Long-Term Results of Periacetabular Rotational Osteotomy Concomitantly With Arthroscopy in Adult Acetabular Dysplasia.

BACKGROUND: Although the long-term results of periacetabular osteotomy in acetabular dysplasia have been well documented, there is paucity in reports on the long-term outcomes of periacetabular osteotomy with simultaneous hip arthroscopy. This study aimed to assess the cumulative 10-year outcomes of periacetabular rotational osteotomy with concomitant hip arthroscopy. METHODS: Through an arthroscopic procedure, the status of the labrum was assessed, and torn labrum was debrided. Evaluations on survival from conversion to total hip arthroplasty and success in radiographic and clinical long-term results were completed in 39 hips (36 patients). Acetabular parameters (center-edge angle, Sharp angle, acetabular-head index, and head lateralization index), Tönnis grades on radiograph, Harris Hip Score, and range of motion of the hip were evaluated. Survivorship analyses were evaluated with the Kaplan-Meier method. RESULTS: Thirty-eight hips (97.4%, 95% confidence interval 0.832-0.996) were preserved for 12.8 ± 1.7 years on average, and only 1 hip was converted to total hip arthroplasty at 7.8 years. All the acetabular parameters were improved (P < .001). Twenty-eight hips (71.8%) showed unchanged or improved Tönnis grades at the latest follow-up. The average Harris Hip Score was significantly better than the preoperative value (P < .001), and range of motion was not significantly different until the latest follow-up. CONCLUSION: Sufficient acetabular reorientation, such as periacetabular rotational osteotomy, with concomitant arthroscopic debridement showed successful long-term outcomes for acetabular dysplasia in adults.

Navigation-assisted minimal invasive total knee arthroplasty in patients with extra-articular femoral deformity.

In the presence of extra-articular femoral deformity, total knee arthroplasty (TKA) is difficult to perform because of altered anatomical axis and distorted landmarks. Although minimal invasive surgery (MIS) has known advantage of earlier rehabilitation, MIS with this deformity may have higher incidence of component malposition due to inadequate exposure. Navigation has been shown to increase the accuracy of alignment and may compensate possible complication of MIS. We report 4 cases with extra-articular femoral deformity that underwent MIS-TKA using an image-free navigation system in which preoperatively planned mechanical alignment was surgically achieved with proper positioning of the implants as well as soft tissue balance. Navigation-assisted MIS-TKA may become a valuable mean especially for a patient with a deformed femur in which conventional instruments are difficult to use correctly.

Can We Predict Severity of Osteoarthritis of Knees and Compartmental Involvement Based on a Set of Predefined Clinical Questions in Patients of Knee Pain?

BACKGROUND: We investigated whether the severity of Osteoarthritis (OA) knees can be predicted based on a set of predefined clinical questions (PCQs) about activities of daily living (ADL). We studied the association of demographic factors and advanced radiographic OA (KL 3 and 4) and the relationship between various physical activities and radiographic involvement of knee joint compartments based on PCQs. MATERIALS AND METHODS: Demographic data, radiographic grading of knee OA and PCQs score, were obtained prospectively. Patients' responses to PCQs were marked as scores-that were predefined and graded according to the severity of knee pain. Radiographic knee OA grades were dichotomized and patients were classified as either negative (KL grade 1, 2) or positive (KL grade 3, 4). Multivariate logistic regression was performed to obtain the adjusted odds for total PCQs score in relation with positive radiographic OA considering confounders like age, gender and BMI in the model. Log odds score (LOS) were obtained and ROC analysis was performed on scores to obtain the cut-off value for the screening of knee OA in patients of knee pain. RESULTS: Age and BMI were significantly negatively correlated with PCQs score (r = - 0.473; P < 0.0001 and r = - 0.136; P = 0.046). PCQs scores were significantly lower in females (P = 0.031). Total PCQs score had corresponding OR of 0.901 (P = 0.002) towards knee OA after adjusting for age, gender and BMI. Multivariate model-based LOS resulted in a cut-off of 1.315, which had a sensitivity of 85.5%, specificity of 66.7% and PPV of 92.7%. CONCLUSION: Severity of knee OA can be predicted based on PCQs. PCQs can predict severity of knee OA and patellofemoral or medial tibiofemoral compartment without radiographs. LOS based on demographics and total PCQs score can be developed as a screening tool for advanced knee OA.

