Unilateral versus simultaneous bilateral total knee arthroplasty: A comparative study.

OBJECTIVE: To compare pre-operative characteristics and peri-operative findings in patients undergoing unilateral total knee arthroplasty (UTKA) and simultaneous bilateral total knee arthroplasty (BTKA). To work out safety criterion for selection of patients for simultaneous BTKA. METHODS: Patients undergoing UTKA (39) and BTKA (36) in Department of Orthopaedic Surgery, Combined Military Hospital, Rawalpindi from March 2014 to August 2014 were compared in terms of patient characteristics, underlying pathology, peri-operative blood loss, transfusion requirements and in hospital complications. RESULTS: The mean age of patients undergoing UTKA was 61±11 years and those undergoing BTKA was 64±8 years, with similar male to female ratio (1:1.8) in both groups. Males undergoing BTKA were significantly older than other patients (71±6 years). Primary osteoarthritis was the most common initial diagnosis (59% in UTKA and 89% in BTKA, p<0.05) followed by rheumatoid arthritis. Average blood loss per knee was higher in BTKA procedures but difference did not reach statistical significance. Blood transfusion requirements in BTKA patients not receiving antifibrinolytic agent were significantly higher than in similar UTKA patients (75% vs 17%, p<0.05) but were significantly reduced with peri-operative administration of antifibrolytic therapy (30% BTKA, p<0.05). Complication rates, low in both, were more frequent in BTKA patients with co-morbidities. CONCLUSIONS: In patients requiring bilateral knee replacements, staged total knee replacement [i.e. the two knees are replaced with a gap of at least 3 months] is a safe approach. Unilateral knee replacement is associated with lesser complications and blood transfusion requirements as compared to simultaneous bilateral total knee replacements.

Clinical outcome of cemented bipolar hemiarthoplasty versus Austin Moore hemiarthroplasty for displaced intracapsular fractures of hip in terms of anterior thigh pain in elderly.

OBJECTIVE: To explore a less pain-inciting implant in terms of anterior thigh pain after hip hemi-arthroplasty in displaced intra-capsular fractures of the neck of femur. METHODS: The cross-sectional comparative study was conducted at the Combined Military Hospital, Rawalpindi, from November 2013 to June 2014, and comprised patients of either genders with age above 55 years and having displaced intra-capsular fractures of the neck of femur. The patients were divided into two equal groups, with Group A patients undergoing Austin Moore hemi-arthoplasty and Group B having cemented bipolar hemi-arthoplasty. Follow-up was done at 4, 8 and 12 weeks postoperatively for anterior thigh pain on the basis of visual analogue scale. Mean pain scores for both groups were calculated and compared. RESULTS: There were 60 patients; 30(50%) in each group. The mean age in Group A was 78.40±6.95 years, while in Group B it was 77.16±6.32. The overall male-to-female ratio was 1.8:1. All patients had uneventful postoperative recovery. Mean anterior thigh pain in Group A was statistically higher than Group B (p<0.05). CONCLUSIONS: Compared to Austin Moore hemi-arthoplasty, cemented bipolar hemi-arthoplasty caused significantly lower incidence of anterior thigh pain.

Early release of tourniquet in total knee arthroplasty: Is it worthwhile?

OBJECTIVE: To compare the effects of duration and timing of tourniquet release on perioperative blood loss, transfusion requirement, duration of surgery, length of hospital stay and early complications in total knee arthroplastywith and without additional anti-fibrinolytic therapy. METHODS: The prospective quasi-experimental study was conducted at the Combined Military Hospital, Rawalpindi, from March to August 2014. The patients undergoing total knee arthroplasty were divided into two groups: in Group A tourniquet was released after closure of surgical wound and applying compressive dressing; and in Group-B tourniquet was deflated after cementation of implants following which closure was done. Each group was further divided into those who received tranexamic acid (A-T, B-T) and those who did not (A-C, B-C). Study variables were noted on a proforma and analysed. RESULTS: Of the 75 patients in the study, 27(36%) were male and 48(64%) were females. Calculated blood loss was 408mL and 422mL in group A-T and B-T respectively (p=0.73), and 615mL and 610mL in group A-C and B-C respectively (p=0.95). Tourniquet time was significantly shorter (p<0.0005) in group B whereas duration of surgery was significantly shorter (p<0.0001) in group A (68±9min vs 77±11min). Transfusion frequency was higher in group B. Complication rate in the two main groups was not significantly different (p=0.314). Mean length of hospital stay was not significantly different (p>0.05). CONCLUSIONS: Earlier intra-operative release of tourniquet in patients undergoing total knee arthroplasty was associated with increased surgery time and higher frequency of blood transfusion without conferring any significant benefit.

Preventing the preventable: role of transamine in total knee arthroplasty.

