Is Mediolateral Translation of Femur Caused by Total Knee Arthroplasty Being Ignored?

Purpose: This study aims to show the change in overall congruency due to mediolateral translation after total knee arthroplasty compared with normal knee anatomy. Methods: This study was performed in two parts. In part 1, the relationship between femur and tibia was defined by new parameters on the antero-posterior radiographs of 84 patients. In part 2, this relationship was evaluated on the postoperative radiographs of 136 total knee arthroplasty patients. Two parallel lines to the tibial anatomical axis were drawn tangent to the most lateral and most medial parts of the tibial plateau. After creating medial and lateral tangential lines, the distance between the most lateral point of the lateral femoral epicondyle and lateral tangential line and the most medial point of the medial femoral epicondyle and medial tangential line was measured. Another new parameter described in the study is epicondylar distance ratio. The ratios between the shortest distance between tibial anatomical axis and lateral femoral epicondyle and the distance between tibial anatomical axis and medial femoral epicondyle were defined. Results: It was found that the lateral tangent was not superposed in any measurement to the femoral lateral condyle, the closest tangent was passed, and the mean lateral space distance was 1.8 mm (SD 1.5, 95% CI 0-5.3 mm). The medial tangent was passed from the lateral to the femoral medial epicondyle, and the medial crossing distance was 8.5 mm (SD 5.7, 95% CI 5-14 mm). Epicondylar distance ratio used as the second measurement was 0.8 (0.5-0.9). After total knee arthroplasty measurements showed that the line passing through the lateral tibia crossed the lateral epicondyle of the femur and intersected at an average distance of 4.3 mm (SD 4.1, 95% CI 1-11.2 mm). Conclusions: There is a coronal plane congruence between tibia and femur in the healthy knees, which get changed after total knee arthroplasty.

[The evaluation and management of rotational deformity in cerebral palsy]. / Beyin felcinde rotasyonel deformitenin degerlendirilmesi ve tedavisi.

Rotational deformities are common lower extremity abnormalities in children with cerebral palsy, which include intoeing and outtoeing. Intoeing is caused by one of the three types of deformity: increased femoral anteversion, internal tibial torsion, and metatarsus varus, while out-toeing, the less common form, is caused by femoral retroversion and external tibial torsion. An accurate diagnosis should be made with careful physical and radiographic examination.

Non-traumatic Ceramic Head Fracture in Total Hip Arthroplasty with Ceramic-on-Ceramic Articulation at Postoperative 16th Years.

Ceramic articulation has gained popularity in total hip arthroplasty (THA); however, one of the most important concerns about the use of ceramic materials is the potential for breakage. Importantly, almost all ceramic fractures occur within the first six years after surgery. Here, we present a case report of a 52-year-old female patient who experienced an atraumatic ceramic head fracture at the 16th year after surgery. Key parameters that may be associated with ceramic head fracture are considered to be the use of a 28-mm head and high body mass index (BMI); the patient described here had a BMI of 34.3 kg/m2. Surgical treatment of the case included removal of the broken ceramic head and replacement with an alumina matrix composite ceramic head. At the 12th month follow-up visit, the patient was mobilized independently and could perform her daily activities. Ceramic head fracture after THA may occur even in late periods after surgery. For the treatment of fractures of ceramic material, the fractured component must be removed together with extensive soft tissue excision to ensure that no residual fragments are left behind.

Arthroscopic excision of an ununited ossicle due to Osgood-Schlatter disease.

Surgical excision of the ossicles has been suggested for unresolved sequelae of Osgood-Schlatter disease in adults resistant to conservative measures. A 24-year-old, male semiprofessional soccer player had anterior knee pain during sports activity and climbing stairs that had been treated conservatively for 2 years. On physical examination, there was a permanent tibial tubercle with pain. On radiographic examination, an ununited ossicle was seen beneath the patellar tendon. Arthroscopy was performed through the standard low anterolateral and anteromedial portals close to the patellar tendon. Soft tissue at the retropatellar surface and the inflamed infrapatellar fat pad beneath the patellar tendon were debrided with a motorized shaver. Localization of the ununited ossicle was performed by use of an image intensifier. The ossicle was separated from the surrounding soft tissue with a motorized shaver and removed by use of a grasper. After excision of the ossicle, the inflamed surface of the retropatellar tendon was also debrided. The contouring of the irregular surface of the tibial tubercle was performed by use of a motorized bur. After 6 weeks, the patient returned to sports activities without any restrictions. This study showed that all of the described procedures might be done arthroscopically and sports activity may be allowed earlier.

