Pre-operative flexion contracture determines the functional outcome of haemophilic arthropathy treated with total knee arthroplasty.

End-stage haemophiliac arthropathy can be successfully treated with total knee arthroplasty. However, the functional results may not be as good as anticipated and certain pre-op knee characteristics may alter the functional results. The purpose of this study was to evaluate the functional outcome of TKA in haemophilic patients with specific attention to final range of motion and residual flexion contracture of the joint. Twenty-one consecutive patients were retrospectively reviewed. The average age was 34 years with an average follow-up of 5.7 years. Functional status was evaluated with Hospital for Special Surgery Knee Score. Receiving Operating Characteristics analysis was used to determine the threshold of pre-operative flexion contracture degree to avoid residual knee contracture. The range of motion was increased in 16 joints and unchanged in three joints and decreased in the remaining two. Preoperative average range of motion was 37.6°, improved to 57.1° post-operatively. The average knee score increased from 27.85 (15-30) points pre-operatively to 79.42 (12-94) points at the last follow-up. The degree of pre-operative flexion contracture was found to be a good predictor for residual flexion contracture. (Specificity: 85.7%, sensitivity: 100%, cut-off: 27.5°). Total knee replacement improves the quality of life in patients with advanced haemophilic arthropathy. Statistical analysis revealed that pre-op flexion contracture of 27.5° is an important threshold. Patients should be operated before that stage to gain maximum benefit with minimal gait abnormalities.

Position of the acetabular component determines the fate of femoral head autografts in total hip replacement for acetabular dysplasia.

We have reviewed 54 patients who had undergone 61 total hip replacements using bulk femoral autografts to augment a congenitally dysplastic acetabulum. There were 52 women and two men with a mean age of 42.4 years (29 to 76) at the time of the index operation. A variety of different prostheses was used: 28 (45.9%) were cemented and 33 (54.1%) uncemented. The graft technique remained unchanged throughout the series. Follow-up was at a mean of 8.3 years (3 to 20). The Hospital for Special Surgery hip score improved from a mean of 10.7 (4 to 18) pre-operatively to a mean of 35 (28 to 38) at follow-up. The position of the acetabular component was anatomical in 37 hips (60.7%), displaced less than 1 cm in 20 (32.7%) and displaced more than 1 cm in four (6.6%). Its cover was between 50% and 75% in 34 hips (55.7%) and less than 50% in 25 (41%). In two cases (3.3%), it was more than 75%. There was no graft resorption in 36 hips (59%), mild resorption in 21 (34%) and severe resorption in four (6%). Six hips (9.8%) were revised for aseptic loosening. The overall rate of loosening and revision was 14.8%. Overall survival at 8.3 years was 93.4%. The only significant factor which predicted failure was the implantation of the acetabular component more than 1 cm from the anatomical centre of rotation of the hip.

Total hip replacement in high riding developmental dysplasia of the hip: cementless total hip arthroplasty with femoral shortening using a subtrochanteric resection.

Total hip arthroplasty in younger patients with high riding dislocations is a challenging procedure. Although many procedures have been proposed, our preferred technique for this is to insert a small sized cementless acetabular component in the native acetabulum, a small sized cementless femoral component and perform a subtrochanteric oblique cylindrical resection of 4 centimeters. The femur is fixed with a plate using unicortical screw fixation. This technique is preferred to avoid stretching the neurovascular structures. This procedure was performed on 91 hips of 83 patients with a mean age of 45 years, between 1990 and 2005. After 8 years we observed a 10% failure with a good clinical outcome. The Merle d'Aubigne Hip Scores were improved from 10.65 preoperatively to 34.95 postoperatively. Despite a high complication and failure rate the patients were pleased with the final outcome. We continue to recommend this procedure in this unique patient population.

Erythropoietin for autologous blood donation in total hip arthroplasty patients.

Forty patients who were scheduled for a total hip arthroplasty were enrolled in a prospective study and were randomly divided into two groups. Group 1 received recombinant human erythropoietin (300 U/kg twice a week), and group 2 received placebo. The medication was started 2 weeks before the operation, and only one dose of medication was given after the operation. Autologous blood was administered at the same time as the medication until the hemoglobin level sank to 10 g/dl. Forty-eight and 49 units of autologous blood were collected in group 1 and group 2, respectively. Intraoperative homologous blood was transfused only to patients in group 2. Seven and 13 units of allogenic blood were transfused into group 1 and group 2 patients during the postoperative period, respectively. There were no any significant differences between the groups in terms of early postoperative hemoglobin level and amount of autologous blood collected. However, the increase of the reticulocyte count in patients who received erythropoietin was significantly higher than in the group 2 patients. The study showed that short-term and low-dose erythropoietin usage strongly stimulates the bone marrow. Erythropoietin administration and preoperative autologous blood donation diminished the total units of allogenic blood required during the intraoperative or postoperative period. Autologous blood administration without concurrent erythropoietin did not stimulate the bone marrow adequately.

The value of Tc-99m citrate scintigraphy in chronic osteomyelitis. An indicator of the involved bone.

The authors present a prospective analysis of Tc-99m MDP and Tc-99m citrate scintigraphy in 29 patients who were clinically suspected of having chronic osteomyelitis. All of the patients showed increased Tc-99m MDP uptake on bone scintigraphy involving the area of concern. However, Tc-99m citrate scintigraphy clearly identified the patients with osteomyelitis (N = 18) confirmed either by biopsy or clinical follow-up. Eleven patients who were free of osteomyelitis showed only minimal radiotracer uptake on Tc-99m citrate scintigraphy. These patients had other benign musculoskeletal diseases that were diagnosed by other imaging modalities. In addition to visually interpreting the scintigraphic images, a semi-quantitative analysis was performed by drawing regions of interest over the areas involved and the normal contralateral side, and patients with osteomyelitis were found to have lesion to nonlesion ratios of greater than 1.70. Because Tc-99m MDP is a nonspecific radiopharmaceutical for the evaluation of bone infection, other imaging agents have been investigated. Tc-99m citrate is a small molecule that makes it suitable to penetrate injured capillaries to the edema fluid known to be present in areas of infection. The authors conclude that Tc-99m citrate is a promising agent for localizing and showing the extent of bone infection that will help the surgeon to determine areas of debridement before surgery.

Prostaglandin E2 activity in the synovial-like membrane.

The events leading to aseptic loosening of total hip prostheses occur within the synovial-like membrane that forms around the prosthetic components. Prostaglandin E2 (PGE2) activity in this membrane is believed to be one of the factors that cause aseptic loosening. In this study, the authors investigated the correlation between grades of loosening and levels of PGE2-like activity in the membranes surrounding the implants in 14 patients in which total hip arthroplasty revisions were performed. The membranes of patients with high degrees of loosening demonstrated high levels of PGE2-like activity (P < .01). Among the many factors contributing to loosening of total hip arthroplasties, PGE2 appears to have an important role with its bone-resorbing properties.

Congenital spondylolisthesis in the upper spinal column. Management of two cases.

Two cases of congenital spondylolisthesis involving the cervical and thoracic spinal column are presented. Both patients presented with significant neurologic deficits and responded favorably to stabilization and fusion.