Comparison of Contemporary Surgical Indications for Revision Total Knee Arthroplasty between 2005-2011 and 2012-2017 in a Referral Center.

Background: Different causative factors for revision total knee arthroplasty (TKA) surgeries are elucidated in the arthroplasty registry data of different countries and the patient records at tertiary care centers. We aimed to determine the changes in the causes for revision TKAs before and after 2011 (The year that the Musculoskeletal Infection Society proposed a new definition for periprosthetic joint infection) and the changes in the demographics of patients who underwent revision TKAs during the same time intervals. Methods: Patients who underwent revision TKAs between 2004 and 2017 were evaluated. A total of 291 patients operated before (period 1, n = 139) and after (period 2, n = 152) 2011 were included, while 53 patients with inconclusive diagnoses were excluded. The demographic data of patients and the causes for revision TKAs were collected and compared between the two periods. Results: Infection was the most common cause of revision TKAs during periods 1 (58%) and 2 (48%). Aseptic loosening (46%) and infection (37%) were the 2 most common causes for late revisions during period 2. Aseptic loosening almost doubled during period 2 compared with that in period 1. Age, sex, and body mass index distribution in patients were similar across both the periods. Conclusion: Although the incidence of aseptic loosening has significantly increased since 2011, infection is still the most common cause for revision knee arthroplasty surgery.

Ultra Diced Cartilage Graft in Rhinoplasty: A Fine Tool.

BACKGROUND: Free diced cartilage smaller than 0.2 mm in diameter to smoothen the nasal dorsum is a well-known procedure. However, creating smaller diced cartilage takes a really long time. In contrast, the free diced cartilage technique has some visibility problems, especially in thin-skin patients, although a fine job is done to chop the cartilage. The author aimed to present the "ultra diced cartilage graft" and the way to achieve it, to eliminate the problems of diced cartilage during rhinoplasty, and compare it with free diced cartilage grafting technique. METHODS: Between April of 2015 and December of 2018, the ultra diced cartilage graft technique in 104 patients and the free diced cartilage graft technique in 113 patients were used to smoothen the dorsum or augment the radix/dorsum. Operation records, rhinoplasty outcome evaluation questionnaire, palpation test, and evaluation of the immediate postoperative photographs on the table with postoperative 1-year postoperative photographs by two independent blinded plastic surgeons were analyzed. RESULTS: Ultra diced cartilage seemed superior to free diced cartilage grafting with regard to graft visibility and resorption. CONCLUSIONS: Ultra diced cartilage graft is an effective and easily reproducible technique in rhinoplasty. There is no extra cost, and it is the easiest and fastest way to have this perfectly pliable cartilage have no dead space. The ultra diced cartilage grafting technique should be known by all plastic surgeons to achieve fineness in rhinoplasty. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Evaluation of Dislocation Risk Factors With Total Hip Arthroplasty in Developmental Hip Dysplasia Patients: A Multivariate Analysis.

BACKGROUND: This study aimed to investigate the risk factors for dislocation in patients diagnosed with developmental dysplasia of the hip (DDH) who underwent total hip arthroplasty. METHODS: We retrospectively reviewed 40 patients who developed dislocation and compared them with 400 patients in the control group without hip instability. Patients-, surgery-, and implant-related factors were investigated. Risk factors were evaluated using multivariate logistic regression. RESULTS: The mean follow-up period was 32.3 months. The mean time to dislocation was 4.4 months. There were 7 men (17.5%) and 33 women (82.5%) in the dislocation group and 83 men (20.7%) and 317 women (79.3%) in the control group (P = .627). Diabetes mellitus (DM; P = .032) and history of previous hip surgery for DDH were associated with dislocation (P < .001). The subtrochanteric shortening osteotomy (P = .001), acetabular inclination (P = .037), acetabular anteversion (P < .001), femoral head size (P < .001), and postoperative infection (P = .003) were associated with dislocation. Major predictors of hip dislocation after total hip arthroplasty in patients with DDH were previous hip surgery (odds ratio [OR], 6.76; 95% confidence interval [CI], 1.86-24.6; P = .004), high hip center (OR, 2.90; 95% CI, 1.31-6.38; P = .008), DM (OR, 2.68; 95% CI, 1.06-6.80; P = .037), and acetabular inclination (OR, 2.62; 95% CI, 1.09-6.26; P = .03). CONCLUSION: Patients with DM and previous hip surgery should be informed about increased dislocation rates. Using a larger head diameter and restoration of the true hip rotation center are essential to prevent hip dislocation in these patients. Furthermore, accurate positioning of the acetabular inclination and anteversion are also important.