Intraoperative dislocation of the prosthetic femoral head into the pelvis during total hip arthroplasty.

An 86-year-old woman with severe osteoarthritis and severe pain in her left hip underwent total hip arthroplasty. Intraoperatively, the 22 mm femoral head impinged on the anterior rim of the acetabulum during a reduction maneuver, and disengagement of the femoral head from the neck occurred with migration of the head over the pelvic brim along the inner table of the pelvis. This complication related with hip arthroplasty is underestimated by many orthopaedic surgeons.

[Venous thromboembolism prophylaxis in major orthopaedic surgery: A multicenter, prospective, observational study]. / Majör ortopedik cerrahilerde venöz tromboemboli profilaksisi: Cokmerkezli, prospektif, gözlem çalismasi.

OBJECTIVES: We investigated risk factors for venous thromboembolism (VTE), prophylaxis measures employed, and incidence of symptomatic deep venous thrombosis (DVT) and pulmonary embolism (PE) in patients undergoing major orthopaedic surgery (MOS). METHODS: An open, multicenter, prospective, observational study was conducted in 21 medical centers, comprising 899 patients. Of these, 316 patients (35.2%) underwent total hip arthroplasty (THA), 328 patients (36.5%) underwent total knee arthroplasty (TKA), and 255 patients (28.4%) underwent surgery for hip fractures (HF). Pharmacologic prophylaxis was employed in all the patients. RESULTS: Risk factors for VTE were seen in 73.2% of the patients, the most common being obesity (72%) and prolonged immobilization (36.3%). Low-molecular-weight heparin (91.1%) and fondaparinux (8.9%) were used for prophylaxis, which was short-term in 273 patients (30.4%) and long-term in 626 patients (69.6%). Mechanical prophylaxis was performed with compression stockings in 610 patients (67.9%) and by intermittent pneumatic compression in 67 patients (7.5%). During three-months of follow-up, symptomatic DVT and PE were seen in eight (0.9%) and four patients (0.4%), respectively. Mortality occurred in 10 patients (1.1%). Complications of major and minor bleeding were seen in eight (0.9%) and 40 (4.5%) patients, respectively. CONCLUSION: Effective VTE prophylaxis is associated with low risk of clinically apparent DVT and PE in MOS.

Early tunnel enlargement after arthroscopic ACL reconstructions.

The aim of this study was to evaluate the tunnel enlargement phenomenon after ACL reconstructions performed with hamstrings tendons fixed using the cross pin technique. Sixty-two knees in 62 patients were followed for two years to evaluate the possible clinical implications of the femoral and tibial tunnel enlargements noted after ACL reconstruction. The reconstructions were done with hamstring tendons using the cross-pin technique. Evaluation was based on calculated clinical scores (IKDC and Lysholm knee scores) and quantified by KT-1000 measurements. Sagittal and coronal plane computed tomography and conventional radiography were performed 3 days after operation and were repeated after 3 and 6 weeks, 6, 12 and 24 months, to assess early tunnel enlargement. Although it seems that tunnel enlargement after ACL reconstruction has no impact on the clinical results, long-term implications and potential need for revision surgery must be assessed. In this study, tunnel enlargement was noted fairly early after operation and was thought to be related with drilling of the tunnels. A possible solution to this problem may be drilling the tunnels to a diameter 1 mm smaller than the measured graft diameter, then to enlarge the tunnels to the graft diameter with the appropriate tunnel dilator.

[The use of arthroscopic debridement and viscosupplementation in knee osteoarthritis]. / Gonartrozda artroskopik debridman ve viskosuplementasyonun yeri.

OBJECTIVES: We investigated the effectiveness of arthroscopic debridement followed by viscosupplementation using different hyaluronic acid (HA) products in selected patients with knee osteoarthritis. METHODS: The study included 77 women (mean age 50+/-5 years; range 40 to 60 years) who had mild knee osteoarthritis according to the modified ARA (American Rheumatism Association) criteria and Ahlback classification. All the patients had degenerative meniscal tears. After three weeks from arthroscopic treatment (partial meniscectomy and debridement), the patients were randomly assigned to intra-articular injections of Na-hyaluronate (Orthovisc, n=38), streptococcal HA (Adant, n=21), and Hylan G-F 20 (Synvisc, n=18) given once a week for three weeks. Evaluations were made preoperatively, before and three weeks after injections using a patient satisfaction questionnaire, visual analog scale (VAS), and the WOMAC (Western Ontario and McMaster Universities) osteoarthritis index. RESULTS: All patients had significant improvement following both arthroscopic treatment and viscosupplementation (p<0.0001). Following injections, patient satisfaction (p<0.01), WOMAC and VAS (p<0.0001) scores were significantly improved in the Na-hyaluronate and Hylan G-F 20 groups, whereas the only significant change was in VAS scores in the streptococcal HA group. However, comparison of the three groups did not yield any significant difference with respect to patient satisfaction, WOMAC, and VAS scores (p>0.05). CONCLUSION: Our results suggest that arthroscopic debridement combined with viscosupplementation is an effective treatment option for selected patients with knee osteoarthritis.

