Midterm Outcomes of Unicompartmental Knee Arthroplasty for the Treatment of Knee Medial Compartment Osteoarthritis: A Retrospective Study.

Objectives: Many surgeons avoid performing unicompartmental knee arthroplasty (UKA) due to various concerns. Cohort studies showing the satisfactory outcomes of UKA can convince surgeons to use this technique. In this study, we report the mid-term outcomes of UKA in a series of patients with medial compartment knee osteoarthritis. Methods: Seventeen patients with unicompartmental degenerative joint disease of the knee that underwent UKA and were available for final evaluation were included. The mean age of the patients was 63 ± 5.1 years. The mean follow-up of the patients was 37.2 ± 18.3 months. The outcome measures were the Oxford Knee Score (OKS), Knee Society Score (KSS) for knee score and knee function, Knee injury and Osteoarthritis Outcome Score (KOOS), knee range of motion (ROM), and satisfaction rate on a 5-point Likert scale. Results: In the last follow-up visit, the mean of OKS and knee score section of the KSS were 44.6 ± 3.2 and 83.8 ± 2.1, respectively. The mean knee function section of the KSS was measured at 98.2 ± 7.2. The mean KOOS score and the mean knee ROM were 84 ± 9.4 and 134.4 ± 7º, respectively. The mean VAS for pain was 8.9 ± 1.1 (range 8-10) before the operation and 1.2 ± 0.8 (range 0-2) at the last follow-up. All the patients were very satisfied (n=14) or satisfied (n=3) with the results. No postoperative complication or reoperation was recorded during the follow-up. Conclusion: Unicompartmental knee arthroplasty provides satisfactory outcomes and a high survival rate, at least in mid-term follow-up. These findings suggest increased use of UKA in future workups.

Association of serum vitamin D status with serum pro-inflammatory cytokine levels and clinical severity of fibromyalgia patients.

BACKGROUND & AIM: The role of vitamin D deficiency in fibromyalgia (FM) pathogenesis is not clearly understood. In this study, we evaluated the association of serum vitamin D status of FM patients with laboratory indices of inflammation, as well as clinical indices of FM. MATERIALS & METHODS: Ninety-two female FM patients with a mean age of 42.4 ± 7.4 years were included in this cross-sectional study. Serum vitamin D, serum IL-6, and serum IL-8 levels were evaluated using an enzyme-linked immunosorbent assay. Serum vitamin D levels were categorized as deficient (<20 ng/ml), insufficient (20-30 ng/ml), and sufficient (30-100 ng/ml). The clinical severity of the disease was assessed by the fibromyalgia impact questionnaire (FIQ) and widespread pain index (WPI). RESULTS: The mean serum IL-6 level was significantly higher in vitamin D-deficient patients in comparison with vitamin D-sufficient patients (P = 0.039). The mean serum IL-8 level was also significantly higher in vitamin D-deficient patients in comparison with vitamin D-sufficient patients (P < 0.001). A significant positive correlation was found between the serum IL-8 level and FIQ scores (r = 0.389, p = 0.001) and the WPI of the patients (0.401, p < 0.001). Serum IL-6 level was significantly correlated with the WPI of the patients (r = 0.295, p = 0.004), but not with FIQ scores (r = 0.134, p = 0.066). Serum vitamin D status was not associated with either FIQ scores or WPI. CONCLUSION: In FM patients, serum vitamin D deficiency is associated with higher levels of serum pro-inflammatory cytokines, and higher levels of serum pro-inflammatory cytokines are associated with greater FM impact.

How durable are the effects of cognitive-behavioural therapy in controlling fibromyalgia symptoms? A prospective cohort study.

PURPOSE: Cognitive-behavioural therapy (CBT) is widely used for the treatment of fibromyalgia. However, there is no consensus on the durability of its effects on these patients. In this study, we evaluated how durable are the effects of CBT in controlling fibromyalgia symptoms. METHODS: Forty-eight fibromyalgia patients treated with traditional face-to-face CBT were included. CBT was performed in 20 consecutive group sessions. To evaluate the durability of treatment, the effects of CBT on fibromyalgia symptoms were checked at five time-points: before the CBT, immediately after the CBT, 3 months after the CBT, 6 months after the CBT, and 12 months after the CBT. Outcome measures were the Fibromyalgia impact questionnaire (FIQ) and widespread pain index (WPI). RESULTS: The mean FIQ score of the patients was 68.3 ± 18.8 before the CBT and 50.5 ± 14.1 1 week after the CBT (p < 0.001). The mean post-CBT FIQ score did not significantly change three and 6 months after the CBT (p = 0.11 and p = 0.09, respectively) while the positive effects of CBT significantly diminished after 12 months (p < 0.001). The mean WPI was 10.4 ± 3.6 before the CBT and 8.6 ± 3.1 1 week after the end of CBT (p < 0.001). The mean WPI of three and 6 months was not statistically different from that immediately after the CBT (p = 0.18 and p = 0.15, respectively), while after 12 months, it significantly worsened (p < 0.001). CONCLUSION: CBT's beneficial effects for fibromyalgia patients are durable for 6 months. Complementary CBT sessions could be implemented to boost the CBT effect after this period.