OBJECTIVE: To assess the efficacy and safety of perioperative intravenous Tranexamic Acid in reducing blood loss and transfusion requirements in patients undergoing Total Knee Arthroplasty. METHODS: The prospectivedouble-blind randomised control trial was conducted from March to July 2014 at the Combined Military Hospital, Rawalpindi, and comprised patients below 85 years of age undergoing unilateral or bilateral cemented Total Knee Arthroplasty. The patients were divided into control or Transaminegroups. Two doses of 15mg/kg of Transamine were given to the latter group. All patients were operated under spinal or combined spinal-epidural anaesthesiausing pneumatic tourniquet and similar cemented implant. Primary outcome was postoperative blood loss in drains. Secondary outcomes were the number of blood units transfused, change in haemoglobin level and adverse events. RESULTS: Of the 62 patients on the study, there were 34(55%) patents in the Transaminegroup with a mean age of 64±8.4 years, and28(45%)in the control group with a mean age of 60.8±10.3. The two groups were matched for demographic and blood indices.Mean blood loss via intra-articular drain in the control group was 619±243ml per knee, and 402±169ml per knee in the Transaminegroup. Blood transfusions were required by 14(50%)patients in the control groupand 6(17.6%)in the Transaminegroup. CONCLUSIONS: Perioperative intravenous transamine significantly reduced blood loss as well as blood transfusion requirements.

Effectiveness of Gastrocnemius-Soleus Stretching Program as a Therapeutic Treatment of Plantar Fasciitis.

INTRODUCTION: Plantar fasciitis is a painful ailment that causes frustration to both the patient and physician. Stretching exercises targeting the plantar fascia are an excellent therapy option for plantar fasciitis. OBJECTIVE: To compare the outcome of a gastrocnemius-soleus stretching program versus tendo Achilles stretching exercises for the management of chronic plantar fasciitis. METHODS: Patients aged 30-70 years of either gender with chronic plantar fasciitis were included and randomly divided into two groups. In group A, the gastrocnemius-soleus stretching program was applied, whereas in group B, the tendo Achilles stretching exercises were adopted. The pain score was determined at baseline and after eight weeks, and the change in pain score was calculated. All information was noted in the proforma and then entered and analyzed in the Statistical Package for the Social Sciences (SPSS) software version 21 (International Business Machines (IBM), New York, United States). An independent-samples t-test was conducted to compare the mean change in pain score in both groups. A P value of <0.05 was considered significant. RESULTS: The mean age of the patients in the gastrocnemius-soleus stretching group was 48.70 ± 9.80 years, whereas that in the tendo Achilles stretching exercises group was 48.63 ± 8.43 years. Group A included 16 (53.3%) men and 14 (46.7%) women, whereas in group B, there were 15 (50%) men and 15 (50%) women. The mean change in pain score in group A was 2.57 ± 1.01, whereas that in group B was 1.77 ± 0.57. The difference in both groups was significant (P < 0.05). CONCLUSION: Gastrocnemius-soleus stretching exercises are more effective for reducing the symptoms of plantar fasciitis in the adult population.

Comparison of Frequency and Morbidity of Unilateral Total Knee Replacement Versus Simultaneous Bilateral Total Knee Replacement.

Introduction Total knee replacement (TKR) is a procedure that is often performed on patients who have advanced osteoarthritis and has become more common. Bilateral TKR can be done at the same time and can save time, anesthesia and cost of multiple procedures. Objective To determine the frequency of unilateral and simultaneous bilateral total knee replacement and then compare their outcomes. Methods A total of 95 patients were included and were divided into two groups, i.e., patients undergoing unilateral TKR were grouped as group A and patients undergoing bilateral TKR were grouped as group B. Then patients underwent surgery under general anesthesia. All patients were followed up in the outpatient department (OPD). During follow-up, patients were evaluated for the outcome, i.e., cardiac event, urinary tract infection and surgical site infection. All this information was recorded on proforma while analyzed in SPSS v. 22 (IBM Corp., Armonk, NY). The outcome was compared in both groups by using chi-square test. The P-value ≤ 0.05 was considered as significant. Results The mean age of patients was 63.00 ± 6.17 years. There were 50 (52.6%) males and 45 (47.4%) females. The mean BMI of females was 27.93 ± 2.43 kg/m2. There were 47 (49.5%) patients who underwent simultaneous bilateral surgery while 48 (50.5%) underwent unilateral surgery. It has been observed that after surgery, the cardiac event occurred in one (1.1%) case and that case was from unilateral surgery group; urinary tract infection occurred in four cases, two (4.3%) were from bilateral cases while two (4.2%) were from the unilateral group and surgical site infection occurred in four cases, two (4.3%) were from bilateral cases while two (4.2%) were from the unilateral group. The difference was insignificant in both groups (p>0.05). Conclusion Thus, there was no significant difference observed between both groups regarding complications after surgery.

Effect of body mass index on duration of total knee replacement surgery: A prospective cross sectional study.

