Around-the-knee osteotomies part II: Surgical indications, techniques and outcomes - State of the art.

Recent advances in surgical techniques and planning for knee-based osteotomies have led to improvements in addressing lower extremity malalignment. Part 1 of this review presented the biomechanical and clinical rationale of osteotomies, emphasizing the importance of osteotomies for restoring normal knee kinematics. In Part 2 of this review, indications, surgical technique and outcomes of osteotomies to correct coronal, sagittal and axial plane deformities will be examined. Traditional high tibial and distal femoral osteotomies will be discussed in addition to more recent advanced techniques including biplanar corrections and double-level osteotomies, as well as slope-correcting osteotomies. Patient-specific instrumentation and its use in more complex corrections will also be addressed.

Around-the-knee osteotomies part 1: definitions, rationale and planning-state of the art.

Knee osteotomies are essential orthopedic procedures with the ability to preserve the joint and correct ligament instabilities. Literature supports the correlation between lower limb malalignment and outcomes after knee ligament reconstruction and cartilage procedures. Concepts such as joint line obliquity, posterior tibial slope angle, and intra-articular deformity correction are integral components of both preoperative planning and postoperative evaluations. The concept of preserving and/or restoring joint line congruence during simultaneous correction of varus or valgus deformity can be achieved through several different approaches. With advancements in osteotomy research and surgical planning technology, the surgical decision-making has increased in complexity. Based upon a patient's specific deformity, decisions need to be made whether to perform a single-level (proximal tibia or distal femur) versus double-level (both proximal tibia and distal femur) osteotomy, and whether to correct deformity in a single plane (coronal or sagittal) or perform a biplanar osteotomy, correcting two of the malalignments in either coronal, sagittal, or axial planes. Osteotomy procedures prioritize safety, reproducibility, precision, and meticulous planning. Equally important is the proactive management of possible complications and the implementation of preventive strategies for complications such as hinge fractures and unintentional changes to alignment in other planes. This review navigates the intricate landscape of lower limb alignment, commencing with foundational definitions and rationale for performing osteotomies, progressing through the planning phase, and addressing the critical aspect of complication prevention, all while looking ahead to anticipate future advancements in this field. However, rotational osteotomies and tibial tubercle osteotomies in isolation or as an adjunct procedure are beyond the scope of this review.

Comparison of Hyaluronate & Steroid Injection in the Treatment of Chronic Lateral Epicondylitis and Evaluation of Treatment Efficacy With MRI: A Single-Blind, Prospective, Randomized Controlled Clinical Study.

INTRODUCTION: Injection therapy in refractory cases of lateral epicondylitis might relieve symptoms, although no consensus exists on which material to use. Corticosteroids are widely used but recent literature indicated possible tenotoxic effects and inefficacy in mid- and long-term follow-up (FU). Hyaluronate/hyaluronic acid (HA) might be of better clinical efficacy. Magnetic resonance imaging (MRI) might reflect the clinical changes in the short-term FU. METHODS: A single-blind, prospective, randomized controlled study was designed. A total of 80 patients were included. A total of 40 patients received a single triamcinolone injection and 40 received a hyaluronic acid (HA) injection. Follow-up was repeated at six and 12 weeks. The shortened disabilities of the arm, shoulder, and hand questionnaire (Q-DASH) score; visual analog scale (VAS) for pain at rest, and hand grip strength were collected. Dynamometer measurements were done at baseline and FU examinations. The MRI images at baseline and 12 weeks FU were evaluated. RESULTS: There were significant differences between the groups favoring the triamcinolone group at six weeks. At 12 weeks, no differences existed between the groups in any of the parameters. The MRI grades were nonsignificantly different between baseline and at 12 weeks. CONCLUSION: Both triamcinolone and HA were shown to relieve pain and increase functional outcomes. However, the effects were short-lived. The MRI did not show significant differences at 12 weeks, although clinical improvements were substantial.

The round femoral stem provides a similar clinical outcome but more serious proximal stress shielding compared to the rectangular stem in cementless total hip arthroplasty without a shortening osteotomy in patients with Crowe type 2 or 3 hip dysplasia.

