Total knee prosthesis in a patient diagnosed with ochronotic arthropathy. / Prótesis total de rodilla en paciente diagnosticada de artropatía ocronótica.

Ochronosis is a rare genetic disease of phenylamine and tyrosine metabolism in which an accumulation of homogentisic acid occurs. The accumulation of HGA causes alkaptonuria and deposition in the connective tissue causing a dark colouring of the tissue. In the joints, it can lead to early and very disabling arthropathy, known as ochronotic arthropathy. We present the case of a patient diagnosed with ochronosis and ochronotic arthropathy of the left knee, in which we describe the intraoperative process with the macroscopic and microscopic anatomopathological findings. The patient made good progress after implantation of a total knee prosthesis (TKP), PS type, and was able to follow the same rehabilitation protocol used in patients without ochronotic arthropathy undergoing TKP. The patient showed improvement in the different functional scales, as well as disappearance of pain.

Quadriceps muscle characteristics and subcutaneous fat assessed by ultrasound and relationship with function in patients with knee osteoarthritis awaiting knee arthroplasty.

BACKGROUND: Patients with severe knee osteoarthritis are evaluated for total knee replacement (TKR), whose main indications are persistent pain and severe functional limitations substantially affecting mobility. However, evaluation of pain intensity and functional disability is difficult to standardize. OBJECTIVE: To evaluate the relationship between quadriceps muscle thickness (QMT) and quality; the QMT and subcutaneous fat thickness (SFT) and QMT and function in patients with knee OA on a waiting list for TKR. METHODS: Cross-sectional study in consecutively-enrolled patients. Variables: SFT, QMT and rectus femoris muscle quality, assessed by echointensity (EI). Function by the Timed Up & Go Test (TUG); sociodemographic and clinical variables and physical activity were determined. Karl Pearson correlations and multiple linear regression were used. RESULTS: 61 patients (45 female, mean age 69.7 years [SD 7.2], mean BMI 33.0 [SD 5.7], mean comorbidities 3.3 [SD 2.0], 52.5% regular physical activity) were studied. Mean TUG was 15.1 (SD 6.1). Variables retained in the regression model explained 36% of variability in the TUG. Greater muscle content (percentage) (r = -0,291) was associated with better TUG scores (p = 0.001). Greater muscle EI was negatively (r = -0,364) associated with function (p = 0.006). Older age was associated with worse TUG scores while regular physical activity was associated with better TUG scores (p = 0.001 and p = 0.008, respectively). CONCLUSIONS: A higher percentage of quadriceps muscle and better muscle quality (lower EI) was associated with better function. Age and exercise levels influenced function. Ultrasound may provide.

Proximalize osteotomy of tibial tuberosity (POTT) as a treatment for stiffness secondary to patella baja in total knee arthroplasty (TKA).

INTRODUCTION: Stiffness after a total knee arthroplasty (TKA) is one of the most common post-operative complications. The purpose of this study is the evaluation of the effectiveness of TT proximalization osteotomy of improving a lack of flexion and secondary pain in patella baja (infera) post-TKA. MATERIALS AND METHODS: Between April 2007 and July 2012, TT proximalization osteotomy was performed on 21 patients. The average preoperative flexion was 70° (in a range of 60-80). Clinical pre- and post-operative evaluations were performed with Knee Society Score, Western Ontario and McMaster Universities Arthritis Index scales and a satisfaction survey. Modified Blackburn-Peel index and Portner angle were used to evaluate patellar height. RESULTS: After an average follow-up of 35 months (range 18-48), an average flexion of 100° (range 90-100) and an overall satisfaction were obtained. Clinical scores improved significantly. The Blackburn-Peel index and Portner angle improved significantly from 0.3 (range 0.1-0.5) to 0.4 (0.3-0.5) and from 9 (3-15) to 12 (9-18), respectively. Three patients showed no signs of osteotomy consolidation. However, this was not linked to a lack of extension or an increase in local pain. CONCLUSION: TT proximalization osteotomy provides satisfactory results in improving a lack of flexion and pain in patella baja post-TKR.