Effectiveness of Using Photographs of the Change in Standing Posture on Postoperative Patient-Reported Satisfaction and Quality of Life.

Dissatisfaction is still an important problem in a small but important group of patients who undergo total knee arthroplasty. This study was designed to evaluate the effectiveness of showing patients the change in their standing posture, before and after total knee replacement, using standing photographs (anterior, posterior, and lateral view), on improving self-reported quality of life and satisfaction. Full-length lower extremity radiographs and standing photographs were obtained prior to total knee replacement and 6 months after surgery in the study group. In the control group, radiographs and photographs were not obtained. The hip-knee-ankle angle and mechanical axis deviation were compared between the two limbs and two groups. The changes in the following outcome measures were evaluated from baseline to 6 months after surgery: Short Form-36 Survey, Knee Injury and Osteoarthritis Outcome Score, Western Ontario and McMaster Universities Osteoarthritis Index, Oxford Knee Score, and Knee Society score. Postoperative measures were also compared before and after showing patients their standing photographs, and between two groups. The study and control groups included 71 and 44 patients, respectively, with unilateral or bilateral knee osteoarthritis (Kellgren-Lawrence Grade 3 or 4), with a mean age of 66 years. All patients had a varus malalignment, with significant improvement in postoperative limb alignment (p < 0.001). All self-reported outcome measures improved after surgery (p < 0.05), with the exception of mental health in the Short Form-36. Self-reported scores further improved after patients seeing their standing photographs (p < 0.05), with the exception of mental health and social role functioning. There were also significantly improved scores in the study group than control group after showing photographs (p < 0.05). Showing patients the pre-to-postoperative change in their standing posture might be an easy-to-administer method to improve patient satisfaction with the outcome of total knee replacement and self-reported quality of life. The Level of Evidence for this study is four.

Dynamic Video-Photograph Studio: A New Rhinoplasty Documentation.

BACKGROUND: Photographic documentation of the nose is the standard procedure for many surgeons who perform rhinoplasty across the world. One of the most challenging views in the photograph documentation is the frontal view that requires special photographic skills and may create a bias. Our dynamic video recording process allows us to improve the quality of patient evaluation, making the assessment more convenient and enabling the documentation of high-level rhinoplasty database. OBJECTIVES: Our main goal was to present our selected video recording process that ensures standardized, high-quality documentation of the data from rhinoplasty patients. As per our knowledge, this tool has not been published before. METHODS: We have invented a rotational platform-based chair that allows us to make a dynamic evaluation of the patients under standardized photograph settings (patient's position, camera, and lighting features) through a video recording. RESULTS: We demonstrated that the quality of our rotational video recording process is similar to that of standardized photographs. However, this additional dynamic evaluation helps to avoid Photoshop® corrections which may result in bias. CONCLUSIONS: This high-quality patient evaluation represents advancement in the photograph-documentation process in the modern era of rhinoplasty. This new dynamic video recording process prevents image misinterpretation, helps improve the quality of patient evaluations, makes the process more convenient, and enables the documentation of high-quality data for rhinoplasty patients. Moreover, this new recording process is an excellent tool for educational purposes and presentations. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Response to Commentary on: Dorsal Roof Technique for Dorsum Preservation in Rhinoplasty.

Rhinoplasty is a sophisticated surgery that needs high technical skills with knowledge. The DR technique is a refined technique to deal with the selected cases which are challenging for rhinology (wide dorsum, base and humpy nose). Still, so many things are unknown and one life span will be never enough to solve it. However, the author thinks that any solution fills the gaps, is the only thing we can improve the medicine. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

The Alignment of the Nose in Rhinoplasty: Fix Down Concept.

