Combination of intra-articular autologous activated peripheral blood stem cells with growth factor addition/ preservation and hyaluronic acid in conjunction with arthroscopic microdrilling mesenchymal cell stimulation Improves quality of life and regenerates articular cartilage in early osteoarthritic knee disease.

BACKGROUND: Trauma or osteoarthritis (OA) create articular cartilage defects that cannot efficiently heal, thus leading to significant long-term disability. Failed conservative treatment in cartilage diseases is a known condition that necessitates repair attempts but current methods are inadequate. Recent studies in OA animal models and humans, showed articular cartilage regeneration following combinations of drilling, adult stem cells, and intra-articular hyaluronic acid. OBJECTIVE: In the present series, the authors evaluated the combination of repeated intra-articular (IA) autologous activated peripheral blood stem cells (AAPBSC) with growth factor addition/preservation (GFAP) along with hyaluronic acid (HA) in conjunction with arthroscopic microdrilling mesenchymal cell stimulation (MCS) in early osteoarthritic knee disease that failed conservative treatment. MATERIAL AND METHOD: Four women and one man (median age 56, range 52-59 years) that failed conservative treatment were enrolled. Arthroscopic MCS was performed once in all patients with subsequent IA injection of AAPBSC with GFAP along with IA-HA intra-operatively, repeated at days 7 and 14. The patients were evaluated by WOMAC and KOO scores at baseline, one, and six months. Cancellous bone biopsies were performed to investigate cell attachment, proliferation, and differentiation by electron microscopy and histological staining. RESULTS: All patients improved significantly in WOMAC and KOO scores at one and six months compared to baseline. No adverse effects were seen during the AAPBSC harvesting, arthroscopy and/or IA injections. One month post-surgery, all pain medications could be withdrawn. Electron microscopy scanning revealed cell attachment and proliferation while histological analysis demonstrated that the cell layer on the cancellous scaffold showed increased proteoglycan and glycosaminoglycan content indicating hyaline cartilage presence. CONCLUSION: The combination of intra-articular (IA) autologous activated peripheral blood stem cells (AAPBSC) with growth factor addition/preservation (GFAP) along with hyaluronic acid (HA) in conjunction with arthroscopic microdrilling mesenchymal cell stimulation (MCS) resulted in Quality of Life improvements measured by WOMAC and KOO scores and succeeded in regenerating articular cartilage in early osteoarthritic knee disease that failed conservative treatment. Further controlled studies are warranted to confirm the above results in larger groups.

Cost analysis of peri-operative antibiotic administration in total knee arthroplasty.