Secondary patellar resurfacing in the treatment of patellofemoral pain after total knee arthroplasty.

PURPOSE: This paper reports a prospective review of patients who, between 2004 and 2007, underwent secondary patellar resurfacing (SPR) due to anterior knee pain after a primary total knee arthroplasty (TKA). The aim was to evaluate the clinical outcomes obtained with the SPR and to compare them with radiological findings. METHODS: A total of twenty-seven consecutive patients met the inclusion criteria. There were twenty-three (85%) women and four (15%) men with a median age of 70 years. The patients were evaluated before and after the surgery with the same functional scores and radiological parameters. Bone scintigraphy was also used in the assessment, and a CT-scan was performed in order to evaluate the femoral component rotation. The median time between TKA and SPR was 18 months. RESULTS: With a median follow-up of 23 months, seventeen patients (63%) reported a clear subjective improvement after SPR, and patellofemoral scores (primary outcome measure), KSS and WOMAC (secondary outcome measures) showed a statistically significant improvement following the procedure. There were no significant changes after SPR in the Insall-Salvati ratio, the lateral patellar displacement or the lateral patellar tilt. The mean time between TKA and SPR had no statistically significant effect on outcome. The bone scintigraphy revealed increased patellar uptake in seven cases, but this was not related to subsequent improvement after SPR. Rotational computed tomography showed a median internal rotation of the femoral component of 1º. The complications observed were a patellar component loosening and an acute post-infection. CONCLUSION: No clinical or radiological parameter was found to be related to the final outcome after SPR. There was a discrepancy between functional scale scores and the patient's subjective satisfaction.

Hyaline cartilage surface study with an environmental scanning electron microscope. An experimental study.

To obtain images of the articular surface of fresh osteochondral grafts using an environmental scanning electron microscope (ESEM). To evaluate and compare the main morphological aspects of the chondral surface of the fresh grafts. To develop a validated classification system on the basis of the images obtained via the ESEM. The study was based on osteochondral fragments from the internal condyle of the knee joint of New Zealand rabbits, corresponding to fresh chondral surface. One hundred images were obtained via the ESEM and these were classified by two observers according to a category system. The Kappa index and the corresponding confidence interval (CI) were calculated. Of the samples analysed, 62-72% had an even surface. Among the samples with an uneven surface 17-22% had a hillocky appearance and 12-16% a knobbly appearance. As regards splits, these were not observed in 92-95% of the surfaces; 4-7% showed superficial splits and only 1% deep splits. In 78-82% of cases no lacunae in the surface were observed, while 17-20% showed filled lacunae and only 1-2% presented empty lacunae. The study demonstrates that the ESEM is useful for obtaining and classifying images of osteochondral grafts.

Intramedullary versus extramedullary tibial cutting guide in severely obese patients undergoing total knee replacement: a randomized study of 70 patients with body mass index >35 kg/m2.

BACKGROUND: Patients with obesity have an increased risk of osteoarthritis of the knee, which can lead to the need for total knee replacement (TKR). TKR may be more complex in obese patients and the correct orientation of the implant is more difficult. We selected patients with body mass index (BMI) >35 kg/m(2) undergoing TKR and studied the utility of an intramedullary tibial cutting guide in facilitating the correct orientation of the tibial implant. METHODS: Seventy patients with BMI >35 kg/m(2) were selected for a prospective, randomized study. Patients were divided into two groups: In group 1 (n=31), the tibial component was implanted using the aid of a intramedullary tibial guide. In group 2 (n=39), the tibial component was implanted using the aid of an extramedullary tibial cutting guide. RESULTS: The two groups were comparable with respect to age, BMI, and degree of preoperative deformity. Mean age was 69.35 in group 1 and 70.06 in group 2. Group 1 had a mean BMI of 39.84 kg/m(2) and group 2 of 40.05 kg/m(2). Postoperative orientation of the femur and tibia and the mechanical axis were within the normal range in both groups. A statistically significant difference between the two groups was observed in tourniquet time, which was longer in group 2 than in group 1 (p=0.038). CONCLUSION: Two types of guide were compared in correctly orienting the tibial component of the TKR in patients with a BMI >35 kg/m(2). The lesser tourniquet time in the group in which the intramedullary guide was used suggest its usefulness because the positioning and orientation of the tibial cut was carried out more rapidly and anatomical references were not needed for correct orientation, as it is guided by the anatomical axis of the tibia. The use of the intramedullary guide reduces surgical time in these patients.

