Osteoarthritis of the knee: review of risk factors and treatment programs with special reference to evidence-based research

Osteoarthritis is a widespread disease leading to physical disability affecting quality of life. It is primarily regarded as a cartilage disease but affect all tissues of a joint. Osteoarthritis can be regarded as an organ failure. Knee osteoarthritis is common in Kuwait, especially in women. The main symptoms are pain, stiffness and weakness affecting knee function. The diagnosis is made by history and clinical examination. A weight-bearing radiograph will fully establish the diagnosis. Many of the patients are also obese, diabetic, hypertensive or affected by other organ failures. The aim is to reduce knee pain and improve knee function which is also beneficial for the other diseases. Initially, we recommend self-management by information about knee osteoarthritis, daily exercise of any type which is pleasant for the individual like walking 10-30 minutes once or twice daily in order to induce light to moderate cartilage load. Further, regular muscle training to increase especially pelvis and lower leg strength and realistic programs to reduce weight is advised. Regular support by a primary care doctor, a physiotherapist or a coach is beneficial.The programisde manding, as it means a change of life-style. Different modalities of non-operative treatment are physiotherapy, pharmacological treatment by analgesics / NS AIDs / glucosamine and injection of steroids or hyaluronic acid. The effect of the pharmacological treatment programs vary. Often the outcome, by evidence based research, is low or at best moderate. If self-management and non-operative treatment fails and the symptoms are pronounced, surgery is an option. Knee prosthesis is the main alternative

Traumatic posterior hip fracture dislocation with ipsilateral intertrochanteric fracture and sciatic nerve palsy in an adult patient

We report a case of post-traumatic posterior hip dislocation and fracture associated with ipsilateral intertrochanteric fracture and sciatic nerve palsy in a young adult. Initial treatment consisted of traction and resuscitation. After failure of closed reduction under general anesthesia, traction through Schanz screw in the neck of femur assisted by anterior capsulotomy to deliver the head of femur was done. Open reduction and internal fixation of intertrochanteric fracture with dynamic hip screw was performed. Skeletal traction through proximal tibia was applied for six weeks. Regular follow-up involved examinations to confirm concentric reduction and stability of the hip joint and assess union of the intertrochanteric fracture and posterior wall acetabulum fracture. Postoperative rehabilitation continued until sciatic nerved recovered over one year. Serial X-rays done for four years after injury did not detect any signs of avascular necrosis of the femoral head. Patient has returned to pre-injury level of daily activity

Septic arthritis due to penicillin resistant neisseria gonorrhoeae unusual host and pathogen combination

Gonococcal infection is not commonly reported in our area. It should be kept in mind that Nisseria gonorrhoeae may cause septic arthritis resulting in a serious orthopedic problem. Penicellinase producing gonococci are appearing more nowadays. The typical host of this condition is female in the child bearing period. The presentation of such condition may be atypical. During the period 2004 to 2006 we received in AL-RAZI hospital three cases of acute gonococcal arthritis two of them had atypical presentation. We report these three cases with the diagnostic and therapeutic implications

Ochronotic knee arthyropathy

Homogentesic acid oxidase deficiency is associated with a rare metabolic disorder known as alkaptonurea or ochronosis. We report a patient with clinical and radiolgic findings of ochronosis affecting the spine and knee joints. Total joint replacement was performed to control severe right knee pain

Knee arthroplasty in Kuwait during 25 years: a national presentation and an international review

Since 1984, 577 knee arthroplasty operations were performed in Al Razi Orthopedic hospital in Kuwait. An increase in the number of these operations occurred during the last four years and in 2007 there were almost 100 knee arthroplasty operations performed. Six out of seven operated patients were female. The mean age at operation was 67 years for male and 62 years for female patients. The vast majority were of the total knee arthroplasty type. In Sweden, with a total population of almost 10 million people, 10,544 primary knee prosthesis were implanted during 2006. In Kuwait, there is no certain statistics regarding the actual number of knee arthroplasty operations as Kuwaiti patients are also operated in private hospitals within and outside the country. It is estimated that 200 - 300 knee arthroplasty operations are performed annually on Kuwaitis. In order to get better epidemiological data and in order to improve the quality assurance of Knee and Hip arthroplasty operations in Kuwait, we propose that a national register is organised. National registers are in use in many other countries. The main indication for a knee arthroplasty is to relieve knee pain and to improve knee function. The operation allows for an active life-style. An active lifestyle, with more walking, is an advantage not only for the knee, but also for the general health. It also helps to better control other diseases like diabetes and obesity. The use of knee arthroplasties in Kuwait is increasing and the outcome of the procedure is generally favorable. It is not an overstatement to say that a well functioning knee arthroplasty means an increased quality of the whole life

Cemented and cementless total Hip replacement. critical analysis and comparison of clinical and radiological results of 182 cases operated in Al Razi Hospital, Kuwait