OBJECTIVES: This study aims to compare clinical and radiological follow-up results of a rectangular (SL-Plus®) or a round (Synergy®) femoral component in patients with Crowe type 2 or 3 hip dysplasia operated with total hip arthroplasty (THA) without a shortening osteotomy. PATIENTS AND METHODS: Between January 2012 and December 2017, a total of 34 hips of 30 female patients (mean age: 42.9±11.6 years; range, 24 to 66 years) were retrospectively analyzed. All patients were evaluated using the Harris Hip Score (HHS) and Visual Analog Scale (VAS) for pain pre- and postoperatively. Intra- and postoperative complications were noted. Evaluation criteria included leg length discrepancy, stem subsidence, bone atrophy or hypertrophy around the stem according to Gruen zones, operative time, and intraoperative blood loss. Correlation analysis of radiological, clinical findings, and stem size was performed. RESULTS: The mean follow-up was 61.3±27.2 months. The mean postoperative HHS was 89.3±6.2 vs. 93.1±9.1, and the mean VAS score 1±0.6 vs. 1±0.8 in round and rectangular stem groups at the final follow-up. No significant differences were detected between the groups in any of the evaluated parameters, except for a more severe degree of stress shielding observed in the round stem group. Round stem size was positively correlated with a more severe stress shielding (r=0.55, p=0.020). No patient had to be revised during the follow-up period. The overall complication rate was 9%. CONCLUSION: Successful and comparable results can be obtained with cementless THA in patients with high riding dysplastic hips implanting either of the femoral components, a rectangular or a round stem. Although the round stem was associated with more common proximal stress shielding, this was not associated with worse clinical outcomes.

Anterior cruciate ligament repair using dynamic intraligamentary stabilization provides a similarly successful outcome as all-inside anterior cruciate ligament reconstruction with a faster psychological recovery in moderately active patients.

OBJECTIVES: This study aims to comparatively evaluate early to mid-term clinical results of case-matched patient groups of primary repairs with dynamic intraligamentary stabilization (DIS) or all-inside anterior cruciate ligament (ACL) reconstruction (ACLR) by an independent group. PATIENTS AND METHODS: Between March 2015 and September 2018, a total of 16 patients operated for ACL injuries with the repair technique were retrospectively identified. Cases were stratified by treatment: DIS technique versus all-inside ACLR and matched at a ratio of 1:2. The ACLR patients were selected from a patient group with an injury-to-operation time interval of fewer than three months. A total of 32 patients were included in the all inside ACLR group. Pre-injury and postoperative International Knee Documentation Committee (IKDC) subjective score, Tegner and Lysholm scores had been obtained. Additionally, ACL-Return to Sport after Injury (ACL-RSI) scale scores, clinical results, and complications were noted. RESULTS: One (6%) patient in the DIS group and two (6%) patients in the ACLR group were lost-to-follow-up and, for a total of 45 patients, 15 in the DIS group and 30 in the ACLR group, were included in the study. The mean postoperative follow-up was 50.8±13.5 months and 48.2±11.4 months in the DIS and ACLR groups, respectively. The Tegner, Lysholm, and IKDC subjective scores were non-significantly different between the groups at any time points. The ACL-RSI scale scores were significantly higher at six (p<0.001) and 12 (p=0.01) months in the repair group. The pivot-shift test was negative in all cases postoperatively. One re-rupture occurred in each group. The reoperation rate at any cause was 25% for the repair and 10% for the ACLR group. CONCLUSION: Primary ACL repair using the DIS technique provides a similar clinical outcome to these by an all-inside ACLR technique in moderately active patients. The DIS technique is reliable and reproducible, and associated with an early and speedier psychological recovery in a carefully selected, non-athlete patient group as observed by an independent group.

Prophylactic Cerclage Cabling Decreases the Intraoperative Periprosthetic Fracture Rate during Cement-Less Total Hip Arthroplasty in Patients with Severe Developmental Hip Dysplasia.