BACKGROUND: Rationale perioperative antibiotic for prevent infection in total knee arthroplasty is well established. The recommendation are preoperative antibiotic should be administered within 1 h before skin incision and prophylactic antibiotics should be administered within 1 h before skin incision, if prolong surgery more than 4-6 hours need addition doses and duration of prophylactic antibiotic administration should not exceed the 24-hour postoperative period then not need for additional antibiotic. If there is evidences of infection, intravenous antibiotic and follow by oral antibiotic is mandatory in acute infection in conjuction with scrub and debridement. Because the burden of infection in joint replacement is disaster, it seemed to increase the antibiotic uses and impact about the cost concerned after total knee arthroplasty. No data available about the pharmaco-economical study of perioperative antibiotic in total knee arthroplasty have been established. OBJECTIVE: Primary outcomes is cost anaylsis of perioperative antibiotic uses in real clinical practice for total knee arthroplasty. Secondary outcome is infectioned total knee that need to reoperative for scrub and debridement. MATERIAL AND METHOD: Prospective opened lable study from joint registry in Police General Hospital from June, 2010 till March, 2011. With minimum 12 months follow-up. Total Knee Arthroplasty was enrolled in the present study about 218 cases. 3 patients lossed follow-up in each groups, so the total number in the present study are 209 patients. Perioperative antibiotic consumption initial doses and followed for 48 hour is divided in 3 group: group 1 Fosmycin 4 g (2 g initially plus 2 g intraoperatively) for 70 patients group 2: Fosmycin 2 g for 68 patients. Group 3: Cefalosporin group for 71 patients. The cost of subsequence uses of intravenous and oral antibiotic were record. And also the cases that need to scrub debridement with the indication of infected total knee arthroplasty were recorded. The minimum follow-up about 12 months (range 12-18 months). RESULTS: The extend of intravenous antibiotic administration postop more than 48 hours in group 1 is 38 patients (54.28%) and oral antibiotic 42 patients (60%), in group 2 is 45 patients (66.18%) and oral antibiotic 40 patients (58.2%), in group 3 58 patients (81.7%) and oral antibiotic 60 patients (84.51%). The percentage of expenses preoperative intravenous and postoperative 48 hour: intravenous antibiotic during hospitalization: post operative antibiotic in group 1 is 19.82%: 59.69%: 20.49%; group 2 is 10.41%: 68.40%: 21.19% and group 3 is 1.39% 80.85%: 17.76%. The average total perioperative cost antibiotic (baht) in group 1: group 2: group 3 are 4,068: 4,776: 5,468. The infected case need operated for scrub and debridement in group 1 is 1 cases, group 2 is one cases and group 3 is 1 cases. CONCLUSION: Overall expense increased in both intravenous and oral antibiotic prophylaxis in total knee arthtroplasty for prevention of infection. The major cost of perioperative antibiotic is intravenous antibiotic more than 48 hours during hospitalization, the least number of patients and percentages of cost is in group 1 than group 2 and 3. The percentage of patients oral antibiotics are least in group 2 than group 1, 3 but the average cost is likely to be quite substantially lower in group 1 then group 2, 3.

Comparing alignment of proximal tibia first cut between narrow and wide saw blade in CAS TKA.

OBJECTIVE: The primary aim of the present study is to comparison between using narrow and wide saw blade of proximal tibial bone cut in close slot cutting block guide verified by computer navigation system. MATERIAL AND METHOD: The authors evaluated 80 knees in 80 patients. After cutting the proximal tibia, the cutting surface was validated using the navigated cutting block adapter, and the angular difference between the cutting surface and that preoperatively planned in the sagittal and coronal planes was recorded. RESULTS: The average cutting error of all knees was 1.8 degrees +/- 2.7 degrees in use narrow blade and 1.2 degrees +/- 2.2 degrees in use wide blade. The authors did not find statistically significant difference between the first 40 patients and the next 40 patients. The average cutting error of sclerotic bone was 2.3 degrees +/- 2.7 degrees in use narrow blade and 1.1 degrees +/- 2.1 degrees in use wide blade. The authors find statistically significant. The average error in the coronal plane was 1.5 degrees +/- 1.1 degrees in valgus and 2 (2.5%) in varus of the 80 knees had a malalignment of more than 1 degrees with respect to the targeted cutting plan. DISCUSSION: Alignment of cutting surface should be checked after cut proximal tibia and recut to reach target alignment and should be cut with wide saw blade especially in sclerotic bone.

Results of computer assisted mini-incision subvastus approach for total knee arthroplasty.