Relationship between knee anthropometry and surgical time in total knee arthroplasty in severely and morbidly obese patients: a new prognostic index of surgical difficulty.

BACKGROUND: Total knee arthroplasty (TKA) in patients with severe and morbid obesity is one of the current challenges in prosthetic knee surgery. The body mass index (BMI) is used to identify patients who may present difficulties during surgery and postoperative complications. We carried out a prospective study with an initial hypothesis that BMI is not associated with tourniquet time in obese patients undergoing TKA and that some anthropometric parameters may be useful in predicting tourniquet time in severely and morbidly obese patients. METHODS: One hundred consecutive patients diagnosed with knee osteoarthritis with BMI > or =35 kg/m(2) scheduled for TKA were prospectively studied. Suprapatellar, infrapatellar, and supra/infrapatellar anthropometric indexes were calculated before surgery. The tourniquet time was determined. RESULTS: The mean BMI was 39.81 kg/m(2) (SD +/- 3.75). A total of 58% of patients were classified as class III obesity (BMI 35-39.99) and 42% as class IV (BMI > or = 40) Mean tourniquet time was 41.67 min (SD +/- 9.26). There was no association between the BMI and tourniquet time. The suprapatellar index was negatively associated with tourniquet time (p < 0.038). DISCUSSION: The BMI is not the only parameter that should be considered in order to identify severely and morbidly obese patients who may have more surgical difficulties during TKA. Preoperative determination of the suprapatellar index helped us to classify these patients according to the morphology of the knee and predicted a longer tourniquet time and, therefore, greater surgical difficulty, in patients with a suprapatellar ratio below 1.6 in this study.

Effectiveness and safety of tranexamic acid administration during total knee arthroplasty.

BACKGROUND: The administration of tranexamic acid (TA) is associated with a decrease in the number of red blood cell (RBC) units transfused. However, concerns about its safety have hindered its broader use. STUDY DESIGN AND METHODS: We evaluated the effect of TA on RBC transfusion and thromboembolic complications in total knee arthroplasty. We retrospectively studied 414 patients, 215 immediately before introducing TA treatment (control group) and after, in 199 patients without history of thromboembolic diseases (TA group). In a subgroup of patients, a lower extremities contrast venography was performed. RESULTS: Fifty-four per cent of control group patients were transfused with RBC while only 17.6% of TA group patients received RBCs. In the TA that group, those transfused received less units (2.83 vs. 1.89), showed smaller mean calculated perioperative blood loss and haemoglobin values at discharge were higher compared to control group (10.1 vs. 9.3 g/dl). Thromboembolic complications were diagnosed in 2.8% of the patients in the control group and in 1.5% in the TA group. Asymptomatic distal deep venous thrombosis was found in 54 (14.8%) of TA group patients and 54 (30.1%) of control patients. TA administration reduced the expenditure for RBC transfusion plus the cost of TA from 148.94 to 33.87 euro per patient. CONCLUSION: Routine administration of TA during total knee arthroplasty to patients without history of thromboembolic disease is associated with a 67% reduction in RBC transfusions and, in those transfused, with a reduction in the number of units administered. TA treatment was not associated with an increase in thromboembolic complications. Transfusion costs are significantly reduced.

