0.103). There was a statistically significant increase in the flexion angle (p<0.001). CONCLUSIONS: After knee arthroplasty, there was a noticeable improvement in the OAB symptoms and UI complaints of the patients. Therefore, we consider that increasing mobility after TKA will positively affect OAB/UI in female patients.

A novel radiological classification system of the distal femur.

INTRODUCTION: In our previous studies, we were able to identify anatomical differences as a predictor for aseptic loosening following primary and revision surgery with the use of rotating hinge prosthesis. This study was performed to answer following question: can a novel radiological classification system of the distal femur be identified? MATERIALS AND METHODS: A total of 200 patients who received standardized anteroposterior (AP) and lateral views of the knee joint were included in this study. On AP radiographs, we measured the distance between inner diameter of the femur at 20 cm proximally from the knee and at a point 2 cm proximally from the adductor tubercle. The ratio of the inner diameter of the femoral canal at 20 cm proximal of knee joint to the inner diameter of medullary canal at 2 cm proximal of adductor tubercle was used as a novel index ratio. Two observers blindly and independently reviewed the anteroposterior radiographs twice. RESULTS: Three groups of anatomical classification can be constructed for each sex according to the 25th and 75th percentiles. A higher distribution of Type C was found in female patients. The median intra-observer reliability for rater 1 was 0.995 (IQR 0.994-0.997). We had also a high inter-observer reliability with ICC of 0.997 (95% CI 0.996-0.998). CONCLUSIONS: The novel classification presents three different types of the knee joint for male and female patients. Type C has a wider inner diaphyseal diameter compared to Type A with a narrow inner diaphyseal diameter.

Variations of cross-sectional meniscal morphology between similar-sized menisci: implications on donor selection for meniscal allograft transplantation.

PURPOSE: This study aimed to investigate the morphological variations in the cross-sectional anatomy of the meniscus between similar-sized matched menisci. MATERIALS AND METHODS: Knee MRI of 329 patients with intact menisci were retrospectively reviewed, and the meniscal length (ML), meniscal width (MW), and cross-sectional dimensions (meniscal height and width) of the anterior, posterior horns, and the corpus were measured. Patients with similar-sized menisci who had less than 1 mm difference in ML and MW were matched. 330 male-to-male medial menisci (MM), 623 male-to-male lateral menisci (LM), 82 female-to-female MM, 233 female-to-female LM, 176 cross-gender MM, and 265 cross-gender LM unique combination of ideally matched pairs (total: 1709) were generated. The disparity in the cross-sectional dimensions, absolute difference, and the paired percent differences was statistically analyzed. RESULTS: The ML and MW in all groups were statistically similar, with a predefined absolute difference of 1 mm both for ML and MW (paired percent difference < 5%). The cross-sectional segmental meniscal dimensions were similar within all groups, but the paired percent differences showed high variations between a mean of 12.1-21.5% and up to 150.9%. The paired percent difference of MM in each segmental dimension was similar among different gender combinations. However, segmental paired percent differences of LM showed statistical differences in anterior horn width (AHW) (p: 0.001) and posterior horn width (PHW) (p: 0.001). In subgroup comparisons, the paired percent difference of AHW was higher in the female-to-female group compared to cross-gender (p: 0.023) and male-to-male groups (p: 0.001). The paired percent difference of PHW was smaller in the male-to-male group compared to female-to-female and cross-gender groups (p: 0.001 for both). CONCLUSIONS: Segmental cross-sectional anatomy showed wide variations despite strict matching in ML and MW. These variations were present in all gender combinations. The meniscal 3D shape is unique, but acceptable limits of similarity need further research. LEVEL OF EVIDENCE: Retrospective study, Level III.

Comparison of Fixation Techniques in Oblique and Biplanar Chevron Medial Malleolar Osteotomies; a Finite Element Analysis.

This study aimed to evaluate different fixation techniques and implants in oblique and biplanar chevron medial malleolar osteotomies using finite element analysis. Both oblique and biplanar chevron osteotomy models were created, and each osteotomy was fixed with 2 different screws (3.5 mm cortical screw and 4.0 mm malleolar screw) in 2 different configurations; (1) 2 perpendicular screws, and (2) an additional third transverse screw. Nine simulation scenarios were set up, including 8 osteotomy fixations and the intact ankle. A bodyweight of 810.44 N vertical loading was applied to simulate a single leg stand on a fixed ankle. Sliding, separation, frictional stress, contact pressures between the fragments were analyzed. Maximum sliding (58.347µm) was seen in oblique osteotomy fixed with 2 malleolar screws, and the minimum sliding (17.272 µm) was seen in chevron osteotomy fixed with 3 cortical screws. The maximum separation was seen in chevron osteotomy fixed with 2 malleolar screws, and the minimum separation was seen in oblique osteotomy fixed with 3 cortical screws. Maximum contact pressure and the frictional stress at the osteotomy plane were obtained in chevron osteotomy fixed with 3 cortical screws. The closest value to normal tibiotalar contact pressures was obtained in chevron osteotomy fixed with 3 cortical screws. This study revealed that cortical screws provided better stability compared to malleolar screws in each tested osteotomy and fixation configuration. The insertion of the third transverse screw decreased both sliding and separation. Biplanar chevron osteotomy fixed with 3 cortical screws was the most stable model.