Deep vein thrombosis after total hip arthroplasty in Korean patients and D-dimer as a screening tool.

INTRODUCTION: This prospective study was designed to confirm risk factors and to assess the incidence of deep vein thrombosis after total hip and surface replacement arthroplasty in Korean patients not receiving anticoagulation prophylaxis and to determine efficacy of plasma D-dimer levels as a screening test. MATERIALS AND METHODS: From May 2003 to August 2004, 221 consecutive patients undergoing unilateral total hip arthroplasty and hip resurfacing were evaluated. All patients underwent ultrasonography preoperatively and venography and/or ultrasonography on postoperative day 7. Plasma D-dimer levels were estimated by latex immuno-assay preoperatively and on days 3 and 7 postoperatively. RESULTS: Of the 221 patients in our cohort, 23 developed deep vein thrombosis (10.4%). Age (r = 0.245, P < 0.001) and gender (r = 0.155, P = 0.021) significantly correlated with deep vein thrombosis. Rise in incidence paralleled increase in age (X(2) = 32.860, P < 0.001). D-dimer levels on postoperative days 3 (gamma = 0.364, P < 0.001) and 7 (gamma = 0.470, P < 0.001) were significantly correlated to the development of DVT. CONCLUSION: While incidence of deep vein thrombosis in Korean population after THA was lower than that in the West; it increased with age, and in female gender. Significant correlation was found between D-dimer levels and the development of deep vein thrombosis.

Total knee arthroplasty with computer-assisted navigation more closely replicates normal knee biomechanics than conventional surgery.

BACKGROUND: Computer-assisted navigation in total knee arthroplasty (TKA) reduces variability and may improve accuracy in the postoperative static alignment. The effect of navigation on alignment and biomechanics during more dynamic movements has not been investigated. METHODS: This study compared knee biomechanics during level walking of 121 participants: 39 with conventional TKA, 42 with computer-assisted navigation TKA and 40 unimpaired control participants. RESULTS: Standing lower-limb alignment was significantly closer to ideal in participants with navigation TKA. During gait, when differences in walking speed were accounted for, participants with conventional TKA had less knee flexion during stance and swing than controls (P<0.01), but there were no differences between participants with navigation TKA and controls for the same variables. Both groups of participants with TKA had lower knee adduction moments than controls (P<0.01). CONCLUSIONS: In summary, there were fewer differences in the biomechanics of computer-assisted navigation TKA patients compared to controls than for patients with conventional TKA. Computer-assisted navigation TKA may restore biomechanics during walking that are closer to normal than conventional TKA.

Long-term Results of a First-Generation Annealed Highly Cross-Linked Polyethylene in Young, Active Patients.

The survivorship of total hip arthroplasty in younger patients is dependent on the wear characteristics of the bearing surfaces. Long-term results with conventional polyethylene in young patients show a high failure rate. This study assessed the long-term results of a first-generation annealed highly cross-linked polyethylene (HCLPE) in uncemented total hip arthroplasty in young, active patients. Between 1999 and 2003, 112 total hip arthroplasty procedures performed in 91 patients with an average University of California Los Angeles activity score of 8 and mean age of 53 years (range, 24-65 years) were included from a prospective database. In all patients, a 28-mm metal femoral head on annealed HCLPE (Crossfire; Stryker, Mahwah, New Jersey) was used. At minimum 10-year follow-up (11.5±0.94 years), Kaplan-Meier survivorship was 97% for all failures (1 periprosthetic infection and 1 late dislocation) and 100% for mechanical failure (no revisions for osteolysis or loosening). This study showed low revision rates for wear-related failure and superior survivorship in young, active patients. Oxidation causing failure of the locking mechanism has not been a problem with Crossfire for up to 10 years.

Experimental evaluation of fiber orientation based material properties of skeletal muscle in tension.