BACKGROUND: The current literature on rhinoplasty focuses mainly on the nasal profile (sagittal plane); however, the nose is a three-dimensional structure, and alignment of the nose in consideration of other aspects is important to achieve an aesthetic result. The author aimed to introduce the fix down concept, which includes fix down technique and the adjunct maneuvers for achieving alignment of the nose in three anatomical planes and improving the results of rhinoplasty in terms of symmetry. METHODS: Between March of 2017 and December of 2017, a total of 102 patients (78 women and 24 men), 13 revision and 89 primary cases, underwent septorhinoplasty with the fix down concept. The noses were evaluated in coronal, sagittal, and axial planes and classified according to their deformities. RESULTS: The functional and aesthetic results were satisfactory for the patients, examiners, and surgeon. No revisions were necessary during the follow-up period. In addition to the fix down technique, ethmoid bone grafting (16 patients), fix up technique (eight patients), dissection of the levator labii superioris alaeque nasi muscle (14 patients), plication of this muscle (four patients), superior-based transposition flap (39 patients), rim grafts (17 patients), mucosa grafts (12 patients), double-layer grafts (nine patients), maxillary deepening (five patients), maxillary augmentation with cartilage/bone grafts (21 patients), and supratip onlay grafts (seven patients) were used as adjunctive maneuvers to achieve symmetry in the frontal, base, and profile views. CONCLUSION: The presented fix down concept will help to provide three-dimensional symmetric noses for rhinosurgeons. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Dorsal Roof Technique for Dorsum Preservation in Rhinoplasty.

BACKGROUND: Management of the nasal dorsum is an important part of rhinoplasty. Hump removal results in the destruction of the internal valve and keystone area, which are reconstructed with either spreader flaps or grafts for aesthetic and functional reasons. OBJECTIVES: The goal of this work was to present the dorsal roof technique for both dorsum reduction and narrowing during rhinoplasty. METHODS: Fifty-two patients (35 females, 17 males) underwent septorhinoplasty surgery with the dorsal roof technique. During the follow-up period, all patients were photographed in the standard views. Photos were examined by two independent plastic surgeons. The pyramidal angles of the patients were measured with a protractor preoperatively and 1 year postoperatively. A rhinoplasty outcomes evaluation questionnaire was administered to all patients at the 1-year follow-up visit. Functional improvement was assessed utilizing self-evaluated nasal patency. The chi-square test was employed for statistical analyses. Data were evaluated retrospectively. RESULTS: Of the 52 patients, 44 completed the 1-year follow-up period and rhinoplasty outcomes evaluation questionnaire. During the follow-up period, no irregularity or residual hump was detected. Significant narrowing was achieved (P < 0.001). High patient satisfaction was achieved, and no functional or aesthetic complications were encountered. CONCLUSIONS: Whenever possible, the dorsal roof technique is preferred to resection or camouflage the dorsum. This technique allows treatment of the wide dorsum, wide nasal base, and dorsal hump without resection, thus maintaining the integrity of the dorsal bone-cartilage complex.

The Effects of Vibration and Pressure Treatments in the Early Postoperative Period of Rhinoplasty.

BACKGROUND: The early postoperative period can be distressing for the patients undergoing rhinoplasty since edema and ecchymosis are common complications. OBJECTIVES: To analyze the effects of the vibration and pressure treatments in the early postoperative period of rhinoplasty. METHODS: Sixty patients, who had undergone rhinoplasty, were randomized into 3 groups: group 1 (control group, n = 20) received classic nasal casting, group 2 (n = 20) received nasal cast with an elastic bandage to hold it on the face, and group 3 (n = 20) received vibration treatment in addition to that in group 2 following the rhinoplasty. They were evaluated preoperatively and postoperatively at 3 and 7 days in a prospective study. The postoperative edema and ecchymosis were scored by 2 independent surgeons. The postoperative pain was measured using the visual analog scale, and the necessity of anti-inflammatory medication (and the dose needed) and the cast comfort was questioned. The sebaceous activity of the nose skin was examined. A preoperative and postoperative seventh day sonographic study was performed to evaluate the tissue edema objectively. RESULTS: The pressure treatment decreased the edema and ecchymosis significantly compared with the control group. The vibration treatment minimized edema, ecchymosis, sebaceous activity of the nose skin, pain score, and the need for anti-inflammatory medication, and increased the cast comfort significantly compared with the other groups (P < 0.0001). CONCLUSIONS: Rapid regression of edema and ecchymosis may be achieved using the vibrating nasal cast technique that may minimize patient discomfort, pain, and sebaceous activity following rhinoplasty.

