Chronic, Neglected Medial Subtalar Dislocation with Associated Talar and Calcaneal Fractures. A Case Report.

Subtalar dislocation is a very rare injury that accounts for just approximately 1% of traumatic dislocations. Stan-dard treatment in acute subtalar dislocations is immediate closed reduction and cast immobilization. Early reduction is of key importance and allows avoiding further damage to soft tissues, nerves and blood vessels. Neglected, chronic subtalar dislocations are seen extremely rarely and only a few cases have been reported in the literature to date. Considering the lack of guidelines and very few literature reports relating to the treatment of such injuries, we have decided to present the case of a male patient with a chronic, neglected, closed medial subtalar dislocation of the right foot with associated fractures of the talar and calcaneal bones. The patient was admitted 4 months post trauma to his right ankle joint caused by a fall from a ladder. An open subtalar reduction was performed with arthrodesis of the talocalcaneal joint and the talonavicular joint of the right foot. The treatment was effective and recreated the me-chanical axis of the limb. One year after the surgery, the patient reported no pain and no limitations in everyday functioning, work and activities. At the one-year follow-up, his AOFAS score was 88/100.

Pseudotumor as a Complication of Total Hip Replacement.

Total hip arthroplasty with metal-on-metal bearing is associated with specific complications: local delayed hypersensitivity reaction (ALVAL) to metal particles, osteolysis and the development of pseudotumors. This process results from the low resistance of the metal bearing to abrasion and corrosion, which causes the release of metal ions into the surrounding tissues. This paper presents the case of a 54-year-old man who required revision surgery due to aseptic loosening of the endoprosthesis with a ceramic (TiN)-on-metal bearing. The removed implants were subjected to material analysis. Mean chemical analysis revealed that the main component of the residue samples was titanium, which constituted 65% of the sample weight, followed by calcium (16%), phosphorus (11%) and aluminum (3.8%). The fissures on the insert were a result of trauma caused by the head, with both elements matching in terms of visible damage. More than 50% of the surface of the head had been damaged due to abrasive wear. The transitional area between the normal and completely delaminated TiN coating shows uneven abrasion, a gradual decrease in coating thickness. In conclusion, the use of endoprosthesis heads with TiN ceramic coating involves very low polyethylene wear. The low resistance of TiN ceramic coating to trauma and the fragility of this coating prevent the use of TiN-coated heads in combination with any non-polyethylene hip endoprosthesis inserts.

The electromyographic activity characteristics of the gluteus medius muscle before and after total hip arthroplasty.

PURPOSE: The clinical outcomes of total hip arthroplasty are influenced by the correct muscle function that determines good, longterm and proper function of the artificial joint. The aim of the study was to analyze the electromyographic activity of the gluteus medius muscle in patients with hip osteoarthritis and after arthroplasty in various static weight bearing conditions, both on the affected and contralateral side. METHODS: The prospective study involved 70 patients qualified for hip replacement. Patients underwent a surface electromyography of the gluteus medius muscle which involved the Trendelenburg test. The normalized results were obtained for both hips, preoperatively and 6 months after arthroplasty. RESULTS: The only muscle activity differences were found at a full load condition of lower limb. In the preoperative assessment, the activity of the gluteus medius muscle was greater on the side qualified for surgery. After arthroplasty and the rehabilitation period, the muscle activity on the operated side decreased and significantly increased on the contralateral side. Detailed analysis of the contralateral side revealed relationship with osteoarthritis. Previous hip arthroplasty of that side resulted in lower muscle activity, similar to fully functional joints. CONCLUSION: The activity characteristics of the gluteus medius muscle vary depending on the condition of the joint, and the characteristics change as a result of the surgical procedure performed on both the operated and contralateral sides. These dependencies should be taken into account in the rehabilitation process, especially at the side opposite to the operated one.

Kinematic gait parameters changes in patients after total knee arthroplasty. Comparison between cruciate-retaining and posterior-substituting design.