Prótesis total de rodilla rígida: factores etiológicos y tratamiento / The stiff total knee prosthesis: etiological factors and treatment

Introducción. La rigidez articular tras una prótesis total de rodilla es una complicación rara, aunque muy molesta para el paciente.Revisión de conceptos. En este artículo hemos llevado a cabo una puesta al día de la etiología y del tratamiento de la rigidez de las prótesis de rodilla.Conclusión. El conocimiento de las causas de la rigidezsuele ayudarnos a obtener mejores resultados. Sin embargo, en estos casos es raro lograr la movilidad completa

Introduction. Although rare, articular stiffness after a total knee arthroplasty is an extremely disabling complication for the patient.Concept review. This paper contains an update on the etiology and treatment of prosthetic knee stiffness.Conclusion. The knowledge of the causes leading to stiffness can help us obtain better results. However, it is not common to achieve full mobility in these cases

Prótesis total de rodilla rígida: factores etiológicos y tratamiento / The stiff total knee prosthesis: etiological

Introducción. La rigidez articular tras una prótesis total de rodilla es una complicación rara, aunque muy molesta para el paciente.Revisión de conceptos. En este artículo hemos llevado a cabo una puesta al día de la etiología y del tratamiento de la rigidez de las prótesis de rodilla.Conclusión. El conocimiento de las causas de la rigidezsuele ayudarnos a obtener mejores resultados. Sin embargo, en estos casos es raro lograr la movilidad completa

Introduction. Although rare, articular stiffness after a totalknee arthroplasty is an extremely disabling complication for the patient. Concept review. This paper contains an update on the etiology and treatment of prosthetic knee stiffness. Conclusion. The knowledge of the causes leading to stiffness can help us obtain better results. However, it is not common to achieve full mobility in these cases

Health-related quality of life in patients with osteoarthritis after total knee replacement: factors influencing outcomes at 36 months of follow-up.

OBJECTIVES: (1) To evaluate health-related quality of life (HRQL) in patients with severe osteoarthritis (OA) undergoing total knee replacement (TKR) and (2) to identify the influence of sociodemographic, clinical, intra-operative and postoperative variables on HRQL at 36 months after TKR. DESIGN: Prospective study with a 36-month follow-up. Preoperative interviews were carried out with 90 in-patients. The disease-specific Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire was used to measure the health status. Sociodemographic, clinical, intra-operative degree of difficulty, in-patient and postoperative data were collected. Associations were analyzed using linear regression models. RESULTS: Of the 90 potentially eligible patients, 67 (54 females, mean age 74.83, standard deviation [SD] 5.57) completed follow-up assessment. There were significant differences between preoperative and postoperative WOMAC pain, stiffness and function scores (P<0.001, P=0.005 and P<0.001, respectively). Variables retained in each of the models explained between 15% and 23% (R(2) adjusted) of the variability of each WOMAC dimension. Higher preoperative WOMAC scores were associated with greater postoperative improvement (P<0.001). Chronic musculoskeletal pain unrelated to knee OA was associated with higher WOMAC pain, stiffness and function dimension scores (P=0.004, P=0.029 and P=0.005, respectively). Severe (Class III) obesity (body mass index [BMI] 35-39.9) was associated with more pain (P=0.049). CONCLUSIONS: In patients with severe OA, HRQL significantly improved at 36 months after TKR, especially in the pain dimension. Lower preoperative WOMAC scores, chronic pain unrelated to knee OA, and severe obesity negatively influenced postoperative WOMAC scores. This disease-specific questionnaire may help to identify patients at increased risk of negative outcomes after surgery.

Health-related quality of life and costs in patients with osteoarthritis on waiting list for total knee replacement.