Biomechanical researches are essential to develop new techniques to improve the clinical relevance. Skeletal muscle generates the force which results in the motion of human body, so it is essential to study the mechanical and structural properties of skeletal muscle. Many researchers have carried out mechanical study of skeletal muscle with in-vivo testing. This work aims to examine anisotropic mechanical behavior of skeletal muscle with in vitro test (tensile test). It is important to understand the mechanical and structural behavior of skeletal muscle when it is subjected to external loading; the research aims to determine the structural properties of skeletal muscle by tensile.testing. Tensile testing is performed on 5 samples of skeletal muscle of a goat at the rate of 1 mm/min with fiber orientation along the length and 45 degrees inclined to the length. It is found that muscle is stiffer in the direction parallel to the muscle fiber than at 45 degrees to the muscle fibers. The tensile strength of the skeletal muscle along the fiber direction is 0.44 MPa at maximum load of 110 N and for direction 45 degrees inclined to the muscle fibers, the strength is 0.234 MPa at max load 43 N. The displacement of Muscle sample against the maximum load is small along the length of the muscle fiber i.e. under longitudinal elongation [15.257 mm] as compared to 45 degrees inclined to the length of skeletal muscle [17.775 mm] and under cross fiber elongation [19.7291 mm by FEA]. The testing is not performed for 90 degrees fiber orientation due to unavailability of soft tissue in cross fiber direction of the required specification, but finite element analysis is done on the skeletal muscle for the cross fiber orientation. As the fiber orientation within skeletal muscle differs with respect to the length of the muscle, the stiffness of skeletal muscle is also changing effectively. Hence skeletal muscle exhibits the anisotropic mechanical behavior.

Corrective tibial osteotomy in young adults using an intramedullary nail.

PURPOSE: The purpose of this study was to document results of a less invasive technique of open wedge proximal tibial osteotomy (PTO) for the varus knee in young adults using an intramedullary tibial nail. MATERIALS AND METHODS: We prospectively studied 24 knees in 16 young patients with varus knee deformity. The mean follow-up was 54 months (range, 36 to 107 months) and the mean age of patients at the time of operation was 25.8 years (range, 18 to 40 years). The open wedge PTO was performed below tibial tuberosity using a percutaneous multiple drill-hole technique. Conventional intramedullary tibial nail was used for fixation without bone graft. Radiographic evaluations were made using mechanical alignment (MA), posterior tibial slope angle, and Insall-Salvati ratio. Union time, loss of correction, implant failure, and associated complications were also investigated. RESULTS: The mean MA was significantly changed from -9.7° preoperatively to 1.1° at the final follow-up (p<0.001). There was no significant change in the proximal tibial anatomy and patellar height. All patients achieved radiographic bony union at an average of 3.1 months without loss of correction. The only complication was knee pain due to nail prominence in 3 patients. CONCLUSIONS: Radiographic evaluation indicated that PTO using an intramedullary tibial nail leads to significant improvement in radiographic parameters without changes in posterior tibial slope or patellar height. We found that this technique could be a less invasive and effective alternative for correction of the varus knee in young adults.

Valgus intertrochanteric osteotomy and fibular strut graft in the management of neglected femoral neck fracture.

PURPOSE: A prospective study of neglected femoral neck fractures in mostly young patients was conducted to evaluate whether our technique of valgus intertrochanteric osteotomy with fibular strut grafting and osteosynthesis with dynamic hip screw and double-angle side plate can facilitate union with consistent satisfactory clinical outcomes. METHODS: Forty-one consecutive patients (27 males, 14 females) of neglected femoral neck fractures treated between April 2002 and December 2009 were studied. The average age of patients was 45.41 years (±11.67, range 20-62 years). The average interval since injury was 14 weeks (±10.21, range 4-44 weeks). The cases were evaluated radiographically and clinically. RESULTS: The average follow-up period was 32.5 months (±8, range 24-54 months). Radiographically union was seen in 39 patients at the nonunion site. The average time to radiographic union was 16.82 weeks (±3 weeks, range 12-24 weeks). Average Harris Hip Score (HHS) was 19.9 (±7.9, range 10-35) preoperatively and 90.9 (±10.35, range 62-100) at the latest follow-up. At that time clinical outcomes were excellent in 31, good in four, fair in three and poor in three patients. CONCLUSION: Our mechanobiological surgical technique is reproducible with radiographic union achieved in 95.12% cases (39 patients) at the nonunion site and consistent excellent or good functional outcome in 85% of patients over a 32-month average follow-up. We recommend this procedure for neglected femoral neck fractures.

Long proximal femoral nail in ipsilateral fractures proximal femur and shaft of femur.

