Prevalence of anterior knee pain after patellar retention total knee arthroplasty: Comparison of patients with rheumatoid arthritis versus primary osteoarthritis.

OBJECTIVE: The aim of this study was to investigate whether there is an increased risk of anterior knee pain (AKP) after total knee arthroplasty (TKA) without patellar resurfacing in patients with rheumatoid arthritis (RA) versus primary osteoarthritis (OA). METHODS: This study was a retrospective review of 388 patients (577 knees) who underwent TKA without patellar resurfacing between 2003 and 2011, with a minimum of 5 years of follow-up. Patients were divided into two groups: Group OA (273 knees of 206 patients; 83 males, 123 females; mean age: 64.4 (47-87) years) and Group RA (304 knees of 182 patients; 92 males, 90 females; mean age: 50.7 (21-72) years). In the clinical evaluation, the knee range of motion (ROM) and several outcome measures such as The Knee Society Score (KSS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, and International Knee Documentation Committee (IKDC) scores were used preoperatively and at the final follow-up visit. The quality of life was measured using Short Form (SF)-36 MCS and PCS scores. The primary outcome was the frequency and severity of patient-reported AKP. The AKP Scale was used to determine the severity of AKP. RESULTS: The IKDC raised from 21.62 (range, 13-29.9) preoperatively to 85.1 (range, 80-88) for group OA and from 21.8 (range, 13-29.9) to 85.2 (range, 81-88) for group RA (p < 0.001). The mean KSS improved from 28.35 (range, 22-38) preoperatively to 90.04 (range, 88-95) for group OA and from 21.9 (range, 18-35) preoperatively to 89.7 (range, 86-95) for group RA. The mean WOMAC increased from 20.61 (range, 17.4-24.2) preoperatively to 95.7 (range, 90.9-97.7) for group OA (p < 0.001) and from 20.2 (range, 16.7-24.2) preoperatively to 95.8 (range, 90.9-98.5) for group RA (p < 0.001). The mean ROM improved from 80.14° (range, 55°-130°) preoperatively to 113.17° (range, 95°-140°) in group OA (P = 0.003) and from 73.4° (range, 10°-130°) to 112.8° (range 90°-140°) in group RA (P = 0.003) postoperatively. The frequency of AKP was 8% in Group OA and 7% in Group RA (p = 0.27). For patients with AKP, the mean AKP Scale was 92.74 (range, 84-98) in Group OA and 93.39 (range, 82-98) in Group RA (p = 0.3). CONCLUSION: After TKA without resurfacing the patella, patients with RA were determined to have a similar risk for AKP as those with OA. LEVEL OF EVIDENCE: Level III, Therapeutic Study.

Effectiveness of posterior structures in the development of proximal junctional kyphosis following posterior instrumentation: A biomechanical study in a sheep spine model.

INTRODUCTION: Proximal junctional kyphosis - PJK has been defined by a 10 or greater increase in kyphosis at the proximal junction as measured by the Cobb angle from the caudal endplate of the uppermost instrumented vertebrae (UIV) to the cephalad endplate of the vertebrae 1 segments cranial to the UIV. In this biomechanical study, it is aimed to evaluate effects of interspinosus ligament complex distruption and facet joint degeneration on PJK development. MATERIALS AND METHODS: Posterior instrumentation applied between T2 - T7 vertebrae using pedicle screws to randomly selected 21 sheeps, divided into 3 groups. First group selected as control group (CG), of which posterior soft tissue and facet joints are protected. In second group (spinosus group, SG) interspinosus ligament complex which 1 segment cranial to UIV has been transected, and third group (faset group-FG) was applied facet joint excision. 25 N, 50 N, 100 N, 150 N and 200 N forces applied at frequency of 5 Hertz as 100 cycles axial to the samples. Then, 250 N, 275 N and 300 N forces applied static axially. Interspinosus distance, kyphosis angle and discus heights was measured in radiological evaluation. Abnormal PJK was defined by a proximal junctional angle greater than 100 and at least 100 greater than the corresponding preoperative measurement. RESULTS: In CG group, average interspinosus distance was 6,6 ± 1.54 mm and kyphosis angle was 2,2 ± 0.46° before biomechanical testing, and they were measured as 9,4 ± 1.21 mm and 3,3 ±0.44° respectively after forces applied to samples. In SG group, average interspinosus distance was 6,2 ± 1.72 mm and kyphosis angle was 2,7 ± 1.01° before experiment, and they were measured as 20,8 ± 5.66 mm and 15,1 ± 2.34° respectively after forces applied to samples. In FG group, average interspinosus distance was 4,8 ± 1.15 mm and kyphosis angle was -1 ± 4.14° before experiment, and they were measured as 11,1 ±1.96mm and 11 ± 2.87° respectively after forces applied to samples. In comparison to group CG, statistically significant junctional kyphosis was seen on both FG and SG group after statistical analysis. (p < 0.05). PJK was seen statistically significant more on SG group than FG group. (p < 0.05). Not any statistically significant difference was seen on measurement of disk distances among three groups. (p > 0.05) CONCLUSIONS: Protecting interspinosus ligament complex and facet joint unity during posterior surgical treatment for spine deformation is vital to prevent PJK development. Based on our literature review, this is the first biomechanical study that reveals interspinosus ligament complex are more effective on preventing PJK development than facet joints.

