Complications following Iliac Wing Fibrosarcoma.

The aim of this case report is to underline surgical strategies for complications in a case of a young man with fibrosarcoma of the bone treated with pelvic resection followed by reconstruction with massive bone allograft. A type I pelvic resection was performed as a radical resection of tumor followed by a biological reconstruction of iliac wing using frozen allograft. The iliac allograft was fixed in place using 4 screws. The immediate postoperative period was complicated with local sepsis of reconstructed site treated with pediculate omentoplasty. After 1 year from surgery, the X-ray exam showed an integrated allograft. After 20 years from the first surgery, the patient presented with the left hip pain of 3-month duration with mechanical pattern. The X-ray and CT exam showed the left hip arthritis and no signs of recurrence. A total hip arthroplasty with dual mobility cup and uncemented stem was performed. Despite the immediate postoperative local infection, the allograft was left in place and integrated after all. Omentoplasty could be a very useful technique in eradicating local infection, due to the immunogenic properties of the omentum. The allograft is still strong enough to give support for a hip arthroplasty at 20 years after implantation.

Cost Effectiveness Analysis of Knee Osteoarthritis Treatment.

INTRODUCTION: Resource allocation is challenging in times of economic restraint and cannot be based only on clinical judgments, but must also take into account economic aspects. A method for assessing patient outcome is to estimate the quality-adjusted life years (QALYs). These will quantify the benefit gained by a certain treatment by measuring the change in health-related quality of life with time. This study will assess the cost effectiveness of conservative management, consisting in rehabilitation program, and compare the cost effectiveness of total knee arthroplasty when implanted to a non operated arthritic knee with cost effectiveness of the same procedure following high tibial osteotomy. MATERIALS AND METHODS: This study reviewed 30 patients who were treated for knee osteoarthritis with rehabilitation care (group 1-G1), 30 patients who underwent unilateral TKA to an non-operated knee (group 2-G2) and 30 patients who underwent TKA following HTO for degenerative arthritis of the knee (group 3-G3). The economical endpoint were the total direct costs (Euro), based on DRG rates for procedures. The cost effectiveness analysis was assessed by the ratio between direct costs as assessed by the economical endpoint and the associated patient benefit as assessed by the clinical endpoint (EUR/QALY). RESULTS: No statistically significant differences was found between G2 and G3 regarding clinical or radiological outcomes of this study. Yet the patients who did not previously suffered a HTO procedure showed lower mean values of KSS, ROM and femurotibial angle. A significant benefit is observed for G2 and G3 towards G1 patients. Neither a clinically relevant nor a statistically significant association between groups is observed in G2 and G3 (median benefit estimates 2.5 versus 2.6 QALYs). Median benefit estimate for patients who did not previously suffered a HTO procedure was though smaller then benefit for those who did. A median cost effectiveness ratio of 1800 EUR/QALY (450 - 2000 EUR / QALY) was found based on the EuroQuol scores for G1; 1268 EUR/QALY (720 - 2160 EUR/QALY), for G2, and 1975 EUR/QALY (720 - 2160 EUR/QALY) for G3. DISCUSSION: Regarding surgical treatment, the results showed a statistically significant better cost benefit relation for patients from G2 (p 0,001). Conservative management for knee OA is neither clinically effective for pain or disease progression nor cost effective, when applied for late stages of OA. CONCLUSION: We report the lowest cost per QALY in the literature for TKA. If financial constraints is a cause for rationalizing the medical services, careful patient selection to optimise the clinical and economical aspects of procedures may help to improve further the cost-effectiveness of these interventions.

Comparative study of design and PCL-substituting systems of total knee prosthesis.

UNLABELLED: The aim of this study is to assess postoperative results obtained by different knee implants. The main implant types differences are given by generally implant design and by PCL substituting systems that are used. MATERIAL AND METHOD: Between 04.2004 - 02.2012 we have performed 506 total knee arthroplasties (TKA), on a group of 460 patients. Our choice, was for cemented total knee prostheses, using PCL-substituting systems. Regarding general design and PCL-substituting systems of the implant we had divided the main group in three lots. In order to assess post operative result we had used the American Knee Society Score(AKSS). RESULTS AND DISCUSSIONS: All prostheses types that we had implanted, had registered satisfactory values of AKSS. Our study showed that one group scored higher values of AKSS, compared the other two, but there are not statistical semnificative differences (p=0,09).

The influence of total knee arthroplasty on postural control.