PURPOSE OF THE STUDY Cementless stems in highly dysplastic hips are considered to increase the risk of femoral fracture and associated morbidity. Several authors speculated to use prophylactic cabling in this patient group to prevent intraoperative fractures. This study aims to reveal objective results regarding the perioperative complications in a large and consecutive patient group with respect to use of prophylactic cabling. MATERIAL AND METHODS A retrospective comparative study was planned. A total of 122 consecutive patients with dysplastic hips of Crowe type 3 or 4, operated on with total hip arthroplasty (THA) and shortening osteotomy using a rectangular femoral stem were included. Patients were stratified according to use of a diaphyseal prophylactic cerclage cable. Perioperative complications were recorded. Clinical outcome was measured in terms of Harris Hip Score and Visual Analog Scale (VAS) for pain. All results were compared between the groups. RESULTS The mean follow-up time was 27 months. Two (2%) versus five (14%) patients had a fracture at the diaphyseal level in cabled versus non-cabled groups. Difference between groups was statistically significant (p=0.01). Relative risk of fracture in case of a non-cabling was 5.8 (p=0.03). Eleven (9%) patients had a non-displaced fracture at the metaphyseal level. No significant differences were detected with respect to preoperative clinical outcome scores or change in these scores between groups. CONCLUSIONS Femoral diaphyseal fracture rates are low when cementless, rectangular stems are used in dysplastic high riding hips. Prophylactic cerclage cabling further decreases the fracture risk and eases treatment in case of a fracture without causing additional complications and therefore is recommended. Key words: intraoperative fracture, periprosthetic fracture, total hip arthroplasty, cerclage cabling, developmental hip dysplasia, transverse shortening osteotomy.

A Higher Initial Tensioning Force of an ACL Graft Results in a Higher Graft Force After Screw Fixation Irrespective of the Screw Diameter: A Biomechanical Study.

BACKGROUND: The intra-articular graft force (IAGF) in anterior cruciate ligament reconstruction decreases quickly over the first hours after surgery. Nevertheless, little is known about whether the initial extra-articular tensioning force (EATF) and screw diameter affect the graft force after fixation. PURPOSE: To investigate the effects of different EATFs on the IAGF of a soft tissue graft fixated via a bioabsorbable interference screw over 100 minutes after fixation and to evaluate the effects of different screw diameters within 1 mm of the tunnel width during this process. STUDY DESIGN: Controlled laboratory study. METHODS: In this biomechanical study, a porcine quadruple-strand soft tissue graft was inserted into the tibial anterior cruciate ligament tunnel. On the extra-articular side, 3 loads were applied during retrograde insertion of the bioabsorbable interference screw (6, 7, and 8 mm): 20 N, 80 N, and maximum manual EATF (Nmax). Nine study groups consisting of 10 tibiae each were created to test the effects of different EATFs and screw sizes. The IAGF was measured up to 100 minutes after the EATF was released. RESULTS: An EATF ≥80 N resulted in a larger IAGF for all screw sizes at 100 minutes. There were no significant associations between the IAGF at 100 minutes and different screw diameters. Inserting the tibial screw significantly increased the IAGF in all groups, with the exception of Nmax applied in groups with 7- or 8-mm screws. When compared with the end of screw insertion, after the release of the EATF, the IAGF dropped by 55% to 77 % at 100 minutes. CONCLUSION: An initial EATF ≥80 N is associated with a significantly larger IAGF at 100 minutes in this cadaveric simulation. The IAGF in soft tissue grafts decreased substantially after the retrograde placement of an interference screw. A recommendation regarding screw diameter with respect to the IAGF cannot be given. CLINICAL RELEVANCE: To obtain a higher residual graft force after bioabsorbable interference screw fixation, an initial EATF ≥80 N should be applied according to this model. The significant decrease in graft force after the release of the EATF indicates that the reconstructed knee cannot be mechanically stabilized after the surgery.

[Sealing of Femoral Tunnel with Autologous Bone Graft Decreases Blood Loss]. / Utesnení femorálního kanálu autologním kostním stepem snizuje krevní ztrátu.