The quality of life analysis of knee prosthesis with complete microprocessor control in trans-femoral amputees.

OBJECTIVE: The aim of this study was to analyze the patient demographics, etiology of limb loss as well as reporting SF-36 scores for microprocessor prosthesis users in Turkish population. METHODS: We reviewed 72 patients (61 male and 11 female; mean age: 37.7 ± 10.7) with uni-lateral, above knee amputation and a history of regular and microprocessor prosthesis use. All patients were called back for a last follow-up and they were asked to fill a self-administered general health status questionnaire (SF-36). RESULTS: According to the SF-36 results; physical component score (PCS) score was 46 ± 7.3 and mental components summary (MCS) score was 46.5 ± 9.1. These scores have statistical similarity with Turkish healthy controls, except SF (social functioning) sub-dimension. PCS score for women microprocessor users were significantly lower than men (43.3 vs. 48.7, p = 0.03), but MCS scores were similar in between genders (46 vs. 48.2, p = 0.13). Conventional prostheses usage time was positively correlated with physical function (PF) scores (r = 0.322, p = 0.010). Microprocessor prosthesis usage time was negatively correlated with role limitations due to emotional problem (RE) scores (r = -0,313, p = 0.009). CONCLUSION: The quality of life surveys were showed that the loss of an extremity have higher physical and psychological impact on women's physical scores. Overall, SF-36 results were similar in microprocessor using amputee's and Turkish normal controls. LEVEL OF EVIDENCE: Level IV, therapeutic study.

COMPLICATIONS AND MIDTERM OUTCOMES OF HEMIARTHROPLASTY IN HEMODIALYSIS PATIENTS.

OBJECTIVE: The aim of this study was to evaluate the functional results, complications, and morbidity and mortality rates in patients with end-stage chronic renal failure (ESCRF) with collum femoris fractures who were treated with hemiarthroplasty. METHODS: From 2005 to 2013, patients with ESCRF admitted to our hospital with collum femoris fracture and treated with hemiarthroplasty were retrospectively evaluated, and 44 hips in 42 patients were included in the study. Duration of hospital stay, bleeding, complications, morbidity and mortality were recorded for each patient. At the last control evaluation, patients were assessed via pelvis x-ray and functional status according to Harris Hip Score (HHS). RESULTS: Patients required a mean 2.7 units of erythrocyte suspension. Mean hospital stay was 19.74 days. The most common complication was bleeding. The complication rate was 38.1%; mortality rate at first-year follow-up was 42.8%, and mean HHS was 74.5. CONCLUSION: Collum femoris fractures are more common in ESCRF patients due to metabolic bone disease, and these patients had many comorbidities which may exacerbate high complication and mortality rates. Orthopedic surgeons should consider these higher complication rates and inform patients about the consequences of this treatment. Level of Evidence IV, Case Series.