Pes anserine detachment in posteromedial approach to the tibial plateau fracture provides better intraoperative exposure without compromising the flexor muscle strength.

PURPOSE: During the posteromedial approach to the tibial plateau fracture (TPF), pes anserine is generally retracted. However, pes anserine detachment could provide a better fracture site exposure. Even so, the general conception is that the latter could negatively affect flexor muscle strength. We aimed to evaluate the effect of pes anserine detachment on the flexion force and functional outcomes of TPF with posteromedial involvement. METHODS: In this retrospective-prospective cohort study, 22 TPF patients with Schatzker type IV who were managed with posteromedial approach and pes anserine detachment were included. The knee flexion force was measured 12 months after the surgery at several angles of flexion (30°, 60°, and 90°) and rotations (internal and external). The International Knee Documentation Committee (IKDC) and the Knee Injury and Osteoarthritis Outcome Score (KOOS) were used to assess knee function. A visual analog scale (VAS) was used to measure knee pain. RESULTS: The mean strength of the knee flexor muscle was not statistically different between the involved and non-involved sides at 30°, 60°, and 90° knee flexion, and also at the internal and external rotation. The mean IKDC score of the patients was 81.6 ± 7.8. The mean KOOS score of the patients was 82.2 ± 9.1. The mean VAS for pain was 2.4 ± 1.8. The mean knee range of motion was 124 ± 10.5°. CONCLUSION: Pes anserine release and re-attachment in the posteromedial approach to the TPF has no detrimental effect on the flexion muscle strength and knee function. LEVEL OF EVIDENCE: Therapeutic Level IV.

Evaluation of early complications, outcome, and mortality in Coronavirus Disease 2019 (COVID-19) infection in patients who underwent orthopedic surgery.

BACKGROUND: A higher mortality and morbidity rate has been reported in COVID-19 patients undergoing surgery. To reduce the morbidity and mortality rate in COVID-19 patients undergoing orthopedic procedures, we aimed to increase the threshold for surgical planning. METHODS: In a prospective cohort study, COVID-19 patients who underwent elective or emergent orthopedic surgery in three orthopedic surgery centers from February 2020 to September 2020 were included. In this period, 6751 patients were scheduled for orthopedic surgery. To increase surgical threshold planning, all patients with grade 5 of the American Society of Anesthesiologists (ASA) classification and patients with COVID-19 related moderate to severe pulmonary involvement were identified as high-risk patients and were excluded. RESULTS: 35 deaths occurred during the study. The frequency of deaths was significantly higher in patients with COVID-19, 6 (9.4%) than patients without COVID-19, 29 (0. 43%). The average hospitalization stay was 12.8 ± 12.1 days. The odds ratio (OR) for death was significantly higher in patients with COVID-19 than patients without COVID-19. [OR: 8.13, Confidence interval 95% (CI95%) (5.02-11.25), P: 0.001]. Four (6.3%) COVID-19-associated complications were recorded in this series that all were respiratory failure requiring unexpected postoperative ventilation. Twenty surgical complications (31.3%) were recorded. The odds ratio for ICU admission was significantly higher in patients with COVID-19 than patients without COVID-19. [OR: 5.46, CI 95% (2.68-8.68), P: 0.001]. CONCLUSIONS: An increased threshold for orthopedic surgery is suggested for COVID-19 patients with a mortality rate of 9.3%, which is less than the mortality rate in other studies. Level of evidence III.

A More Positive Culture by Resin-containing Media Usage after Suspicious Arthroscopic Infections in Patients Receiving Antimicrobial Therapy.