[The effect of risedronate treatment on bone turnover markers in patients with hip fracture]. / Kalça kiriklarinda risedronat tedavisinin kemik yikim ürünlerine etkisi.

OBJECTIVES: The effect of risedronate treatment on bone resorption was investigated quantitatively by measuring N-telopeptide levels in urine of patients with hip fracture. METHODS: Forty-six women (mean age 75 years) who underwent surgical treatment for intertrochanteric or femoral neck fractures due to minor trauma were divided into two groups according to the order of presentation. One group (26 patients; mean age 77+/-5 years) received oral risedronate 5 mg/day after the fifth postoperative day, while the other group (20 patients; mean age 73+/-6 years) received no drug treatment. Patients who had been on treatment for Paget's disease or osteoporosis or those with renal failure were excluded. Urine samples were collected from all the patients on the second day of hospitalization and at the end of three months to measure N-telopeptide levels, one of the bone turnover markers, with the use of the Osteomark NTx ELISA laboratory kit. RESULTS: The mean urine N-telopeptide level decreased by 49.7% at the end of three months of treatment with risedronate (p<0.0001), whereas there was a 5.8% increase in the N-telopeptide level of the control group. The two groups differed significantly with respect to the levels of bone resorption at the end of three months (p<0.0001). CONCLUSION: Risedronate treatment was found effective in decreasing bone resorption and thus in reducing the risk for refractures in patients with hip fractures due to minor trauma.

The effects of intra-articular levobupivacain versus levobupivacain plus magnesium sulfate on postoperative analgesia in patients undergoing arthroscopic meniscectomy: A prospective randomized controlled study.

OBJECTIVE: The aim of this study was to compared the effectiveness of intraarticular levobupivacain with levobupivacain and magnesium sulfate. METHODS: In this prospective randomized double blinded study, 96 patients (67 male, 29 female; age range: 18-65 years) with ASA (American Society of Anesthesiologist) score I and II, who had undergone arthroscopic meniscectomy operation, were divided to 3 groups that had postoperative analgesia with intra-articular saline injection (control group), levobupivacain injection (L group) or levobupivacain and magnesium sulfate injection (LM group). Patients were compared with postoperative VAS (Visual Analog Score) score during rest and activity, opioid analgesic need, non-opioid analgesic need and other medication needs. RESULTS: Postoperative VAS scores during rest and activation at early postoperative period were significantly lower at LM group when compared with L group and lower than control group at all time periods. Opioid analgesic need, non-opioid analgesic need and other medication needs for non-pain symptoms were lower at LM group when compared with L and control groups at all time periods. CONCLUSION: Intraarticular magnesium sulfate plus Levobupivacain injection is a safe and effective method for post operative pain management after arthroscopic meniscectomy.

Pedobarographic Analysis in Total Knee Arthroplasty.

Pedobarographic gait analysis is a useful tool for the determination of loading distributions and alterations on the lower extremity and their reflection on the foot sole after many orthopaedic surgical applications. To date, there have been no studies evaluating the relationship between component alignment and changes of pedobarographic gait analysis in total knee arthroplasty (TKA). We aimed to investigate the effects of TKA and prosthetic alignment on the distribution of pedobarographic parameters. Quantitative gait patterns of 47 patients were prospectively evaluated by using pedobarography 1 week before surgery and at the seventh month, on average, postoperatively. Component positions were assessed, and all applications were divided into three groups according to tibial component position as varus, neutral, and valgus. Pedobarographic results were compared between pre- and postoperative values for all applications and compared among the groups. Mean postoperative tibiofemoral angle was 5.4 degrees in valgus, and preoperative knee scores were markedly improved postoperatively. The range of tibial component alignment changed between 1 and 4 degrees in the varus and valgus groups. Plantar loading parameters (force and pressure) were significantly decreased in all operated knees, especially in forefoot and midfoot. In varus tibial components, plantar loading values decreased in midfoot and hindfoot. However, in the neutral and valgus groups, similar alterations of plantar loadings were obtained, which included decreasing in forefoot and midfoot with significant increase in hindfoot. Plantar loading distribution changed statistically significantly after TKA despite good clinical and radiographic results. Tibial component alignment was also responsible for plantar loading distribution. Tibial components in varus position create different foot loading characteristics compared with neutral and valgus aligned components. Pedobarographic evaluation in TKA allows clinicians to obtain a proper understanding of abnormal gait caused by component malposition.