OBJETIVO: O objetivo deste estudo foi avaliar os resultados funcionais, as complicações e as taxas de morbidade e mortalidade em pacientes com insuficiência renal crônica em estágio terminal (IRCT) com fraturas do colo do fêmur tratados com hemiartroplastia. MÉTODOS: De 2005 a 2013, pacientes com IRCT internados em nosso hospital com fratura do colo do fêmur e tratados com hemiartroplastia foram avaliados retrospectivamente, e 44 quadris em 42 pacientes foram incluídos no estudo. Durante a estadia hospitalar, hemorragia, complicações, morbidade e mortalidade foram registradas para cada paciente. Na última avaliação de controle, os pacientes foram examinados com radiografias da pelve e quanto ao estado funcional, de acordo com o Harris Hip Score (HHS). RESULTADOS: Os pacientes precisaram em média 2,7 unidades de suspensão de eritrócitos. A estadia hospitalar média foi 19,74 dias. A complicação mais comum foi hemorragia. A taxa de complicações foi 38,1%; a taxa de mortalidade no primeiro ano de acompanhamento foi 42,8% e o HHS médio foi 74,5. CONCLUSÃO: As fraturas de colo do fêmur são mais comuns em pacientes com IRCT, em decorrência da doença óssea metabólica, e esses pacientes apresentam muitas comorbidades que podem exacerbar as altas taxas de complicação e mortalidade. Os cirurgiões ortopédicos precisam considerar esses altos índices de complicações e informar os pacientes sobre as consequências desse tratamento. Nível de Evidência IV, Série de Casos.

Periprostetic Joint Infection Caused by Salmonella: Case Reports of Two Azathioprine and Prednisolone Induced-immunocompromised Patients.

Periprosthetic joint infection (PJI) due to Salmonella is rare. It frequently occurs patients receiving immunosuppressive medicine. We describe two periprosthetic Salmonella infection of two immunocompromised patients. Both of patients were receiving azathioprine and prednisolone therapy. First patient presented six years after total hip arthroplasty with a huge abscess on her right thigh that was reached to femoral component through the lytic area of lateral femur. Second patient presented with drainage from his hip and he had undergone two-step revision surgery for PJI 3 months ago. There is no consensus in the treatment of periprosthetic salmonella infections. We prefer two-step revision surgery for these infections as previously described in the literature.

Charcot arthropathy of the knee after unsuccessful spinal stenosis surgery: A case report.

INTRODUCTION: Charcot arthropathy was first described in 1868 by Jean Martin Charcot as a progressive and destructive joint disease. Diabetes, polyneuropathy, syphilis, syrengomyelia and chronic alcoholism are the main causes of the disease. In this study we present a Charcot arthropathy of the knee seen after unsuccessful spinal stenosis surgery. PRESENTATION OF CASE: We report here a case of 62 years old patient with Charcot arthropathy at her left knee developed one year after spinal stenosis surgery. The patient's knee joint was already beyond the fragmentation and coalescence stages at the moment of physical examination. Patient had already been treated for Charcot foot four years before spinal surgery. Because of an unsuccessful spinal surgery, proximal migration of the level of the sensorineural loss negatively affected the polyneuropathy and eventually resulted in Charcot knee joint in a short period of time. DISCUSSION: However, the etiology of the neuropathic arthropathy hasn't been well described yet, it is usually seen at patients with diabetes mellitus as a long-term complication with or without polyneuropathy. In addition to the spinal canal pathologies, it is reported that Charcot arthropathy can be seen even after spinal anesthesia procedures. CONCLUSION: In conclusion, spinal procedures should be applied with extra caution on the patients with polyneuropathy or any neuropathic arthropathy. It should be remembered that it is possible to encounter unexpected complications such as proximally migration of the level of sensorineural loss and progression of the actual disease after spinal procedures of these patients.

Total hip arthroplasty in patients with ankylosing spondylitis: Midterm radiologic and functional results.

INTRODUCTION: The aim of this study was to evaluate the clinical and radiological outcomes of total hip arthroplasty (THA) in patients with Ankylosing Spondylitis (AS). PATIENTS AND METHODS: One hundred five hips of 61 AS patients (mean age: 41.3 ± 10.2 years) who underwent THA between 1997 and 2012 were included into the study. Dorr's classification of proximal femoral geometry, acetabular protrusio, bone ankylosis, acetabular protrusion, Brooker classification of heterotopic ossification (HO), Gruen and Charnley classifications of implant loosening were used in radiographic assessments. Patients were called back to return for an additional long-term follow-up for functional assessment. RESULTS: Cementless total hip arthroplasty was used in 83 hips (79%) and cemented TKA was used in 22 hips (21%). The overall rate of aseptic loosening was 7.6% at a mean follow-up of 5.4 years. Femoral loosening was statistically similar in cemented and cementless femoral components (14% vs. 8%, p = 0.089). Acetabular component loosening was statistically higher in patients with any degree of HO (p = 0.04). Regardless of the type of femoral implant (cemented or cementless), femoral component loosening was higher in Dorr's type C patients (p = 0.005). The average pre-operative HSS was 46.6 ± 16.3, and it improved to 80.7 ± 18.7 at last follow-up (p < 0.01). CONCLUSION: Revision incidence was similar in between ankylosed and non-ankylosed hips. While complication rates are high, significant functional improvement can be achieved after THA in patients with AS.

