Angular cheilitis-an oral disease with many facets.

Cheilitis is a common inflammatory disorder of the vermillion and adjacent skin of the lips. A special type is angular cheilitis. The disease has a mixed etiology, mostly with bacterial and fungal components. Angular cheilitis may be a clinical sign of an underlying disease. It has two age peaks: one during childhood and another in adults. It becomes more frequent with aging. Clinical presentation, differential diagnoses, and treatment are discussed. Angular cheilitis is of importance in primary care of patients, in geriatrics, dentistry, pediatrics, internal medicine, and in dermatology.

Total Knee Arthroplasty in Patients with Ipsilateral Hip Fusion: Technical Notes and Literature Review.

Numerous studies report the success and outcomes of the total knee arthroplasty (TKA); however, few papers present patients with knee osteoarthritis and ipsilateral hip fusion. One controversy when treating patients requiring a TKA with prior ipsilateral hip fusion is whether to first perform a total hip arthroplasty (THA) of the fused hip, followed by the ipsilateral TKA, or to proceed with the TKA without replacing the hip; studies suggest that the position of the fused hip is a key factor when making this therapeutical decision. In addition, performing a TKA in patients with an ipsilateral fused hip may require modifications to the surgical technique generated by the lack of joint mobility in the hip. We identified 12 studies encompassing 30 patients with hip fusion and ipsilateral TKA in current orthopedic literature, but only six offered insights on patient positioning on the operating table during surgery. This study aims to review the current literature on patients with knee osteoarthritis and prior ipsilateral hip fusion and to present some technical considerations when performing a TKA on a 75-year-old patient with hip ankylosis who underwent a total ipsilateral knee arthroplasty in our clinic.

Updates on Biomaterials Used in Total Hip Arthroplasty (THA).

One of the most popular and effective orthopedic surgical interventions for treating a variety of hip diseases is total hip arthroplasty. Despite being a radical procedure that involves replacing bone and cartilaginous surfaces with biomaterials, it produces excellent outcomes that significantly increase the patient's quality of life. Patient factors and surgical technique, as well as biomaterials, play a role in prosthetic survival, with aseptic loosening (one of the most common causes of total hip arthroplasty failure) being linked to the quality of biomaterials utilized. Over the years, various biomaterials have been developed to limit the amount of wear particles generated over time by friction between the prosthetic head (metal alloys or ceramic) and the insert fixed in the acetabular component (polyethylene or ceramic). An ideal biomaterial must be biocompatible, have a low coefficient of friction, be corrosion resistant, and have great mechanical power. Comprehensive knowledge regarding what causes hip arthroplasty failure, as well as improvements in biomaterial quality and surgical technique, will influence the survivability of the prosthetic implant. The purpose of this article was to assess the benefits and drawbacks of various biomaterial and friction couples used in total hip arthroplasties by reviewing the scientific literature published over the last 10 years.

Biomechanical Comparison of Conventional Plate and the C-Nail® System for the Treatment of Displaced Intra-Articular Calcaneal Fractures: A Finite Element Analysis.

The C-Nail® system is a novel intramedullary fixation method for displaced intra-articular calcaneal fractures. The aim of this study was to evaluate the biomechanical performance of the C-Nail® system and compare it with conventional plate fixation for the treatment of displaced intra-articular calcaneal fractures using finite element analysis. The geometry of a Sanders type-IIB fracture was constructed using the computer-aided design software Ansys SpaceClaim. The C-Nail® system (Medin, Nové Mesto n. Morave, Czech Republic) and the calcaneal locking plate (Auxein Inc., 35 Doral, Florida) and screws were designed according to the manufacturer specifications. Vertical loading of 350 N and 700 N were applied to the subtalar joint surfaces to simulate partial weight bearing and full weight bearing. Construct stiffness, total deformation, and von Mises stress were assessed. The maximum stress on the C-Nail® system was lower compared with the plate (110 MPa vs. 360 MPa). At the bone level the stress was found to have higher values in the case of the plate compared to the C-Nail® system. The study suggests that the C-Nail® system can provide sufficient stability, making it a viable option for the treatment of displaced intra-articular calcaneal fractures.

Treatment of C1.1 (AO-41) tibial plateau fracture: A finite element analysis of single medial, lateral and dual plating.