INTRODUCTION: The aim of this study is to assess the changes induced by the unilateral total knee arthroplasty procedure in human postural control. MATERIALS AND METHODS: The measurements were performed using the "AMTI AccuGait" force plate. Subjects completed three consecutive double-limb standing balance trials. The mediolateral and anteroposterior displacements were derived from the force and moment profiles measured by the force platform. The path length per unit time (average velocity) and Elipse 95 (collect 95% of data) were also assessed. RESULTS: Mediolateral displacement increase of 3.4% was observed postoperatively. Postoperative anterolateral displacement increase of 23.2% was recorded. The average velocity also rose by 16.8% postoperatively. The Elipse 95 grew by 33.7%postoperatively. DISCUSSION: Excepting mediolateral displacement, all the other studied parameters showed significantly (p 0.05) higher values in the postoperative period compared with the preoperative one, in both open and closed eye trials. CONCLUSIONS: The study results demonstrate that balance control is weaker shortly after unilateral knee arthroplasty,than in the preoperative period. Although proprioception is altered in osteoarthritic knees, the TKA procedure may additionally affect proprioceptors. The TKA causes additional instability in the days after the procedure, therefore the risk of falling injuries is higher in this period.

Stress distribution on a valgus knee prosthetic inclined interline -- a finite element analysis.

Total knee arthroplasty following valgus deformity is a challenging procedure due to the unique set of problems that must be addressed. The aim of this study is to determine, with a finite element analysis, the load distribution for an inclined valgus prosthetic balanced knee and to compare these results with those of a prosthetic balanced knee with an uninclined interline. Computational simulations, using finite element analysis, focused on a comparision between load intensity and distribution for these situations. We studied valgus inclination at 3 and 8 degrees. We noticed that for an inclination of 3 degrees, the forces are distributed almost symmetrically on both condyles, similar to the distribution of forces in the uninclined interline case. The maximum contact pressure is greater, increasing from 15 MPa to 19.3 MPa (28%). At 8 degrees of inclination, the contact patch moved anterolateraly on the tibia, meaning that the tibial condyles will be unequally loaded. The maximum contact pressure increases to 25 MPa (66%). These greater forces could lead to polyethylene wear and collapse. Additional tibial resection could be a useful method for balancing in severe valgus knee, when valgus inlination does not exceed 3 degrees.

Arthroplasty risk after kidney or liver transplant.

In recent years the rate of kidney or liver transplantation has increased considerably, with an increasing rate of immunosuppressant medication for secondary bone disorders. As the rate of organ transplantation increases, the greater predisposition of these patients to hip or knee arthroplasty is noticed. Although arthroplasty is safe in the general population, its safety in liver transplant recipients is unclear. The purpose of this study is to evaluate safety and durability of hip or knee arthroplasties in liver or kidney transplanted patients. Our study included 5 hip and knee arthroplasties performed in transplanted liver and kidney. All patients underwent immunosuppressive therapy. All cases were submitted to postoperative antibiotic therapy and in the case of cemented implants, antibiotic impregnated cement was used. There were no major short-term or long-term complications. We noticed no case of postoperative sepsis, and implant durability has not been affected by the directly transplant related causes. In conclusion arthroplasty for patients with kidney or liver transplant has a positive impact on their quality of life, being a safe and successful procedure with minimum perioperative safeguards.

6 years follow-up of hip revision surgery.

Revision total hip arthroplasty often presents surgeons with difficult bone loss problems. The purpose of this study was to evaluate the results of hip revision surgery according to bone stock We evaluated, in a retrospective study, 148 hip revision surgeries during 2004 to 2010. The Harris Hip Score (HHS), the acetabular cementation, the AAOS classification, the SOFCOT 99 bone loss grading and Barrack classification were used for clinical and radiological assessment. It can be observed significant improvement of HHS from a mean value of 45 preoperatively to 77.2 points postoperatively. Grade B acetabular cementation was observed in a significantly higher rate for situations that needed acetabular allograft reconstruction and where it cannot be performed because of allografts lack. Barrack grades C and D cementation were associated with 70% of SOFCOT 99 stage III and IV cases and only 5% of SOFCOT 99 stage 0-II cases.Using bone graft seems to be a reliable solution for restoring bone stock and stabilizing the cup in revision total hip arthroplasty with type II-IV acetabular defect according to the AAOS classification. Because SOFCOT 99 stages III-IV are often associated with poor cementation we prefer using uncemented distally fixed with screws revision stems for these cases.

The extended use of modular knee endoprostheses.