Osteomalacia and coxa vara. An unusual co-existence for femoral neck stress fracture.

INTRODUCTION: Femoral neck stress fractures are not uncommon. Several causes exist about these fractures. Osteomalacia is one of the most common cause of insufficiency fractures and coxa vara can produce a focal concentration of mechanical stress in the femoral neck and may cause stress fractures. This case study is about the co-existence of these two pathologies in a patient with bilateral femoral neck stress fracture. PRESENTATION OF CASE: A 26-year-old woman admitted to our department with a complaint of bilateral groin pain and diagnosed as bilateral coxa vara and osteomalacia. Medical treatment for osteomalacia and staged bilateral Pauwels' osteotomy was performed. After 2 years of follow-up, good result was obtained. DISCUSSION: There are several risk factors for stress fractures and osteomalacia and coxa vara are two of the causes. Osteomalacia results in softening of the bones and coxa vara can produce a focal concentration of stresses in the femoral neck. CONCLUSION: Joint and bone pain without any trauma should be investigated and bone metabolism disorders should be kept in mind. There might be co-existing factors related with stress fractures, and they must be treated simultaneously.

Bilateral femoral neck fractures secondary to chronic carbamazepine use treated by bilateral dynamic hip screw: A case report.

INTRODUCTION: Bilateral femoral neck fractures without major trauma are rare and related to several conditions. Insufficiency fractures due to the use of anti-epileptic drug are one of the rare causes. This case study is about bilateral femoral neck insufficiency fractures resulting from chronic use of anti-epileptic drug. PRESENTATION OF CASE: A 26-year-old woman was referred to our emergency department with a complaint of bilateral groin pain and a 12-year history of irregular carbamazepine use. The diagnosis was bilateral femoral neck insufficiency fractures due to irregular long-term carbamazepine use. One-stage bilateral dynamic hip screw osteosynthesis was performed. After 2 years of follow up, good result was obtained. DISCUSSION: There are several risk factors for insufficiency fracture, and antiepileptic drug related osteoporosis is one of the reason. These drugs have negative effect on bone methabolism and bone mineral density. CONCLUSION: To our knowledge, this is the first case in the literature of bilateral femoral neck insufficiency fracture due to chronic carbamazepine use. Joint and bone pain with a history of long-term use of anti-epileptic drug should be investigated carefully, and insufficiency fractures should be kept in mind.

Hip fractures in extremely old patients.

AIMS: The purpose of this study was to report a less seen age-group (>90) of hip fractures and to assess the predictors of functional loss, complications and mortality. METHODS: Thirty-two patients at a mean age of 92.8 (±2.7) were treated in a single institution and reported at a mean follow-up of 2.02 (±1.35) years. RESULTS: Mortality was similar between proximal femoral nailing (PFN) and bipolar cemented hemiarthroplasty (BCH) in first year (p = 0.17) but significantly high in following years in BCH (p = 0.035) and patients with cardiac disease (p = 0.054). CONCLUSION: Hip fractures are challenging in extremely old patients and associated with increased mortality and disability.

The effect of strut allograft and its position on Vancouver type B1 periprosthetic femoral fractures: a biomechanical study.

The aim of this study is to assess the biomechanical advantage of adding strut allograft and the effect of its position on the construct in Vancouver type B1 fractures. Fifteen forth-generation synthetic femurs were used and created a fracture model at the tip of prosthesis, and subsequently fixated with a lateral plate only, lateral plate and medial strut, lateral plate and anterior strut. Rotational and axial tests were performed. In all loading tests, the plate with medial strut group was stiffer than the other constructs and had higher failure load values and had less displacement in the fracture site. A combination of a plate with a medial strut allograft provides more mechanical stability on periprosthetic femoral fractures near the tip of a total hip arthroplasty.

Comparison of locked plating and intramedullary nailing for periprosthetic supracondylar femur fractures after knee arthroplasty.