Which International Consensus Meeting Preoperative Minor Criteria is the Most Accurate Marker for the Diagnosis of Periprosthetic Joint Infection in Hip and Knee Arthroplasty?

BACKGROUND: The accurate preoperative diagnosis of periprosthetic joint infection (PJI) is critical. The aim of this study was to evaluate the diagnostic accuracy and performance of the 2018 International Consensus Meeting (ICM) preoperative minor criteria for the diagnosis of chronic PJI in total hip and knee arthroplasty. METHODS: We retrospectively reviewed 260 patients that underwent a revision knee or hip arthroplasty at our institution between 2015 and 2017. All major and minor 2018 ICM criteria (except erythrocyte sedimentation rate, D-dimer) were available for all patients included. Cases with at least 1 major criterion were considered as infected. Receiver operative characteristic curve analysis was performed for preoperative minor criteria. RESULTS: The diagnostic performance of the preoperative minor criteria ranked as per the area under the curve was PMN% (0.926), alpha defensin (0.922), white blood cell count (0.916), leukocyte esterase (0.861), and serum C-reactive protein (0.860). Increasing the PMN % cutoff from 70% to 77.8% improves the diagnostic accuracy (86.5% vs 90.8%). The highest diagnostic performance was achieved by combining all 5 preoperative parameters, and at current ICM thresholds, the diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive were 93.5%, 95.4%, 92.1%, 89.7%, and 96.5%, respectively. CONCLUSION: The diagnostic performance of preoperative minor criteria was outstanding (PMN%, alpha defensin, white blood cell count) or excellent (leukocyte esterase, serum C-reactive protein). PMN% showed the best diagnostic utility (area under the curve) and should have an increased weight-adjusted score in the ICM scoring system.

Effect of cartilage thickness mismatch in osteochondral grafting from knee to talus on articular contact pressures: A finite element analysis.

OBJECTIVES: The aim of this study was to investigate the effect of cartilage thickness mismatch on tibiotalar articular contact pressure in osteochondral grafting from femoral condyles to medial talar dome using a finite element analysis (FEA). MATERIALS AND METHODS: Flush-implanted osteochondral grafting was performed on the talar centromedial aspect of the dome using osteochondral plugs with two different cartilage thicknesses. One of the plugs had an equal cartilage thickness with the recipient talar cartilage and the second plug had a thicker cartilage representing a plug harvested from the knee. The ankle joint was loaded during a single-leg stance phase of gait. Tibiotalar contact pressure, frictional stress, equivalent stress (von Mises values), and deformation were analyzed. RESULTS: In both osteochondral grafting simulations, tibiotalar contact pressure, frictional stress, equivalent stress (von Mises values) on both tibial and talar cartilage surfaces were restored to near-normal values. CONCLUSION: Cartilage thickness mismatch does not significantly change the tibiotalar contact biomechanics, when the graft is inserted flush with the talar cartilage surface.

Risk Factors for Aseptic Loosening After Total Knee Arthroplasty with a Rotating-Hinge Implant: A Case-Control Study.

BACKGROUND: Successful results have been reported in association with the use of a rotating-hinge prosthesis for primary total knee arthroplasty (TKA). The objective of the present study was to identify risk factors for aseptic loosening in patients who underwent primary TKA with rotating-hinge knee prostheses. METHODS: The records of 1,235 patients who underwent primary TKA with a rotating-hinge prosthesis at our center were evaluated. A total of 125 patients who underwent revision were further evaluated according to the inclusion and exclusion criteria, and 33 patients who underwent revision because of aseptic loosening were then compared with a group of 30 patients who did not require revision surgery. All data, including radiographic measurements, were obtained from records prior to the primary TKA. RESULTS: On the basis of our review of demographic, anthropometric, clinical, surgical, and radiographic findings, we found that higher body mass index (BMI) was associated with revision. The majority of patients with aseptic loosening had loosening of the femoral component. Furthermore, the inner femoral diameter at 20 cm proximal to the knee joint (on both anteroposterior and lateral images) was found to be predictive of revision among those with aseptic loosening. Receiver operating characteristic curve analysis showed that an inner diameter of the femur of >19 mm on anteroposterior images had a sensitivity of 91% and specificity of 87% for predicting the need for revision surgery in patients with aseptic loosening. CONCLUSIONS: This is one of few studies that has focused on determining risk factors for the failure of rotating-hinge prostheses following TKA surgery. Our findings indicate that a novel variable, the inner (diaphyseal) diameter of the femur at the point 20 cm proximal to the knee joint, is an extremely reliable predictor of revision surgery in patients with aseptic loosening. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Risk factors for aseptic loosening in complex revision total knee arthroplasty using rotating hinge implants.