In this study we present the results of a series of cemented Exeter and cementless Zweymuller implants. Subject and Methods: Eighty-seven cemented and 95 cementless hip replacements for different hip pathologies were followed for an average period of 36 months for cementless and 60 months for cemented cases. Clinical results were calculated using the Merle d'Aubigne score. The orientation of the prosthetic components and the fixation of the cup and stem were analyzed. The clinical and radiological results were compared using statistical methods. In the average period of 36 months in cementless and 60 months in cemented hip replacements the clinical results improved significantly when compared with the preoperative score [p < 0.05]. Sixty-seven cemented acetabular cups [77.1%] were in the desired position [30-50°] and 20 cemented cups [22.9%] were outside this range. Seventy-six cups [80%] were in the desired degree of abduction and 19 [20%] were outside this range. All cups except 1 were anteverted or neutral. Of the femoral stems, 173 were in the neutral position, 5 in the valgus and 4 in the varus position. Cemented cups were more commonly loose and cemented and cementless stems did equally well. No significant differences in rate of complications were found. Cementless acetabular implants had better clinical results and a lower loosening rate at 3 years of follow-up compared to cemented implants at 5 years of follow-up. The cemented femoral implants were equally stable compared to the cementless ones

Arthroscopically assisted reduction and fixation of tibial plateau fracture

To evaluate the role of arthro scopically assisted reduction and fixation in patients with tibial plateau fracture. Al Razi Orthopedic Hospital, Kuwait. Forty-five consecutive patients with tibial plateau fracture were included in this study. They were graded as Schatzker type I-IV and were operated upon using arthroscopy to control reduction and fixation of the fracture. Fifteen fractures were fixed using three cancellous screws whereas the remaining thirty fractures were fixed using two cancellous screws. Nine patients had anterior cruciate ligament [ACL] tear and were treated by ACL reconstruction after healing of the fracture because of instability. Twenty-seven patients had meniscal injuries. Nine injuries were treated by meniscal repair whereas partial menisectomy was performed in 18 patients. All cases started rehabilitation within the first week after their surgery. All patients were assessed at the end of 36 months. Clinically, 33 cases showed full range of motion that was painless. Six cases had mild pain and were able to demonstrate a range of motion from 0 to 80 degrees. Six patients had mild chronic swelling. Radiologically, all cases showed a complete union after 12 weeks. No patient showed osteoporotic or osteoarthritic changes. Arthroscopically assisted reduction and fixation of tibial plateau fracture avoids arthrotomy of the knee joint, helps in diagnosis of other associated intra-articular injuries and facilitates early rehabilitation. It may also give a better final outcome when compared with conventional arthrotomy

use of locked nails in the treatment of humeral shaft: Delayed union and nonunion

To assess the results and clinical outcome of delayed union and nonunion humeral shaft treatment using locked medullary nails. The Russel and Taylor humeral locking nail was used to treat 21 patients with humeral shaft fractures at Al Razi hospital, Kuwait, from 1997 to 2001. Of these, 8 had delayed union and 13 nonunion. Also, 13 had previous operative treatment, while 8 had nonoperative treatment, Antegrade nailing was done in all cases, and all nails were fixed statically. Autogenous iliac bone grafts were used in 17 cases. Of the 21 cases of fractures, 19 were united. Only 2 cases had persistent nonunion. Eighteen cases had satisfactory shoulder function, and 3 lost shoulder abduction between 40 and 65 degrees. Our data showed that humeral locked nails can achieve satisfactory clinical results in treating humeral shaft delayed unions and nonunions

Complications of anterior cruciate ligaments reconstrucion patellar tendon versus gracilis and semitendinosus autologous graft

To evaluate, out of the possible causes, the risk factors arid complications of arthroscopic anterior cruciate ligaments [ACL] reconstruction using PT arid STG [four strands] in patients with chronic torn ACL. Al Razi Orthopedic Hospital, Kuwait. A total of 245 patients with chronic ACL deficient knee underwent arthroscopically-assisted reconstruction with either autologous patellar tendon graft or gracilis arid semitendinosus [four strands]. Preoperatively, no significant difference between the two groups was noted with respect to age, or level of activity. A standardized rehabilitation program was used for all the patients after surgery. The patients were evaluated at a minimum of three years postoperatively [range 37-48 months]. No significant differences between the two groups [chi square analysis] with respect to subjective complaints, functional level of activity or objective laxity evaluation, including KT 1000 measurement, were found. Patello femoral pain arid crepitus developed in 25% arid 8% in PT arid STG groups, respectively. Fracture of the patella, patellar tendinitis cyclops lesion and loss of movement were common complications noticed in the PT group, while premature amputation of the hamstring tendon, infection and injury to the saphenous nerve was noted in the STG graft. Late patellar fractures, extensor mechanism rupture, failure of graft fixation and reflex sympathetic dystrophy are rare complications and were not seen in our patients. Details of our complications, possible causes, risk factors and the management of these factors are presented. Familiarity with the regional anatomy arid its variation, proper surgical technique, proper placement of the tibial and femoral tunnels, adequate notchplasty, rigid fixation of the graft, early mobilization with extension of the knee, gradual flexion and rehabilitation with routine use of prophylactic antibiotics are key to avoid or decrease these complications in arthroscopic ACL reconstruction. It was noticed that isolated tear of ACL is a common injury. It is also clear that most of ACL injuries, if not all, occur in males, as there are not many female sports players in Kuwait. However, we have operated on two female athletes [one Judo arid one basketball player] recently. These two females were not involved in the study