OBJECTIVES: To determine: (1) health-related quality of life (HRQL) in patients with severe osteoarthritis (OA) on a waiting list (WL) for total knee replacement (TKR) and to compare it with general Spanish reference population values (RPVs); (2) the influence of sociodemographic and clinical variables on HRQL dimensions and (3) the use and cost of resources related to knee OA. METHODS: Cross-sectional study. HRQL was measured by Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Medical Outcomes Study 36 Item Short Form Health Survey (SF-36) questionnaires. Sociodemographic and disease characteristics, body mass index, pharmacological treatment and the cost and use of economic resources related to knee OA during the 6-months previous to baseline were recorded. Relationships were analyzed using linear regression models. RESULTS: One hundred consecutive outpatients (71 female, mean age 71+/-6.89 years, mean disease duration 11.84+/-10.52 years) were included. Patients showed worse HRQL measured by SF-36 than the reference population, mainly in physical function, physical role and bodily pain dimensions (P<0.05). A low number of visits to physicians were recorded (mean 0.62+/-1.04). Total mean direct medical costs were 200.24 euro (95%CI 167.08-233.40) and total mean direct non-medical costs were 1234.87 euro (95%CI 812.74-1657.00). CONCLUSIONS: The HRQL of patients on a WL is worse than that of the reference population. The main costs of these patients were on non-medical resources, mainly due to functional limitations and loss of autonomy. The results suggest little compliance with knee OA management guidelines.

Use of freeze-dried bone allograft with platelet-derived growth factor for revision of a glenoid component.

Glenoid replacement is technically challenging. Removal of a cemented glenoid component often results in a large osseous defect which makes the immediate introduction of a revision prosthesis almost impossible. We describe a two-stage revision procedure using a reversed shoulder prosthesis. Freeze-dried allograft with platelet-derived growth factor was used to fill the glenoid defect. Radiological incorporation of the allograft was seen and its consistency allowed the placement of a screwed glenoid component. There were no signs of new mature bone formation on histological examination. The addition of platelet-derived growth factor to the allograft seems to contribute to an increase in incorporation and hardness, but does not promote the growth of new bone.

The effect of an educational program to improve health-related quality of life in patients with osteoarthritis on waiting list for total knee replacement: a randomized study.

OBJECTIVE: To evaluate the effect of therapeutic education and functional readaptation (TEFR) on health-related quality of life (HRQL) in patients diagnosed with osteoarthritis on a waiting list for total knee replacement (TKR). METHODS: Randomized controlled trial of 9 months duration was conducted. One hundred consecutive outpatients (71 females, mean age 71 years (range 50-86), mean disease duration 11.84+/-10.52 months) were included. Patients were randomized in two groups. The intervention group received TEFR added to conventional (pharmacological) treatment (n=51). The control group received conventional (pharmacological) treatment only (n=49). The main outcome variable was self-reported HRQL measured by the Spanish version of Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Secondary outcomes were general HRQL measured by Short Form Health Survey general questionnaire (SF-36), number of visits to general physicians and their cost. Assessments were done at baseline and at 9 months. MAIN RESULTS: Eighty patients completed the study. Significant improvement in the WOMAC function was found at 9 months in the TERF group with respect to the control group (P=0.035). Consumption of analgesics increased significantly in the TERF group compared with controls (P=0.036). Significant improvements in pain (P=0.027) measured by WOMAC and in bodily pain (P=0.043) and physical function (P=0.031), measured by SF-36, were observed in the intervention group with respect to baseline. CONCLUSIONS: The function dimension measured by WOMAC of patients who received both pharmacological treatment and TERF improved with respect to the control group receiving only pharmacological treatment. This suggests that a program of TEFR during the period on the waiting list for TKR may reduce the negative impact of this situation.

Knee osteoarthritis: interpretation variability of radiological signs.

The aim of this study was (1) to determine the variability in detecting radiological signs of knee osteoarthritis (OA) between an orthopaedics specialist, a fourth-year resident in the speciality and a recently qualified doctor and (2) to determine which of the existing criteria show the greatest variability when used by the three participants to detect the degree of evolution of the pathology. This observational study included radiographs of 95 patients with knee pain. Osteophytes, narrowing of joint space (excluding inter-osteophyte bridges) subchondral sclerosis, subchondral cysts, collapse of the central joint cortical bone and lateral deformity, according to the criteria of Kellgren and Lawrence, modified by Kallman et al. were evaluated. Anteroposterior radiographs were used. Knees that had undergone previous surgery were excluded. Cohen's kappa index was used to calculate the degree of agreement between observers. The concordance analysis showed a low level of agreement among the three observers of the radiological variables with a maximum of 50% in some parameters. The authors discuss the possible causes of this low level of agreement. The low degree of agreement of 50% among the three observers is in line with previous reports and suggests that better training of observers is necessary and that the use of any classification is problematic.