PURPOSE OF THE STUDY Total knee arthroplasty is commonly used procedure with advanced stage arthritis which causes extensive blood loss intraoperatively and postoperatively. Purpose of this study is to show the effectiveness of sealing of femoral tunnel with bone grafting in preventing blood loss. MATERIAL AND METHODS 288 patients with primary bicompartmental knee arthroplasty who were operated in between April 2012 and June 2015 are retrospectively studied. Two groups are formed according to sealing of femoral tunnel with autologous bone graft or not. Group 1 was the plugged group with 192 patients and group 2 was the unplugged group with 96 patients. Operation time, arthrotomy method, anticoagulant therapy, postoperative care were similar in between two groups.'Independent sample t-test' is used to compare two groups as statistical method. RESULTS Postoperative lowest hemoglobin levels are higher in plugged group (p < 0.001). Drain outputs are much less than unplugged group (p < 0.001). There is no statistically significant difference between amount of given erythrocyte suspensions. DISCUSSION In the literature there are many attempts to reduce blood loss and allogenic blood transfusion. Some systemic or local usage of medical therapies, mechanical interventions such as cold application or intraoperative fibrin sealers are some of them. There are a few studies favoring usage of plugs and a few do not. Our findings showed less blood loss with usage of autologous bone grafting but did not significantly affect the blood transfusion amount. CONCLUSION Autologous bone grafting is a free to use, non-time consuming and an effective method to reduce blood loss. Key words: knee arthroplasty, plug, sealing of femoral tunnel, blood loss.

Comparison of short-term results of intraarticular platelet-rich plasma (PRP) and hyaluronic acid treatments in early-stage gonarthrosis patients.

The present study aimed to compare short-term clinical outcomes between intraarticular platelet-rich plasma (PRP) and hyaluronic acid (HA) treatments in early-stage gonarthrosis patients. Data of gonarthrosis patients, who were stage 1 or stage 2 according to Kellgren-Lawrence classification and underwent intraarticular PRP or HA treatment, were obtained retrospectively. The patients received treatment for three times at one-week intervals (intraarticular PRP or HA). They were evaluated using the Knee Society's Knee Scoring System (KSS) and the visual analog scale (VAS) scoring system before treatment and at the second and sixth months of treatment. The study included 132 patients (mean age, 55.06±8.41 years). Sixty-three patients (86 knees) were in the HA group and 69 patients (89 knees) were in the PRP group. Changes in KSS and VAS scores over time and the differences between the treatment groups in terms of changes in KSS and VAS scores over time were significant. In conclusion, PRP appears to be an appropriate option for intraarticular treatment in patients with early-stage knee osteoarthritis.

Predicting ICU mortality: a comparison of stationary and nonstationary temporal models.

OBJECTIVE: This study evaluates the effectiveness of the stationarity assumption in predicting the mortality of intensive care unit (ICU) patients at the ICU discharge. DESIGN: This is a comparative study. A stationary temporal Bayesian network learned from data was compared to a set of (33) nonstationary temporal Bayesian networks learned from data. A process observed as a sequence of events is stationary if its stochastic properties stay the same when the sequence is shifted in a positive or negative direction by a constant time parameter. The temporal Bayesian networks forecast mortalities of patients, where each patient has one record per day. The predictive performance of the stationary model is compared with nonstationary models using the area under the receiver operating characteristics (ROC) curves. RESULTS: The stationary model usually performed best. However, one nonstationary model using large data sets performed significantly better than the stationary model. CONCLUSION: Results suggest that using a combination of stationary and nonstationary models may predict better than using either alone.

Identifying patient subgroups with simple Bayes'.

Medical records can form the basis of retrospective studies, be used to evaluate hospital practices and guidelines, and provide examples for teaching medicine. Each of these tasks presumes the ability to accurately identify patient subgroups. We describe a method for selecting patient subgroups based on the text of their medical records and demonstrate its effectiveness. We also describe a modification of the basic system that does not assume the existence of a preclassified training set, and illustrate its effectiveness in one retrieval task.

Using computer modeling to help identify patient subgroups in clinical data repositories.

OBJECTIVE: The ability to accurately and efficiently identify patient cases of interest in a hospital information system has many important clinical, research, educational and administrative uses. The identification of cases of interest sometimes can be difficult. This paper describes a two-stage method for searching for cases of interest. DESIGN: First, a Boolean search is performed using coded database variables. The user classifies the retrieved cases as being of interest or not. Second, based on the user-classified cases, a computer model of the patient cases of interest is constructed. The model is then used to help locate additional cases. These cases provide an augmented training set for constructing a new computer model of the cases of interest. This cycle of modeling and user classification continues until halted by the user. MEASUREMENTS: This paper describes a pilot study in which this method is used to identify the records of patients who have venous thrombosis. RESULTS: The results indicate that computer modeling enhances the identification of patient cases of interest.