BACKGROUND: Mini-incision subvastus approach is soft tissue preservation of the knee. Advantages of the mini-incision subvastus approach included reduced blood loss, reduced pain, self rehabilitation and faster recovery. However, the improved visualization, component alignment, and more blood preservation have been debatable to achieve the better outcome and preventing early failure of the Total Knee Arthroplasty (TKA). The computer navigation has been introduced to improve alignment and blood loss. The purpose of this study was to evaluate the short term outcomes of the combination of computer assisted mini-incision subvastus approach for Total Knee Arthroplasty (CMS-TKA). MATERIAL AND METHOD: A prospective case series of the initial 80 patients who underwent computer assisted mini-incision subvastus approach for CMS-TKA from January 2007 to October 2008 was carried out. The patients' conditions were classified into 2 groups, the simple OA knee (varus deformity was less than 15 degree, BMI was less than 20%, no associated deformities) and the complex deformity (varus deformity was more than 15 degrees, BMI more was than 20%, associated with flexion contractor). There were 59 patients in group 1 and 21 patients in group 2. Of the 80 knees, 38 were on the left and 42 on the right. RESULTS: The results of CMS-TKA [the mean (range)] in group 1: group 2 were respectively shown as the incision length [10.88 (8-13): 11.92 (10-14], the operation time [118 (111.88-125.12): 131 (119.29-143.71) minutes, lateral releases (0 in both groups), postoperative range of motion in flexion [94.5 (90-100): 95.25 (90-105) degree] and extension [1.75 (0-5): 1.5 (0-5) degree] Blood loss in 24 hours [489.09 (414.7-563.48): 520 (503.46-636.54) ml] and blood transfusion [1 (0-1) unit? in both groups], Tibiofemoral angle preoperative [Varus = 4 (varus 0-10): Varus = 17.14 (varus 15.7-18.5) degree, Tibiofemoral angle postoperative [Valgus = 1.38 (Valgus 0-4): Valgus = 2.85 (valgus 2.1-3.5) degree], Tibiofemoral angle outlier (85% both groups), and Knee society score preoperative and postoperative [64.6 (59.8-69.4) and 93.7 (90.8-96.65)]: 69 (63.6-74.39) 92.36 (88.22-96.5)]. The complications found in both groups were similar. No deep vein thrombosis, no fracture at both femur and tibia, no vascular injury, and no pin tract pain or infection was found in both groups. CONCLUSION: The computer assisted CMS-TKA) is one of the appropriate procedures for all varus deformity, no limitation with the associated bone loss, flexion contractor, BMI, except the fixed valgus deformity. To ensure the clinical outcomes, multiple key steps were considered as the appropriate techniques for this approach which included the accurate registration, precision bone cut and ligament balances, and the good cement techniques.

Clinical outcomes of minisubvastus approach for minimally invasive total knee arthroplasty.

OBJECTIVE: To examine the clinical outcome of minisubvastus approach, a true quadriceps-sparing approach for minimally invasive knee arthroplasty. MATERIAL AND METHOD: Between January 2005 and January 2008, 398 knees were included in this study. We evaluated the results of primary total knee arthroplasties performed with minisubvastus approach in patients at a minimum 1-year follow-up period. A retrospective review of the patient medical records was used. RESULTS: The mean wound length was 11 centimeters and mean blood loss was about 478 milliliters. An average total operative time was 112 minutes. The mean femorotibial angle was corrected from 8 degrees varus preoperatively to 4 degrees valgus postoperatively. Pain assessed by WOMAC score was much improved as the mean score decreased from 50.84 at preoperative to 26.81 at one-year postoperative period. CONCLUSION: Minisubvastus arthroplasty is effective and can be performed in almost of knee deformities.

Reliability and clinical outcomes of preoperative evaluations in modern total hip resurfacing and total hip arthroplasty in patients with osteonecrosis of the femoral head.

BACKGROUND: Modern total hip resurfacing has been associated with excellent intermediate outcome in patients with osteonecrosis hip who are under 60 years., Up to 30-50% necrosis area in X-ray and MRI are theoretically acceptable to perform total hip resurfacing. However, both of plain X-ray and MRI still are uncertain information to precisely support decision making for either hip resurfacing or hip arthroplasty. OBJECTIVE: Double setup operations (resurfacing or arthroplasty) were developed (i) to evaluate the reliability of preoperative evaluation based on plain X-ray and MRI comparing to the intra-operative finding after the completion of bone surface cut in hip resurfacing femoral procedure and (ii) to examine the early outcome for this double set up techniques. MATERIAL AND METHOD: Between September 2004 to December 2008, 45 osteonecrosis hips (40 patients) were managed with double setup in which was either total hip resurfacing or total hip arthroplasty. The final intraoperative decisions were performed and then the comparison of the reliability of pre-operative evaluation was done. Outcomes assessment was examined based on Harris Hip score, Oxford hip score, university of California Los Angeles (UCLA) activity score, Short form-12 score, complications, and radiographic alignment including radiolucencies. RESULTS: Twenty-five hips finally were performed with total hip resurfacing and the rest twenty hips were performed with total hip arthroplasty. Preoperative evaluation plans were unchanged from arthroplasty to resurfacing by intra-operative evaluation in 20 of 33 hips, representing the approximate reliability 61%. All 13 cases whose preoperative plans were changed had preoperative radiographic necrotic head involvement more than 50%, cystic change > 1.5 cm in size, superior head collapse more than 8 mm. The follow-up mean time was 28.6 months (5-50). All postoperative functional scores at the last follow-up (HHS, Oxford, UCLA, SF12) were significantly improved from preoperative functional score (p < 0.001). Pulmonary embolism was found in one patient with sickle cells induced osteonecrosis hip and no further complication after recovery. There was no postoperative infection, fracture neck of femur, DVT, nerve palsy, radiographic change. CONCLUSION: Double setup operations were found efficacious to provide reliable information for the resurfacing surgeons to avoiding the too early total hip arthroplasty in the young patients. As a result, the patients can preserve their femoral heads at best.