PURPOSE: This study aimed to determine the risk factors of aseptic loosening (AL) in complex revision total knee arthroplasty (TKA) cases using rotating hinge knee prosthesis. METHODS: Patients who had undergone re-revision rotating hinge prosthesis surgery between January 2012 and December 2017 were included. Parameters related to AL were retrospectively reviewed. For this purpose, 31 aseptic loosening patients and 30 control patients were included in the study. Various risk factors were evaluated. Risk factors for AL after re-revision were determined using univariate and multiple logistic regression analyses. RESULTS: Thirty-one AL patients and 30 control patients were included. In the AL group, tibial tantalum cone and impaction grafting were performed significantly less frequently than the control group (p = 0.002 and p < 0.001). Logistic regression analysis revealed that smoking, right-sided TKA, and large femoral canal anteroposterior diameter were factors that increased the risk of AL after re-revision, while tibial tantalum cone decreased the risk of loosening. Smokers had an 11.847-fold higher risk for AL; right-sided TKA led to a 4.594-fold higher risk for AL. However, the presence of a tibial tantalum cone was associated with an 8.403-fold lower risk for AL. CONCLUSIONS: We conclude that smoking, right-sided prosthesis, and large femoral canal diameter increased the risk of AL, while tantalum cone and impaction grafting reduced this risk in patients who underwent re-revision surgery with rotating hinge prosthesis after TKA.

Does tourniquet use decrease blood loss following primary total knee arthroplasty in Jehovah's Witness patients?

OBJECTIVES: This study aims to investigate the use of multiple blood management strategies and the effect of tourniquet on the estimated blood loss (EBL) in Jehovah's Witness (JW) patients who underwent primary total knee arthroplasty (TKA). PATIENTS AND METHODS: Twenty-two self-reported JW patients (9 males, 13 females; mean age 66.8±8.6 years; range, 51 to 83 years) who underwent primary TKA between January 2014 and January 2020 in our institution were retrospectively reviewed. A standard blood management protocol that consisted of hypotensive anesthesia, local and systemic administration of tranexamic acid (TXA) and intraoperative cell salvage was applied to all patients. Patients were divided into two groups: with (n=11) and without (n=11) tourniquet use. The EBL was calculated according to Meunier's formula. Hemoglobin (Hgb), hematocrit (Hct), and EBL on the first and third postoperative days were compared statistically. RESULTS: There was no significant difference between groups regarding postoperative Hgb (p=0.801 and p=0.767), Hct (p=0.617 and p=0.895), Hgb decline (p=0.311 and p=0.822), and EBL (p=0.067 and p=0.284) at first and third postoperative days. None of the patients required blood transfusion. No wound complication or symptomatic deep vein thrombosis was seen during the hospital stay. CONCLUSION: Combined use of hypotensive anesthesia, intravenous administration of TXA, intraoperative periarticular injection, and cell salvage seem to be sufficient in controlling the blood loss in JW patients during TKA. Additional tourniquet use may not further decrease the EBL.

Injury of the infrapatellar branch of the saphenous nerve due to hamstring graft harvest.

PURPOSE: Sensory disturbance around the surgical incision due to injury of the infrapatellar branch of the saphenous nerve can be seen in the anterior cruciate ligament reconstruction. In this research, we aimed to compare the incidence, extent of sensory loss, its clinical effect, and natural course caused by two different skin incisions used for hamstring graft harvest. METHODS: Vertical incision for 36 patients and oblique incision for 42 patients used for graft harvest were included in this study. Sensory loss areas were documented at 6th week, 3rd month and 6th month. Pin prick examination is used to detect the change in sensation. Digital photographs of hypaesthesia were taken and analysed by computer for area detection. The length of incision and subjective complain of sensory loss were also noted. RESULTS: At 6th month, 77% (28/36) of the vertical incisions were associated with persistent sensory loss when compared to the oblique incision (45%, 19/42). The measured area of hypaesthesia was significantly higher in vertical incision (42.4 ± 22.3 cm2) than that in oblique incision (9.3 ± 15.3 cm2) at 6th month. The area of hypaesthesia gradually shrunk in size from distal to proximal in direction. Also, subjective cutaneous anaesthesia was higher in vertical incision (15/36, 41%) than oblique incision (6/41, 14%) at 6th month. CONCLUSION: Oblique incision with less risk of nerve damage is better for graft harvesting. Area of hypaesthesia gradually reduces with time and even recover totally. As a possible complication, nerve injury and its benign prognosis should be explained to the patient before surgery.