The effects of indoor and outdoor sports participation and seasonal changes on vitamin D levels in athletes.

OBJECTIVE: Nowadays, people tend to spend more time in the closed areas and benefit less from sunlight. In this study, we examined the results of vitamin D measurements of athletes from different disciplines in different months and aimed to determine if the synthesis of vitamin D decreases or not according to exercise environment and month. METHODS: The study was conducted in participants aged 5-52 years. A total of 555 elite-level sportsmen who were admitted to our Sports Medicine Clinic in the study participated in this study. Indoor and outdoor environmental and seasonal effects on the measurements in different months were statistically evaluated. Independent-samples test and definitive statistics were used for statistical analyses and a p-value less than 0.05 has been considered significant. RESULTS: The study group consisted of 229 male and 326 female athletes. The serum 25-hydroxyvitamin D concentration was observed; 120 (21.6%) athletes have severe serum vitamin D deficiency (<11-20 ng/mL). Vitamin D levels were not significantly different from outdoor athletes (393; 70.8%). Winter measurements of vitamin D levels were significantly lower than those measured in autumn (p = 0.000). CONCLUSION: Increasing vitamin D levels are very important especially in participating athletes and additional supplements are recommended whenever necessary. Gender and indoor/outdoor sports participation showed no statistically significant outcomes on vitamin D levels. However, winter season had a negative effect on vitamin D levels. Therefore, adequate precautions should be taken to increase vitamin D, especially during winter, to maintain the best performance of the athletes.

The incidence of biphalangeal fifth toe: Comparison of normal population and patients with foot deformity.

BACKGROUND: Pedal biphalangism, which was also defined as symphalangism, is seen at a frequency that cannot be ignored; however, no study can be found in the literature evaluating biphalangism in normal population in comparison to those who have foot disorders. The aim of this study was to evaluate the incidence of the pedal fifth toe symphalangism in normal population and in patients with foot deformity including hallux valgus, pes planus, pes cavus, and pes equinovarus. We hypothesized that pedal fifth toe symphalangism may be a predisposing factor or an accompanying structural variation for foot deformity. MATERIALS: Patients admitted to the emergency department of our center in October and November 2016 were defined as the control group, and patients with the diagnosis of hallux valgus, pes planus, pes cavus, and pes equinovarus treated between 2011 and 2016 in our department were defined as the foot deformity group. Individuals who had anteroposterior, oblique, and lateral radiographs of foot were included in the study. RESULTS: One thousand and four patients participated in the cross-sectional observational study. Biphalangeal fifth toe was found in 328 of 1004 (32.7%) patients. In foot deformity group ( n = 672), 222 patients (33%) had biphalangeal fifth toe. In the control group, 106 (31.9%) of the 332 patients had biphalangeal fifth toe. There was no statistically significant difference in the incidence of biphalangeal fifth toe between the two groups ( p = 0.72). CONCLUSIONS: According to the results of this study, biphalangeal fifth toe is a common pedal anatomical variant seen approximately in one-third of the population who have either foot deformity or not. This information may be valuable for podiatrist undertaking the conservative or surgical treatment of fifth toe-related disorders.

Lumbar spine posture and spinopelvic parameters change in various standing and sitting postures.