Modular knee prostheses have been used since the 1980's. Their goal was to offer an alternative to reconstructing large bony defects without using bone grafting. Initially, they were used for reconstruction after resection of tumours about the knee. Their success encouraged their use in the treatment of some failed total knee arthroplasties, with large bony defects and severe ligamentous instability. We have implanted 7 modular knee prostheses between July 2006 and January 2009. There were 4 tumoral cases, 1 case of desarthrodhesis after a Campanacci procedure and two cases of failed total knee arthroplasties. We have achieved encouraging results using these implants with all but one patient surviving at two years after surgery. All the implants were considered to function normally regarding range-of motion, muscle strength and gait. The surgical and medical management of patients with bone sarcomas has advanced greatly during the last 20 years, improving their overall survival. Thus, the surgeons are provided with increased abilities to perform limb-sparing or joint-mobility sparing surgery.

Great omentum plasty--original method of treatment of the septic complications of hip and pelvis surgery.

UNLABELLED: The septic complications after hip arthroplasty are extremely severe due to frequent chronicity and prosthesis looseness, despite the expensive long-term antibiotic treatment. Starting from the well-know function of the greater omentum to isolate any septic intraperitoneal processes (an "extended lymph node"), we initiated a surgical technique which uses the greater omentum in the treatment of septic complications after hip surgery. METHOD: The technique consist in mobilisation of the greater omentum along the right or left gastroepiploic artery according to the affected hip, and placing it in the septic area after passing it anterior or posterior of the inguinal ligament. Between 1997 and 2004 we performed this technique on 5 patients (4 men and 1 woman) with ages ranking between 24 and 47, which presented chronic infections after hip arthroplasty (4 cases) and after iliac bone resection-reconstruction for fibrosarcoma (1 case). RESULTS: The post-operatory evolution was favourable in all cases. In one case the local septic process pursued demanding a reintervention that revealed that the great omentum has been retracted from the hip area. In 4 cases the septic processes has withdraw spectacularly. CONCLUSIONS: The use of the greater omentum in the treatment of septic complications after hip and pelvic surgery represents in some cases the only effective solution. This technique requires a good collaboration between orthopaedic and general surgeons.

Total hip arthroplasty in secondary systemic lupus erythematosus femoral head avascular necrosis.

Systemic lupus erythematosus is a multisystem disease with a large spectrum of clinical manifestations and a variable course. Lupus is marked by both humoral and cellular immunologic abnormalities, including multiple auto-antibodies especially anti DNA antibodies. Epidemiology - female predominance, occurring usually between second and fourth decade of life, more frequently in hispanic and black patients. Family predominance has been noticed. Provocative agents - ultraviolet light, viral infections, drugs and situational stresses. Pathogenesis - pathological features can affect a large spectrum of internal organs and systems - osteoarticulary injuries, skin rash, lymphadenopathy, glomerulonephritis, myocarditis, digestive system lesions. Musculo skeletal abnormalities include migratory arthritis, effusion and stiffness in small and large joints. Articular erosions are uncommon. Skeletal abnormalities include osteopenia and osteonecrosis, due to two pathological mechanisms: vasculitis and long term corticotherapy. Fifteen to twenty percent of SLE patients are affected by femoral head avascular necrosis (FHAN). Diagnosis rests on clinical signs - hip pain, limited range of motion, walking with a limp.; radiological findings - best grouped in Arlet-Ficat standing system; MRI - high sensitivity, especially in infraradiological stages. Treatment - in incipient stages core decompression represents the best therapeutical option. In advanced, arthritis stages, total hip arthroplasty (THA) is the standart treatment. Three implant types are available: bipolar, uncemented and cemented. An increased number of cotyloidites occurred after bipolar implants. Emphasised osteopenia and excessive bleeding represent contraindications for uncemented implants. Considering all of this, cemented implants are considered, the right choice, methacrylate cement providing strong and durable fixation of THA implants to bone. No meaningful differences were observed in postoperative functional recovery between LSE patients and other etiology FHAN patients.

[Resection--reconstruction in malignant tumors of the locomotory apparatus]. / Rezectia--reconstructie în tumorile maligne ale aparatului locomotor.

The malignant bone and soft tissue tumors, represents, like any other type of cancer, a continuous challenge for surgeon, who is constrained to search and find new techniques, to improve not only the life expectancy, but the quality of the life too. This aim determined orthopedic surgeons to perform new operations, with a complex technique, like resection - reconstruction of the limb. In orthopedic clinic of Elias Hospital, we had 35 patients with malignant tumors of the limbs; we performed 14 resection--reconstructions, with or without preserving the joint mobility. In 3 cases, we used for reconstruction, modular endoprosthesis and we were able to preserve limb integrity and, also, the joint normal function. The good results we achieved until now represents a motivation for us to continue the battle against this terrible affection.