Introduction: Obesity and increased BMI has raised concerns throughout the globe. As obesity is often associated with many serious medical conditions. Obesity, older age and gender are major contributing factors for knee replacement surgeries. We aimed to compare the mean duration of surgery in obese and non-obese patients undergoing total knee replacement. Methods: A Cross-sectional study is conducted at the orthopedic department at Shifa international hospital, Islamabad during June 2021-Dec 2021. Study is conducted to assess the effect of BMI on duration of total knee arthroplasty. Sample size was calculated to be 105 with 95% confidence limit. Data will be analyzed using SPSS version 22. Quantitative variables like age, BMI and duration of surgery were presented as mean and standard deviation. Qualitative variables like gender, laterality (unilateral/bilateral), and ASA were presented as frequency and percentage. Results: There were more females undergoing the procedure than males. The predominant age group was found to be 56-65 years. On BMI classification scale, a far greater number of individuals were found to be obese constituting more than ⅗ of the study population and almost ⅕ of the patients were overweight. The Association of BMI Classification & Duration of Surgery has a significant p value of 0.00. Conclusion: A linear and direct relation was observed between body mass index and duration of surgery. There may be other contributing factors and will need more data and research.

Intra-articular Versus Intravenous Tranexamic Acid in Primary Total Knee Replacement.

Background Total knee replacement (TKR) is an artificial joint surgical procedure that replaces the damaged articular surfaces of the knee joint. Despite several studies on the efficacy of intra-articular and intravenous Tranexamic acid (TX) use in reducing blood loss following TKR, the route of TXA administration is still an ongoing topic of debate. Our study aimed to compare total knee replacement efficacy (hemoglobin level, hematocrit level, hospital stay, and complications) of intra-articular and intravenous tranexamic acid administration. Material and Methods  A Prospective study was conducted at the Department of Orthopedics, Shifa International Hospital, Islamabad. The study duration was six months (August 2020 to February 2021). A sample size of 60 patients was calculated using the WHO calculator. Patients were selected through non-probability consecutive sampling. Patients were randomly divided into two groups; Group A was given intraarticular TXA, while group B was given intra-venous TXA following total knee replacement. Patients were followed for 48 hours. Data were analyzed using SPSS version 24. An Independent T-test was applied, and a P value≤0.05 was considered significant. Results A total of 60 patients were included in the study. There were 20 (33.3%) male and female 40 (66.7%). The mean age of patients was 64.4±10.8SD. Post-operative hemoglobin level in group A was 11.09±0.39SD, and in group B was 9.93±1.73SD (p=0.03). Postoperatively, the mean HCT level in group A was 30.53±4.26SD and group B 26.88±5.48SD (p=0.01). Conclusion Intra-articular administration of TXA is more effective than intravenous administration in controlling postoperative blood loss following total knee replacement.

Modified suture anchors for open bankart repair.

OBJECTIVE: To evaluate the efficacy of cancellous screws as suture anchors, in open Bankart repair. STUDY DESIGN: Case series. PLACE AND DURATION OF STUDY: Department of Orthopaedics, Combined Military Hospital, Rawalpindi, from March 2009 to October 2010. METHODOLOGY: Fourteen patients with recurrent anterior dislocation were included in the study. Through anterior approach three 4 mm partially threaded cancellous screws were placed at the anterior Glenoid rim. Prolene-1 suture was tied around these screws which acted as anterior anchors and was used to re-attach the capsule and labrum back to bone. The mean duration of follow-up was 8 months. The patients were evaluated at 3 monthly intervals with a physical examination, radiographs, the modified shoulder rating scale of Rowe and Zarins and American Shoulder and Elbow Surgeons score. RESULTS: The mean operating time was 58 minutes. There was no immediate/early postoperative complication. At the last follow-up none of the patients had recurrence or radiological evidence of hardware failure/complication. Eleven patients (79%) had a score of 90 points on the scale of Rowe and Zarins and 12 patients (85.7%) had a score of at least 90 points on the scale of the American Shoulder and Elbow Surgeons scale. Ten patients (71%) had full range of motion in all planes. CONCLUSION: Use of cancellous screws as a suture anchor is a safe and cost-effective substitute of commercially available suture anchors in open Bankart repair.

Limb salvage in malignant tumours of the upper limb using vascularised fibula.

INTRODUCTION: Modern reconstructive techniques can prevent amputation in most cases of malignant musculoskeletal tumours. The free fibula has emerged as the primary method of bridging long bone gaps during limb salvage. METHODS: Limb salvage was attempted in 23 patients (15 males and eight females) aged 17-57 years. The tumour was located in the humerus in 18 patients, radius in four patients and the metacarpals in one patient. Osteogenic sarcoma was the most common tumour (11 cases) followed by Ewing's sarcoma in six patients. After neoadjuvant chemotherapy, MRI was repeated and resectability assessed. Wide local excision was performed and the bony defect bridged by free fibulae. RESULTS: All the flaps survived. The average length of defect reconstructed was 18 cm and the average time for bone union was 7 months. At a minimum follow up of 12 months, 21 patients were alive and disease free. One patient required amputation due to recurrence and one died of metastatic disease. Secondary surgery was needed in eight patients (five tendon transfers, two latissimus dorsi flap readjustments and one bone graft). Overall patient satisfaction was high with 21/23 patients having a useful limb. CONCLUSION: Limb salvage in the upper limb using vascularised fibula in patients with malignant musculoskeletal tumours can result in good tumour control along with reasonable limb function.