Modified Grice-Green subtalar arthrodesis performed using a partial fibular graft yields satisfactory results in patients with cerebral palsy.

The aim of this study was to report the experience with the use of a modified Grice-Green technique, which was performed using a partial subperiosteal fibular bone graft because of valgus unstable foot in children with cerebral palsy. Fifteen feet of 11 patients were evaluated on the basis of the appearance of the feet, clinical symptoms, and radiographic measurements. After an average follow-up duration of 24 (9-39) months, all feet showed satisfactory clinical and radiological results. Solid fusion and sustained correction took place in all feet. The gap at the donor site was bridged with new bone in all cases. No donor-site morbidity was detected. This modification of the Grice-Green technique can be used effectively in the correction of planovalgus foot in cerebral palsy.

[Comparison between the lateral and medial approaches in terms of functional and cosmetic results in the surgical treatment of type III supracondylar humeral fractures in children]. / Cocuklarda suprakondiler humerus tip III kiriklarin tedavisinde lateral ve medial girisimler ile cerrahi tedavi sonuçlarinin fonksiyonel ve kozmetik açidan karsilastirilmasi.

OBJECTIVES: We compared the functional and cosmetic results of lateral and medial approaches in the surgical treatment of type III supracondylar humeral fractures in children. METHODS: The study included two groups in which type III supracondylar humeral fractures were treated using either lateral (12 boys, 8 girls; mean age 7.2 years; range 4 to 12 years) or medial (16 boys, 4 girls; mean age 7.4 years; range 3 to 11 years) approaches and internal fixation. Functional and cosmetic results were assessed according to the criteria proposed by Flynn et al. The mean follow-up periods were 19.8 months (range 8 to 30 months) and 19.5 months (range 12 to 27 months) in the lateral and medial approach groups, respectively. Patient satisfaction was also inquired regarding the site of the incision scar. RESULTS: In the lateral approach group, functional results were excellent in 18 patients (90%), good in one patient (5%), and fair in one patient, while cosmetic results were excellent in 19 patients (95%) and good in one patient. In the medial approach group, 19 patients (95%) had excellent and one patient (5%) had good functional results, while all the patients had an excellent cosmetic result (p>0.05). Complications were seen only in the lateral approach group, including transient ulnar nerve palsy in one patient, and cubitus varus deformity due to limited range of motion in another. The satisfaction rates concerning the site of the incision scar were 25% and 70% in the lateral and medial approach groups, respectively. CONCLUSION: Although no significant differences were found between the lateral and medial approaches in terms of functional and cosmetic results, the medial approach may be more convenient due to a lower risk for ulnar nerve injury and to a greater acceptability of the medial incision scar on the part of the patients.

Comparison of switch-therapy modalities (enoxaparin to rivaroxaban/dabigatran) and enoxaparin monotherapy after hip and knee replacement.

OBJECTIVE: Prevention of deep venous thrombosis (DVT) and associated pulmonary embolism following major orthopedic surgeries is challenging, and there is an increased interest in developing new treatment strategies. We compared 2 switch-therapy modalities-enoxaparin to rivaroxaban and enoxaparin to dabigatran-and enoxaparin monotherapy for preventing DVT after total knee arthroplasty (TKA) and total hip arthroplasty (THA). METHODS: This was a prospective, non-blinded, randomized controlled study. We selected 180 eligible patients out of 247 patients undergoing TKA or THA. During the preoperative checkup, patients were randomized to receive either enoxaparin (enoxaparin group) or switch-therapy regimens, comprising enoxaparin during hospitalization and rivaroxaban (rivaroxaban group) or dabigatran (dabigatran group) during the outpatient period. All patients were evaluated for DVT using Doppler ultrasonography (USG) 6 weeks postoperatively. The primary efficacy outcome was the prevention of symptomatic or Doppler ultrasonography (USG)-proven DVT, whereas the primary safety outcome was the incidence of bleeding during the DVT-prophylaxis period. RESULTS: Doppler USG at 6 weeks after surgery revealed no signs of DVT in any patient. During the hospitalization period, only 2 major bleeding events were reported (1 [1.6%] in the enoxaparin group and 1 [1.6%] in the dabigatran group). No major bleeding events were reported during the outpatient follow-up period in any group. Differences among the 3 groups regarding bleeding events were not statistically significant (p>0.05). CONCLUSION: When using switch-therapy modalities, clinicians can take advantage of the safety of enoxaparin during the hospitalization period and ease of use of new oral anticoagulant drugs during the outpatient period.