PURPOSE: The patients expect optimal knee function after Total Knee Arthroplasty. It is necessary to apply appropriate surgical technique and supervised physical therapy. The optimal management of posterior cruciate ligament remains controversial. Both implant designs, i.e., cruciate retaining and posterior substituting, allow the orthopedic surgeon to achieve excellent clinical outcomes, as measured by commonly used questionnaires. Such methods of assessment may poorly reflect the functional status of patients. Therefore, three-dimensional gait analysis is recommended to evaluate the outcomes of surgical intervention. This study sought to determine differences in kinematic gait parameters and Knee Society Score between cruciate-retaining and posterior-substituting patients. METHODS: 23 individuals after cruciate-retaining total knee arthroplasty and 19 individuals after posterior-substituting total knee arthroplasty were subjected to gait analysis using three-dimensional motion capture system BTS Smart DX 7000. In addition, gait was assessed in 21 patients with knee osteoarthritis and in 30 healthy individuals. RESULTS: The study did not reveal differences between cruciate-retaining and posterior-substituting groups, both in terms of Knee Society Score and kinematic gait parameters. There were also no differences in kinematic gait parameters between patients from the knee osteoarthritis group and total knee arthroplasty groups. The analyzed parameters in all of the groups differed significantly from those found in healthy individuals. CONCLUSIONS: Surgical technique and implant design do not affect values of kinematic gait parameters evaluated under natural walking speed. Several months after surgery the patients still demonstrated alterations in gait pattern, similar to those recorded in patients with knee osteoarthritis.

A bioresorbable polylactide implant used in bone cyst filling.

The aims in treating patients diagnosed with critical-sized bone defects resulting from bone cysts are to replace the lost bone mass after its removal and to restore function. The standard treatment is autologous or allogeneic bone transplantation, notwithstanding the known consequences and risks due to possible bone infection, donor site morbidity, bleeding and nerve injury and possible undesirable immune reactions. Additionally, allogeneic grafts are inhomogeneous, with a mosaic of components with difficult-to-predict regenerative potential, because they consist of cancellous bone obtained from different bones from various cadavers. In the present study, a 22-year-old patient with a history of right humerus fracture due to bone cysts was diagnosed with recurrent cystic lesions based on X-ray results. The patient qualified for an experimental program, in which he was treated with the application of a bioresorbable polylactide hybrid sponge filled with autologous platelet-rich plasma. Computed tomography and magnetic resonance imaging performed 3, 6, and 36 months after surgery showed progressive ossification and bone formation inside the defect cavity in the humerus. Three years after treatment with the bone substitute, the patient is pain free, and the cystic lesions have not reoccurred.

Gait analysis in patients after unilateral hip arthroplasty.

BACKGROUND: Osteoarthritis (OA) is the most common joint pathology and the main cause of disability in elderly persons. Arthroplasty still remains the most effective treatment of OA. Routine post-operative patient assessment does not include an objective functional examination leading to conclusions regarding the need of further rehabilitation. This role is played by gait analysis performed in patients after arthroplasty. The aim of the study was to conduct a quantitative and qualitative analysis of selected gait parameters in patients after unilateral cementless hip arthroplasty. MATERIAL AND METHODS: The study involved a group of 16 patients who were examined before and after hip arthroplasty. Gait analysis was conducted before surgery and at least 6 months after the procedure. The Smart DX BTS system for spatial gait analysis was used. RESULTS: The duration of the stance phase on the affected side was 63.8 [% gait cycle] and was significantly shorter (p<0.05) than the phase on the unaffected side, with a duration of 69.4 [% gait cycle]. After surgery, the duration of swing phase on the unaffected side increased (p<0.05) from 30.6 to 35.1 [% gait cycle]. A statistically significant change was also found in the double support phase (the arthrotic limb as the front limb), which was markedly shortened. The average length of a single and double step, cadence, average gait velocity, and the velocity of leg swing in the swing phase increased. The range of hip mobility increased in all planes, especially in the sagittal plane. CONCLUSION: The space and time gait parameters with regard to the operated leg after hip arthroplasty indicate an improvement as compared with the baseline results; however, they do not reach the values found in healthy persons.