Recursos de osteosíntesis en fémur porótico / Osteosynthesis resources for osteoporotic femur

Objetivos. Exponer dos técnicas quirúrgicas de refuerzo de una osteosíntesis convencional en situaciones especiales de debilidad ósea del fémur, como son las fracturas periprotésicas, las fracturas patológicas y los fracasos de osteosíntesis previas en pacientes de edad avanzada. La debilidad del hueso puede llegar a dificultar la realización de osteosíntesis estables en fracturas de fémur porque impide el correcto anclaje del material, ya sean agujas, cerclajes o especialmente tornillos. Material y método. Se evaluaron 13 pacientes (media de edad de 78,3 años), 9 de los cuales sufrieron fracturas periprotésicas de fémur, dos fracasos de osteosíntesis previas, un caso de pseudoartrosis tras una fractura periprotésica y una fractura diafisaria en un fémur muy osteoporótico, en los cuales se han utilizado dos técnicas de refuerzo del hueso: el cementado endomedular y el implante de contraplacas atornilladas de aloinjerto óseo congelado. Resultados. Se realizó un seguimiento de estos pacientes en un período que oscila entre 12 y 72 meses (media de 26,2 meses). En un caso se produjo una pseudoartrosis de la fractura por ocupación accidental del foco de fractura por el cemento acrílico. En los 12 casos restantes se consiguió la consolidación. Conclusiones. El cementado endomedular y la utilización de contraplacas atornilladas de aloinjerto óseo son dos recursos técnicos útiles en situaciones especiales en las que es necesario realizar una osteosíntesis estable sobre un hueso muy débil (AU)

The use of fascia lata and bone allograft for uncontained defects in revision knee arthroplasty.

One of the possibilities in the reconstruction of severe bone loss in revision total knee arthroplasty is impaction bone grafting with support of a mesh. We report the use of a fascia lata allograft as a biological mesh for keeping involved impacted bone graft in one case of uncontained tibial bone defects.

Allograft reconstruction of the distal humerus after resection of a breast solitary metastasis: eleven years follow-up.

Resection is a rare indication for the treatment of solitary skeletal metastasis (SSM), and provides an opportunity to cure the oncologic patient. Reconstruction after resection can imply a difficult problem depending on the size and the location of the metastasis. In the reported case, an en-bloc resection of a SSM of a breast cancer located in the distal humerus was performed in 1990. Reconstruction of the osteoarticular defect has been achieved with a massive allograft. At eleven years follow-up the patient remains free of illness and shows a good functional result. With the result obtained in the reported case, we suggest that osteoarticular allograft can be of considerable value for reconstruction after excision of SSM in the distal humerus, and that cure can be achieved with the radical resection of a SSM of breast cancer.

Long-term results of hemipelvic allograft: Report of four cases.

Reconstruction after the excision of pelvic tumors involving the pelvic ring implies difficult problems. Restoration of the function is difficult and an allograft can be one of the possible solutions. Pelvic allograft is recommended by many authors to reconstruct the pelvic ring following extensive resections of bone tumors. Between 1988 and 1989, we performed hemipelvic resection and allograft reconstruction in 4 patients with pelvic sarcomas. The mean age was 42.3 years (range 38-48), consists of 3 male and 1 female. One case developed an infection and one case showed recurrence, both responding to surgical treatment. Outcome in those cases in which surgery was curative to the primary tumor was satisfactory at 10 years follow-up, with a mean total Enneking score of 25.3 (range 24-27) and a good functional result in Merlé D'Aubigne functional score. Despite the limited number of cases presented, our results added to the reported results in the literature led us to consider that allografts are valuable in pelvic reconstructions after en-bloc resections for bone tumors.