A new capsuloplasty technique in open reduction of developmental dislocation of the hip.

A meticulous capsuloplasty is needed to maintain concentric reduction in the surgical treatment of developmental dysplasia of the hip (DDH). The authors present a new capsuloplasty technique that was named as 'reverse U-shaped capsuloplasty'. It was performed in 72 dislocated hips of 62 children with a mean age of 2.7 years. The reverse U-shaped flap, created in the redundant superolateral capsule was turned downwards, advanced medially, anteriorly and inferiorly and brought over the anteroinferior capsular incision. After a mean follow-up period of 3 years there was neither redislocation nor restriction of the hip joint motion in any hips.

Solitary cystic tuberculosis of long tubular bones in children.

Five children (mean age 3.4 years) with solitary cystic tuberculosis of proximal femur or proximal tibia were treated by surgical debridement and curettage combined with anti-tuberculosis anti-biotherapy. The mean follow-up period was 4.3 years and clinical and radiological healing was observed in all cases. It was concluded that solitary cystic tuberculosis of long tubular bones, which was a rare manifestation in children, should be kept in mind especially for metaphyseal lesions in the lower limbs and should be differentiated from several osseous lesions including infections and bone tumours.

Missed isolated posterior malleolar fractures.

OBJECTIVE: The aim of this study was to evaluate the injury mechanism and clinical and radiological results of the patients with isolated posterior malleolar fracture. METHODS: Seven patients (5 male, 2 female; mean age: 32 years; range: 23-40) with a missed isolated posterior malleolar fracture were included in the study. All patients had initially been examined for an ankle sprain in the emergency room, where the initial plain radiographs did not show any abnormality. Due to the long lasting symptoms all patients underwent an MRI scan by the 3rd week which revealed a posterior malleolar fracture. Patients were treated with an ankle brace for 3 weeks. All patients were followed up for 1 year. Bone healing and degenerative changes were evaluated with plain Radiographs, including a 50° external rotation lateral. Clinical outcome was evaluated with American Orthopedic Foot and Ankle Society ankle hindfoot scale. RESULTS: Fracture healing was seen in 6 of the 7 patients by the 6th week. There was no radiographic healing by 6th month in the remaining patient. Mean AOFAS ankle hindfoot scores at the beginning of the treatment and at 3rd month were 20 (11-31) and 86 (43-96), respectively. There was no instability or degenerative changes at one-year follow-up. CONCLUSION: Isolated posterior malleolar fracture should be kept in mind in patients who present with pain at the posterior part of the ankle following a forced plantar flexion and/or axial compression injury. A 50° external rotation lateral radiograph can be useful in detecting the fracture.

An atypically located large subchondral cyst in an osteoarthritic hip joint: a case report.

INTRODUCTION: Osteoarthritic subchondral cysts within or around the hip joint can sometimes be difficult to distinguish from primary osseous and soft tissue tumors due to their radiological appearance and uncommon location. CASE PRESENTATION: We report the case of a 74-year-old Turkish man with a subchondral cyst arising from the hip joint, eroding the acetabulum and located on the medial side of the iliac bone, which imitated a soft tissue tumor. This cystic lesion was resected and the results of histopathological analysis of tissue samples were found to be consistent with an osteoarthritic cyst. CONCLUSIONS: The present case illustrates how an osteoarthritic subchondral cyst can grow into the soft tissue planes in the presence of destruction of the articular cartilage and subchondral bone continuity, and present as an apparent soft tissue tumor.

Deep venous thrombosis and pulmonary embolism as rare complications after hallux valgus surgery: case report and literature review.

The incidence and life-threatening complications of thromboembolic disease after major orthopedic surgical procedures have been extensively defined in the medical literature. However, there are few studies concerning the incidence of thromboembolic disease after foot and ankle surgery. We describe a 57-year-old female patient who underwent surgery for bilateral hallux valgus deformities and was diagnosed as having deep venous thrombosis and pulmonary embolism after the surgery despite early mobilization and mechanical prohylaxis. Her preoperative physical examination revealed varicose veins in both cruris. She was treated for pulmonary embolism with low-molecular-weight heparin and an oral anticoagulant in the postoperative period. Although venous thromboembolism is more commonly described after proximal lower-extremity procedures, it can occur after foot and ankle surgery, particularly if the patient has certain risk factors. Therefore, in addition to mechanical prophylaxis, pharmacologic prophylaxis should be kept in mind in such patients.