Bicondylar tibial plateau fractures pose many challenges in surgical treatment. The aim of the present study was to analyze three methods of reduction, single medial, single lateral, and dual plating, for the treatment of a bicondylar tibial plateau fracture, through finite element analysis (FEA). A simple metaphyseal fracture, type C1.1 (AO-41) was modeled on a CT-derived 3D model of the knee. Lateral and medial proximal tibial polyaxial plates with screws were modeled and placed accordingly for the three methods of reduction. Simulation of physiological type loading corresponding to the maximal weight acceptance phase during a slow walking gait cycle was performed using FEA. Values of stress and strain were recorded near the fracture lines. Dual plating provided a decrease of stress and strain in the tibial plateau area. However, the differences in the values among the three cases were small. The stress concentration areas were located in the vicinity of the fracture, predominantly in the area of the tibial plateau. Considering the limitations of the present study, the results revealed that dual plating leads to smaller stress and strain values near the fracture lines in the tibial plateau area. However, values obtained for single lateral plating are close in range. Considering the complexity of the surgical approach for dual plating, single lateral plating may be a solution for good reduction with fewer surgical risks and complications. Further studies on the C1.1 fracture (AO-41) are needed to analyze the complex issue of reducing and stabilizing such a fracture and to characterize the postoperative state while providing predictable parameters for an optimal result.

Patient specific instrumentation versus conventional knee arthroplasty: comparative study.

BACKGROUND: The key to a successful knee replacement is restoring normal kinematics with a neutral alignment, thus a hip-knee-ankle (HKA) angle of 180° (within 3° limits). Conventional TKR is proven to have excellent results but relies in extensive visual referencing of bony landmarks. Customised cutting blocks provide accurate bone cuts, also lowering the risk of fat embolism, blood loss and operating time. METHOD: We share our experience comparing two different TKA techniques using patient specific instrumentation (PSI) with the Visionaire knee and conventional instrumentation (CVI) from the same system (Genesis II Smith&Nephew). A total number of 80 knees were divided into two equal groups, 40 PSI and 40 CVI respectively, operated between April 2013 and August 2014. One female patient had bilateral TKR during this period, at six months interval, both with the PSI. RESULTS: All operated knees had varus deformity, with a mean HKA of 168° (PSI) vs 163° (CVI). We used tranexamic acid (double-dose scheme) and suction drains for 48 hours, with a mean blood drainage in the PSI group of 185 ml and Hb levels of 11.2 g/dl at three days post, compared to 260 ml and 10.7 g/dl in the CVI. Mean blood loss was 3.5 g/dl in PSI, and 4.2 g/dl in the CVI. On the long leg standing radiograph at six weeks, all knees were aligned in frontal plane, with simillar HKA values (178.9° PSI vs 178.6° CVI). Bone cuts measured intraoperatively proved to be accurate within a 1 mm limit. CONCLUSIONS: We cannot recommend PSI-TKR for a better outcome. It is an alternative to conventional and computer-assisted TKR, but further studies are needed to evaluate weather surgical or economic benefits may be achieved by choosing customised instruments.

EFFECT OF TRANEXAMIC ACID USE ON POSTOPERATIVE BLOOD LOSS IN TOTAL KNEE ARTHROPLASTY.

AIM: To monitor the effect of tranexamic acid use (Exacyl) on postoperative bleeding (aspiration), autologous blood transfusion (autotransfusion), allogeneic blood transfusion and postoperative anemia (difference between preoperative and immediate postoperative hemoglobin levels) in total knee arthroplasty. MATERIALS AND METHODS: This retrospective observational study was conducted on a sample of 457 patients who underwent endoprosthetic knee arthroplasty in the interval January 1, 2008-July 3O, 2014 at the Traumatology-Orthopedics Clinic of the Iasi Rehabilitation Hospital. The mean age of the study group was 66 years (range 32-84 years), 74.4% were female, 39.8% presented varus and 6.1% valgus malalignment. The study group was subdivided into two groups: Group 1 served as controls and underwent surgery without the administration of tranexamic acid and Group 2 received tranexamic acid. RESULTS: In group 1 the average amount of blood lost was significantly higher than in group 2, 1168.94 ml vs. 452.9 ml (p < 0.001). The use of a cell saver was required in 70% of group 1 patients with an average amount of auto transfused blood of 480.70 ml, significantly more frequent and in greater amounts than in group 2 (below 10%) with an average of 15.05 ml (p < 0.001). In this study tranexamic acid had not a statistically significant favorable effect on blood transfusion requirements and anemia syndrome. CONCLUSION: Tranexamic acid has a favorable effect on postoperative blood loss and its associated complications, with a favorable impact on both early clinical and functional recovery.

Pre-operative radiological measurement of femoral rotation for prosthetic positioning in total knee arthroplasty.