The early outcome of Birmingham hip resurfacing: an independent Thai surgeon experiences.

BACKGROUND: Modern metal-on-metal total hip resurfacing show improvement outcome as a viable alternative arthroplasty in the young, but in Thailand it remains controversial whether this procedure is appropriate by Thai surgeon. Some in doubt this procedure may need high technical demand and may not valuable in Thailand. OBJECTIVE: To analyze the early clinical and radiographic outcomes of Birmingham Hip Resurfacing (BHR) by Thai surgeon in Thailand. MATERIAL AND METHOD: Between January 2006 and December 2008, thirty-eight patients (forty hips) who were operated with BHR by same surgeon. The authors evaluated Harris Hip score, Oxford hip score, University of California Los Angeles (UCLA) activity score, Short form-12 score, and complications as well as radiographic alignment and radiolucencies. RESULTS: At a mean follow up of 16.2 months (3 to 33). The mean pre-operative and last follow up Harris Hip score were 35.1 (27 to 41) and 96.4 (95 to 98) (p < 0.001) respectively. The mean Oxford hip score were 44.3 (37 to 52) and 12.4 (11 to 13) (p < 0.001) respectively. The mean UCLA activity score was 3.4 (3 to 4) and 8.8 (8 to 10) (p < 0.001) respectively. The mean SF12 were 18.2 (14 to 23) and 62.2 (59 to 64) (p < 0.001) respectively. There was no patient with radiological evidence of loosening or thinning of the femoral neck. Four cases had intra-operative transient blood pressure drop while impacting metal cup into circumference sealed acetabulum. However no subsequence post operative complication was detected. There was one case with pulmonary embolism in secondary osteonecrosis from sickle cell anemia and resolve without any complication. One case with fracture neck of femur due to osteochondroma removal at anterosuperior head neck junction which exposure too much cancellous bone. She had got successfully conversion to metal on metal total hip replacement with post operative excellent result. There was no infection, deep vein thrombosis and nerve injury. The survival rate was 97.5%. CONCLUSION: As femoral head bone preservation procedure, BHR in this study provides excellent and promise result. Longer study is needed to address more complications. The authors are support the use of BHR in young active patient in Thailand.

Vascularity of the femoral head after Birmingham hip resurfacing. A technetium Tc 99m bone scan/single photon emission computed tomography study.

To investigate the vascularity of femoral heads after Birmingham hip resurfacing (BHR), we used a visual scale to assess technetium Tc 99m HDP planar and single photon emission computed tomography bone scans of 36 arthroplasties in 32 asymptomatic patients for an average of 26 months after BHR. The validity of this method was demonstrated by comparing levels of radiation detected from within and immediately adjacent to a BHR prosthesis placed on a technetium Tc 99m radioisotope tracer-filled hollow tube and further validated in vivo by comparing radiation levels from bilateral hip scans in human subjects with 2 normal hips and with unilateral BHR. All femoral heads scanned postoperatively appeared vascular. We speculate that preserved femoral head vascularity after BHR may be related to increased intraosseous blood supply from metaphyseal vessels in arthritic hips.