BACKGROUND: Ipsilateral fractures of the proximal femur and femoral shaft are extremely uncommon injuries which occur in young adults who sustain a high energy trauma. A variety of management modalities have been tried to treat this complex fracture pattern ranging from conservative approach to recently introduced reconstruction nails. All these approaches have their own difficulties. We studied the outcome of long proximal femoral nail (LPFN) in the management of concomitant ipsilateral fracture of the proximal femur and femoral shaft. MATERIALS AND METHODS: We analysed the prospective data of 36 consecutive patients who had sustained a high energy trauma (30 closed fractures and 6 open shaft fractures) who had concomitant ipsilateral fractures of the femoral shaft associated with proximal femur fractures treated with LPFN between December 2005 and December 2011. The mean age was 39 years (range 28-64 years). Twenty nine males and seven females were enrolled for this study. RESULTS: The patients were followed up at three, six, twelve, and eighteen months. The mean healing time for the neck fractures was 4.8 months and for the shaft fractures was 6.2 months. The greater trochanter was splintered and widened in two cases which eventually consolidated. Two patients had superficial infection, two patients had lateral migration of the screws with coxa vara which was due to severe osteoporosis detected during the followup. We had two cases of nonunion of shaft fracture and one case of nonunion of neck fracture. Two cases of avascular necrosis of femoral head were detected after 2 years of followup. No cases of implant failure were noted. Limb shortening of less than 2 cms was noted in four of our patients. The functional assessment system of Friedman and Wyman was used for evaluating the results. In our series 59.9% (n = 23) were rated as good, 30.6% (n = 11) as fair, and 5.5% (n = 2) as poor. CONCLUSION: Long PFN is a reliable option for concomitant ipsilateral diaphyseal and proximal femur fractures.

Comparative evaluation of human placental extract for its healing potential in surgical wounds after orthopaedic surgery: an open, randomised, comparative study.

The study was conducted to compare the efficacy and safety of topical application of purified extract of human placenta (placentrex gel) versus povidone iodine for its wound healing potential after orthopaedic surgeries. In this open, comparative, randomised study, 79 patients above 18 years of age undergoing elective clean and uncontaminated orthopaedic surgery (open fracture reduction, spine surgery and debridement of wound) were enrolled in the study after obtaining written informed consent. Enrolled patients were randomised as per the PC generated randomisation chart (Rando 1.2, 2004) to receive either topical application of human placenta purified extract (PE) on the surgical wound or topical application of povidone iodine (PI) ointment on the surgical wound. Both preparations were applied topically on the surgical wound after the surgery, on days 3, 7 and on day 10, if required. Assessment of surgical wound was done after recovery from anaesthesia and on days 3, 7 and 10 based upon wound healing, physicians' global assessment of response to therapy (PGART) scale, pain and adverse effects. All 79 patients (40 PE and 39 PI) completed the study on day 10 as per the study protocol. Healing of the wound was observed in all patients. The number of patients reporting pain on days 3, 7 and 10 were similar in both PE and PI treatment (p, 0.527) groups. Wound induration was observed in 6 patients (15.00%) of PE and 15 (38.46%) of PI on day 7 (p, 0.041). None of the patients reported any side/adverse events during the study period. Purified placental extract and povidone iodine have comparative wound healing effects.

Comparative evaluation of human placental extract for its healing potential in surgical wounds after orthopaedic surgery: an open, randomised, comparative study.

The study was conducted to compare the efficacy and safety of topical application of purified extract of human placenta (placentrex gel) versus povidone iodine for its wound healing potential after orthopaedic surgeries. In this open, comparative, randomised study, 79 patients above 18 years of age undergoing elective clean and uncontaminated orthopaedic surgery (open fracture reduction, spine surgery and debridement of wound) were enrolled in the study after obtaining written informed consent. Enrolled patients were randomised as per the PC generated randomisation chart (Rando 1.2, 2004) to receive either topical application of human placenta purified extract (PE) on the surgical wound or topical application of povidone iodine (PI) ointment on the surgical wound. Both preparations were applied topically on the surgical wound after the surgery, on days 3, 7 and on day 10, if required. Assessment of surgical wound was done after recovery from anaesthesia and on days 3, 7 and 10 based upon wound healing, physicians' global assessment of response to therapy (PGART) scale, pain and adverse effects. All 79 patients (40 PE and 39 PI) completed the study on day 10 as per the study protocol. Healing of the wound was observed in all patients. The number of patients reporting pain on days 3, 7 and 10 were similar in both PE and PI treatment (p, 0.527) groups. Wound induration was observed in 6 patients (15.00%) of PE and 15 (38.46%) of PI on day 7 (p, 0.041). None of the patients reported any side/adverse events during the study period. Purified placental extract and povidone iodine have comparative wound healing effects.