Serum prolidase activity and oxidative-antioxidative status in patients with developmental dysplasia of the hip and its relationship with radiographic severity.

BACKGROUND: We aimed to investigate serum prolidase activity and to investigate its association with oxidative-antioxidative status in patients with developmental dysplasia of the hip (DDH). METHODS: Oxidative status parameters, including lipid hydroperoxide (LOOH), total oxidant status (TOS), and the oxidative stress index (OSI), and antioxidative status parameters, free sulfhydryl groups (Total -SH), and total antioxidative capacity (TAC), as well as serum prolidase activity were assessed in patients with DDH (n = 93), and in healthy controls (n = 82). The severity of dysplasia was evaluated according to the Tonnis grading system. RESULTS: Serum prolidase activity and the oxidant parameters (LOOH, TOS, and OSI) were significantly higher and the antioxidant parameters (Total -SH and TAC) were significantly lower in patients with DDH compared to the controls (P < 0.005 for all). Serum prolidase activity was positively correlated with the Tonnis grade of DDH and LOOH, TOS, and OSI levels (P < 0.001 for all), but inversely correlated with total -SH and TAC levels (P < 0.001 for all). CONCLUSION: Increased levels of serum prolidase activity, LOOH, TOS, and OSI, and decreased levels of total -SH and TAC, may be associated with DDH, and these parameters may be useful adjunctive tools to assess the severity of DDH.

Evaluation of prolidase activity and oxidative status in patients with knee osteoarthritis: relationships with radiographic severity and clinical parameters.

We investigated serum prolidase activity and oxidative/antioxidative status in patients with knee osteoarthritis (OA) and evaluated its relationships with radiographic severity and clinical parameters. The study population consisted of 137 patients with knee OA and 134 healthy volunteers. The severity of knee OA was classified according to the Kellgren-Lawrence criteria. Each patient was also evaluated clinically according to the Western Ontario and McMaster University Osteoarthritis Index (WOMAC). Serum prolidase activity was measured spectrophotometrically. Oxidative status was assessed by measuring serum lipid hydroperoxide (LOOH) and total oxidative status (TOS). Antioxidative status was assessed by measuring serum-free sulfhydryl groups (-SH = total thiol) and total antioxidant capacity (TAC). Oxidative stress index (OSI) was calculated. Serum prolidase activity was significantly lower in the knee OA group than in the control group (p < 0.001). The serum prolidase activities decreased with the severity of knee OA. Furthermore, serum LOOH, TOS, and OSI levels of the knee OA group were significantly higher than those of the controls (p < 0.001 for all), whereas TAC and -SH levels did not differ between the two groups (p > 0.05). In a multiple regression analysis, WOMAC score was independently associated with serum prolidase activity (ß = -0.340, p < 0.001). Decreased serum prolidase activity and elevated LOOH, TOS, and OSI levels may be associated with knee OA, and serum prolidase activity may be a useful adjunctive indicator of the progression of knee OA in follow-up.

The body composition of patients with knee osteoarthritis: relationship with clinical parameters and radiographic severity.

BACKGROUND AND AIMS: We investigated body composition in knee osteoarthritis (OA) patients and evaluated its relationship with clinical parameters and radiographic severity. METHODS: Sixty-four patients with knee OA (52 females and 12 males with a mean age of 57.7 ± 8.6 years) and thirty healthy volunteers (20 females and 10 males with a mean age of 56.3 ± 9.5 years) were evaluated. Controls were selected among similar to demographic and hematologic characteristics of patients. Body compositions were assessed via bioelectrical impedance analysis (BIA). Each patient was clinically evaluated by the Western Ontario and McMaster University Osteoarthritis Index (WOMAC). In addition, radiographic severity was classified according to Kellgren-Lawrence's criteria. RESULTS: Phase angle, body capacitance, resistance, reactance, lean body mass, and intracellular water values of the patients with knee OA were found to be significantly lower than those of the controls (p < 0.05). Furthermore, fat mass and extracellular water levels were significantly higher in the patients compared to the controls (p < 0.05). Lean body mass was inversely correlated with WOMAC score (r = -0.716, p < 0.001), whereas fat mass was moderately correlated with WOMAC score (r = 0.281, p < 0.05) in bivariate analysis. However, with respect to the body composition, there was no significant difference between early grades and late grades in the knee OA with patients (p > 0.05). CONCLUSION: Body composition assessed using BIA might be associated with knee OA, and be a noninvasive tool for diagnosis of knee OA. However, body composition may not be predictive of the progression of knee OA.