PURPOSE: This study aimed to compare differences in lumbosacral and spinopelvic parameters between pain developers and non-pain developers as well as the effects of various posture changes. METHODS: A total of 38 consecutive participants, 20 standing-induced low back pain developers (mean age: 27.7 ± 5.3; mean BMI: 22.64 ± 2.95) and 18 non-pain developers (mean age: 29.0 ± 7.5; mean BMI: 24.2 ± 1.87) (p > 0.05), were prospectively evaluated. Six sagittal plane radiographs were taken. Upright standing posture was used as the reference posture. Lumbar lordosis, lumbosacral lordosis, L1/L2 and L5/S1 intervertebral (IV) joint angles, pelvic incidence, pelvic tilt and sacral slope were measured on each radiograph. RESULTS: There were no significant differences in terms of age, BMI, SF-36 score, or Oswestry Disability Index scores between pain developer and non-pain developer groups (p > 0.05). Pain developers had significantly larger lumbar lordosis, larger L1/L2 intervertebral angles, larger pelvic incidences and sacral slopes in all postures (p < 0.05). The contribution of L5/S1 intervertebral angle to lumbar flexion was higher than that of the L1/L2 intervertebral angle during stair descent, the sitting and the leaning forward while sitting postures (p < 0.05). CONCLUSION: The current study supports the assertion that increased lumbar lordosis is associated with increased pain. Lumbar spine angles change in various postures. The changes were more prominent in pain developers than in non-pain developers. Larger lumbar lordosis due to larger pelvic incidence may be a risk factor for the development of standing-induced low back pain. These slides can be retrieved under Electronic Supplementary Material.

Superior-Based Transposition Flap: A Novel Technique in Rhinoplasty.

BACKGROUND: The cephalic trimming of the lower lateral cartilage (LLC) is an attempt to reduce tip bulbosity; unfortunately, it has the potential to cause a pinched nose deformity and valve collapse. OBJECTIVES: The author sought to use the superior-based transposition (ST) flap to reshape, relocalize, and reinforce the LLC as a support material for both internal and external valves with aesthetic corrections, leaving the scroll area untouched. METHODS: A total of 367 patients (female, 215; male, 152) were operated with the presented technique. The ST flap was simply used to prepare a cartilage flap based on the scroll area in the cephalic portion of the LLC, and then this flap was advanced over the remaining LLC. The data were evaluated retrospectively. RESULTS: Functionally, the ST flap was used to reshape and support the LLC and the internal valve by keeping the scroll intact and increasing the internal valve angle. The support and suspension of the LLC with this novel technique improve the functional results and prevent complications such as stenosis of both the external and internal valve angles. Aesthetically, the convexity and concavity of the LLC could be fixed with the adaptation of these two surfaces in different angles, thereby achieving a narrower, refined, and aesthetically pleasing tip. CONCLUSIONS: This study demonstrates that the ST flap can be one of the main maneuvers performed during rhinoplasty for many purposes, such as reshaping and supporting the LLC, increasing the tip rotation, achieving more aesthetically pleasing tips, suspending the internal and external valves, and protecting the scroll area.

The Use of Bone Dust to Correct the Open Roof Deformity in Rhinoplasty.

BACKGROUND: Hump removal frequently results in an open roof during rhinoplasty, which is conventionally closed with lateral osteotomies. However, if the patient has a narrow bony vault, lateral osteotomies are problematic. In this article, the author presents a new and practical approach to fix the open roof deformity. METHODS: A total of 240 patients (female, n = 187; male, n = 53) were enrolled and operated on with the presented technique. This approach has four steps, as follows: complete submembranous dissection, preparation of spreader flaps, harvesting of bone dust from the bony hump, and placement of the bone dust. The patient's nasal dorsum was evaluated by ultrasonography. During the follow-up period, all patients were photographed postoperatively from standard views using a digital camera. Photographs were inspected by two independent plastic surgeons. A palpation test for the nasal dorsum was conducted by a senior surgeon to identify any irregularities. A rhinoplasty outcomes evaluation questionnaire was administered to all patients at a 1-year follow-up visit. Functional improvement was assessed with self-evaluation of nasal patency. The chi-square test was used for statistical analysis. RESULTS: Of the 240 patients, 182 completed the 1-year follow-up period and rhinoplasty outcomes evaluation questionnaire. Thirty-seven patients were evaluated by ultrasonography at 1 year postoperatively. During the follow-up period, no resorption or displacement was detected. High patient satisfaction was achieved, and no complications were encountered. CONCLUSION: The presented four-step surgical concept was useful for rhinoplasty surgeons to successfully manage open roof deformity in selected patients.