Bilateral neurogenic hip arthropathy. A case report.

Neurogenic arthropathy is a rare joint disorder, characterized by rapid progression and marked destruction of articular surfaces (known as Charcot's joint) with only mild to moderate pain. Most cases are related to diabetic neuropathy, but they may complicate the course of other neurogenic clinical conditions such as neurosyphilis (tabes dorsalis), syringomyelia, myelomeningocele, Peroneal Muscular Atrophy, spine or peripheral nerve injury, alcoholism and avitaminosis. Loss of superficial sensation and proprioception plays a pivotal role in development of arthropathy because it affects the joint's normal protective reflexes and leads to joint instability, degeneration and destruction. The authors describe an unusual case of bilateral neurogenic hip arthropathy in a 61-year old women who developed this condition in the course of multilevel lumbar spondylosis with spinal and nerve root compression. The patient underwent a successful bilateral hip replacement and remains almost asymptomatic contrary to literature reports that suggest high risk of complications after the operative treatment of Charcot's joints.

Minimally invasive approaches in total hip replacement.

Hip Osteoarthritis has always been a challenge for the orthopaedic community and, in the present age of increasing life expectancy and quality, it has become one of the most common causes for orthopaedic surgery. Nowadays, the development of THR focuses on refining the surgical technique, especially on minimising operative tissue injury. Convencional approaches in THR surgery preserve main vessels and nerves and provide excellent visualisation of the operative field but at the expense of muscle attachments and ligaments which are inevitably injured. The authors of MIS concept underline the idea of minimising injury inflicted on the muscle-tendon unit. There are a lot of evidence that the MIS procedures allow for early rehabilitation, shorter in-hospital stay and hasten full functional recovery. They are also associated with decreased perioperative blood loss, reduced postoperative pain and decreased risk of infections.

Minimally invasive approaches in total hip arthroplasty.

The success of operative treatment depends on a quick recovery of limb function. Every injury to a muscle or its attachment is associated with decreased muscle strength and disturbed proprioception, which impedes functional recovery. Minimally Invasive Surgery (MIS) is defined as a surgical technique performed through a short skin incision to avoid injury to muscles and tendons. The advantages of MIS over the classic technique in Total Hip Arthroplasty include: faster recovery, shorter rehabilitation and hospital stay, decreased blood loss, less pain and a shorter scar. The anterior approach to the hip, first described by Robert Judet in 1947 as a modified Smith-Petersen approach, follows the principles of MIS. Other approaches advertised as minimally invasive (posterior, lateral, or double incision approach) are associated with muscle and/or tendon injury. Therefore, they should be referred to as Less Invasive Surgery (LIS). Complications of THA performed with the MIS technique occur most often in women with osteoporosis, above 65 years of age, or with a BMI of more than 32. The rate of complications doubles with surgeons performing less than 50 THAs per year. A special set of instruments facilitates implantation of the endoprosthesis and reduces the number of complications. The anterior approach allows for implantation of an endoprosthesis without damage to muscles and their insertions, reduces tissue damage and, more importantly, decreases the intensity of postoperative pain. Should complications occur, the anterior approach has the advantage of allowing simple access to the proximal femur by extending the approach distally, as in the Smith-Petersen technique. However, the technical challenges of MIS and the risk of complications warrant caution.

Orthopaedic problems in patients affected by alkaptonuria. A case report.

Alkaptonuria is a rare congenital metabolic disorder. A defect of the enzyme homogentisic oxidase results in a block of the metabolic pathway of the amino acids phenylalanine and tyrosine. Deposits of homogentisic acid polymers in connective tissue cause various organ manifestations, including musculoskeletal symptomatology. A 66 year-old woman was twice admitted to our Department because of progressive knee and low back pain. Physical examination and accessory investigations confirmed that her various complaints were caused by underlying alkaptonuria. We use this case and a review of literature to discuss orthopaedic problems in patients with alkaptonuria and describe the cardinal signs and symptoms of this disease, its diagnosis and treatment.