This study aimed to compare the efficacy of two treatment modalities for periprosthetic supracondylar fractures. The results of intramedullary nailing in 7 patients and locked plating in 9 patients were reviewed retrospectively. Mean follow-up was 4.3 years (range : 1 to 13 years). One patient died on the first postoperative day. Union of the fracture was achieved in the other 15 patients, after a mean time of 3.86 months: 3.9 months (range: 3 to 6 months) in the locked plate group and 3.86 months (range : 3 to 5 months) in the intramedullary nail group (p = 0.96). Mean Knee Society Score was 78 points (range : 68 to 84 points) and mean total knee range of motion was 82 degrees (range 70 degrees to 90 degrees) with no significant differences between groups. Sagittal and coronal plane measurements were similar both in the early postoperative period and at the last follow-up. The two treatment modalities had similar results with a high success rate.

Cementless total hip arthroplasty with modified oblique femoral shortening osteotomy in Crowe type IV congenital hip dislocation.

Midterm results of cementless total hip arthroplasty in patients with Crowe type IV congenital dislocation of the hip were evaluated. A modified oblique subtrochanteric shortening osteotomy was used in all patients. A cylindrical femoral stem was used in all patients to stabilize the osteotomy. Mean follow-up was 82 months in 20 hips of 16 patients. Mean Merle D'Aubigné pain score increased from 2.52 to 5.65 points, function score improved from 4.0 to 5.3 points, and mobility score improved from 3.95 to 5.35. Mean greater trochanter height relative to the estimated hip center was 6.8 ± 2.0 cm preoperatively and -1 ± 0.2 cm postoperatively. Complications were dislocations in 3 patients, which were successfully managed without redislocation and fracture of greater trochanter in 3 patients, which healed uneventfully in 2 but with residual Trendelenburg gait in one. Total hip arthroplasty with modified oblique subtrochanteric shortening osteotomy is an effective technique for the treatment for Crowe type IV hip dislocation.

Effect of antibiotic loading on the shear strength at the stem-cement interface (Shear strength of antibiotic loaded cement).

The purpose of this study was to investigate the effects of addition of antibiotics into cement powder on the shear properties of the cement-metal interface. The approach involved adding 800 mg of teicoplanin to 40 g bone cement powder in the t-800 group, 1,600 mg teicoplanin in the t-1,600 group, and no antibiotic in the control group. Industrially prepared bone cement containing 500 mg of gentamicin was used as group g-500. Each group consisted of ten samples. Cement-metal interfaces were produced using metal discs with porous surfaces (1 microm) and templates at the third minute. Shear stability of specimens was measured in a material testing machine. The ANOVA test was used for comparison between the mean shear results of each group. Results showed that mean shear stress to failure values were 12.28+/-3.35 MPa for the control group, 11.72+/-3.09 MPa for the t-800 group, 13.25+/-2.36 MPa for the t-1,600 group and 13.09+/-2.58 MPa for the g-500 group. No statistically significant differences were found between results of the groups. Results of the study have proven that addition of 1,600 mg of teicoplanin or 500 mg gentamycin in 40 g of bone cement does not decrease the shear strength at the cement-metal interface significantly on the day of application.

[The effectiveness of arthroscopic debridement and lavage treatment in osteoarthritis of the hip: preliminary results]. / Kalça osteoartrozunda artroskopik debridman ve eklem yikanmasi tedavisinin etkinligi: Erken sonuçlar.

OBJECTIVES: We evaluated the early results of arthroscopic debridement and lavage procedure in osteoarthritis of the hip. METHODS: The hips of 13 patients (7 women, 6 men; mean age 52 years; range 29 to 74 years) were treated by arthroscopic debridement and lavage in lateral position under general anesthesia. Ten patients had primary coxarthrosis; it was due to acetabular dysplasia in two patients, and to avascular necrosis of the femoral head in one patient. The patients were radiographically and arthroscopically evaluated according to the Kellgren-Lawrence grading system and the Tippett's chondropathy classification, respectively. Preoperative and postoperative assessments of the hips were made according to the Harris hip scoring system. The mean follow-up was 11.2 months (range 5 to 22 months). RESULTS: Harris hip scores increased in eight patients (62%) postoperatively, namely, in only one patient out of six with a radiographically high grade of osteoarthritis (grade 4), and in all seven patients with grade 2 or 3 disease. No complications occurred. Significant negative correlations were found between radiographic and arthroscopic grades and the clinical improvement (p=0.001). However, the patients' age and the preoperative Harris hip score were not correlated with the clinical result. CONCLUSION: Arthroscopic debridement and lavage provides significant clinical improvement during short-term follow-up of osteoarthritic hips with radiographic grades of 3 or less.