PURPOSE: This study outlines the benefits of the seated view radiograph of the knee in evaluation of the pre-operative individual distal femoral torsion (DFT) and for the follow-up of the post-operative rotational positioning of the femoral component in total knee arthroplasty. METHODS: Study on 20 patients who underwent total knee arthroplasty and the correlation between the DFT measured before surgery with this radiology view, the intra-operative external rotation (ER) necessary for the parallel positioning of the femoral component with the transepicondylar axis (TEA) and the post-operative femoral rotational alignment of the prosthesis on the same view. RESULTS: In 90 % of cases the values of internal DFT were between -1(0) and -8(0), while the mean value of the internal rotation (IR) was -4.45(0). The mean value of the ER applied to the posterior bone resection was 4.25(0) (0(0)-7(0)), showing a statistically significant correlation between the pre-operative measurement and the intra-operative one of the posterior condylar angle (PCA) (r = 0.890, p = 0.000). Residual internal femoral malrotation has been identified in four cases, its mean value being 0.4(0). In three patients the pre-operative value of the PCA was higher than the intra-operative one and an internal malrotation of the post-operative femoral component was observed. CONCLUSIONS: The results are encouraging for the further use of this pre-operative view with the premises of increasing the accuracy of prosthetic positioning and reducing the mechanical complications.

Blood Loss Management in Primary Hip Surgery: Is Reinfusion drain A Feasible Option in Maintaining Hemoglobin Levels?

The management of blood loss in primary hip arthroplasty is a controversial topic. Aim: To evaluate the efficacy of reinfusion drains in terms of hemoglobin levels and volume of red blood cell transfused postoperatively. Material and Methods: 295 patients who underwent primary hip arthroplasty were retrospectively assessed. After applying the exclusion criteria, 94 patients were included in the study and were divided into two groups: 45 patients received a reinfusion drain and 49 a suction drain. The following were analyzed: demographic characteristics of patients, preoperative hemoglobin level, 12-h and 24-h postoperative hemoglobin levels and their variations, number of transfused units of packed red blood cells, and postoperative complications. Results: Kruskal Wallis analysis revealed the homogeneity of the study groups (Chi-square=2.40, df=2, p=0.301). A statistically significant lower decline in mean Hb24 was found in suction drain group (p=0.001). Kruskal Wallis test revealed a significantly more frequent postoperative use of a higher number of packed red blood cell units in the suction drain group (Chi-square=28.70, df=2, p=0.001) compared to reinfusion drain group. Conclusions: We failed to demonstrate the superiority of reinfusion drains versus suction drains in maintaining hemoglobin levels.

Adult multifocal pigmented villonodular synovitis--clinical review.

Pigmented villonodular synovitis (PVNS) is a rare, benign proliferative disease of the synovial tissue that affects a single joint or a tendon sheath. Data from the literature present only a few cases of multifocal PVNS. This paper presents multifocal PVNS in the adult. This disease can affect bilateral shoulders, hips and knees. The diagnosis may be delayed by the slow evolution of the disease (up to ten years); some patients may be seen with late-stage degenerative joints, serious complications, painful and functionally uncompensated, with significant locomotion deficit. PVNS requires a radical treatment with prosthetic arthroplasty associated with synovectomy. Complex imaging (X-Rays, magnetic resonance imaging (MRI), ultrasound) and macroscopic appearance of the lesions during surgery confirms the clinical diagnosis of multifocal PVNS with secondary bone lesions. Histology marks the final diagnosis of multifocal PVNS. The postoperative results are good, with recovery in functional parameters of the joints with endoprosthesis.

Periprosthetic femoral fractures--evaluation of risk factors.

UNLABELLED: Endoprosthetic hip arthroplasty is a surgical intervention that significantly improves the quality of the patient's life, with excellent long term results, but with an increased risk of major complications. One such complication is the periprosthetic femoral fracture, which may occur in both young and old patients due to several risk factors typical to the elderly (osteoporosis, fall risk), cementless press-fit implants, implant loosening, and revision arthroplasty. MATERIAL AND METHODS: This study tries to evaluate the risk factors for periprosthetic femoral fractures treated at the Orthopedics and Trauma Department of the Iasi Rehabilitation Hospital. Retrospective evaluations were conducted on 3454 patients with primary hip arthroplasty and 167 patients with revision hip arthroplasty, the surgical procedures being performed between January 1994 and March 2012. The study was conducted on 47 patients (17 males and 30 females, mean age 68 years) with periprosthetic fracture. RESULTS: The incidence of periprosthetic femoral fractures in primary arthroplasty group was 0.89% (0.63% intraoperative and 0.26% postoperative), with a considerably higher incidence for cementless implants (81.39%), and 9.58% in revision arthroplasty group (8.38% intraoperative and 1.19% postoperative). Vancouver type B was the most frequent, both in operative and postoperative revision arthroplasty and in postoperative primary arthroplasty. 88% of the fractures were surgically treated, with a satisfactory postoperative course both in early and long-term follow-up. CONCLUSIONS: Periprosthetic femoral fractures result in increased morbidity and mortality rate, are difficult to treat, and require complex therapeutic strategies depending on risk factors, fracture type, bone stock, and implant stability.