BACKGROUND: Although infections following arthroscopic surgery of cruciate ligament and meniscus are uncommon, they have potentially serious consequences for the graft and articular cartilage. This study aimed to investigate the efficacy of correct sampling and appropriate media, especially resin-containing media, for the detection of infections in patients receiving antibiotics under suspicion of joint infection after arthroscopic anterior cruciate ligament (ACL) and meniscal surgery. In such cases, proper sampling and the use of suitable culture media that cause the neutralization of antibiotics are very effective in isolating microorganisms from the patient samples and positive cultures. METHODS: In total, 10 patients who had received antibiotics with suspected knee infection after arthroscopic ACL and meniscal surgery were identified after referral to surgeons during a period of 10 months and investigated in this study. The sample collection, culture on various media (i.e., resin-containing culture media), microbiological tests, and antibiotic susceptibility tests were performed in this study. The amplification of the mecA gene using PCR assay was accomplished for methicillin-resistant staphylococcus strains. RESULTS: This study was conducted on 10 patients who underwent arthroscopic procedures and had received antibiotics. Overall, joint fluid and tissue culture were positive in 60% of the patients. The resin-containing media revealed a trend toward increased detection of bacteria. Coagulase-negative staphylococcus strains were the most frequently isolated bacteria in arthroscopic ACL surgery infections. Out of five methicillin-resistant staphylococcus strains, four strains were found that were resistant to cefoxitin and positive-mecA designated as methicillin-resistant strains. Except for one case, the rest of the staphylococcal strains were resistant to methicillin but susceptible to vancomycin. CONCLUSION: Despite uncommon and low percentage of infections after arthroscopic ACL and meniscal surgery, the results of our study showed that correct sampling, appropriate cultures, especially aerobic and anaerobic resin-containing media, and microbiological testing remained useful and valuable for diagnosing bacterial infections.

Serum Calprotectin as a Blood-Based Biomarker for Monitoring Knee Osteoarthritis at Early but Not Late Stages.

OBJECTIVE: The identification of early-stage osteoarthritis (OA) is crucial for the deceleration of its progression; however, no reliable biomarker is available for this purpose. The current study aimed to determine the role of serum calprotectin in the detection of early-stage knee OA. DESIGN: In a case-control study, serum samples were collected from 84 patients with primary bilateral knee OA and 52 healthy controls. The radiographic grading of knee OA was performed using the Kellgren-Lawrence classification system. Serum concentrations of calprotectin were measured using an enzyme-linked immunosorbent assay. RESULTS: The mean serum calprotectin level was 2908 ± 2516 ng/mL in OA patients and 901 ± 875 ng/mL in healthy control subjects (P < 0.001). Mean serum calprotectin levels were significantly higher in the lower stages of OA: 3740 ± 2728 ng/mL in OA grade I, 3100 ± 2084 ng/mL in OA grade II, 2246 ± 1418 ng/mL in OA grade III, and 2035 ± 765 ng/mL in OA grade IV (P = 0.047). Serum calprotectin levels were significantly higher in patients with a disease duration <42 months compared with those with a disease duration >42 months (P = 0.043). CONCLUSION: Serum calprotectin level increases significantly in the early stages of OA and shows a reverse association with disease severity. Therefore, it could be suggested as a promising blood-based marker for early-stage knee OA.

The value of serum total oxidant to the antioxidant ratio as a biomarker of knee osteoarthritis.

BACKGROUND & AIMS: The balance between oxidants and antioxidants is known as oxidative balance, which is impaired in many disease conditions such as osteoarthritis (OA). In this study, we aimed to evaluate this balance in OA patients through the evaluation of the oxidant to the antioxidant ratio. MATERIALS AND METHODS: A total of 62 knee OA patients and 20 age, sex, and BMI-matched healthy controls were included in this cross-sectional study. Serum total oxidant status (TOS) and total antioxidant capacity (TAC) were evaluated using the oxidation-reduction colorimetric assay. The TOS to TAC ratio (TOS/TAC) was evaluated as an estimate of the oxidant to antioxidant balance. RESULTS: The mean TOS was 14.2 ± 2 µM in the healthy controls and 23.3 ± 7 µM in the OA patients (p < 0.001). The mean TAC was 38.8 ± 6.6 µM in the healthy subjects and 35.8 ± 12 µM in the OA patients (p = 0.33). The mean TOS/TAC was 0.38 ± 0.09 in the healthy subjects and 0.72 ± 0.3 in the OA patients (p < 0.0001). TOS/TAC value was capable of distinguishing OA patients from healthy controls with the sensitivity and specificity of 87.1% and 80%, respectively (p < 0.001). At the cutoff value of 0.46, positive TOS/TAC (>0.46) was identified in 100% of grade I patients, whereas it was negative in 27.3%, 16.7%, and 16.7% of grades II, III, and IV, respectively (p = 0.039). CONCLUSION: In the knee OA, an equation of the serum TOS to TAC could be a good representative of oxidative balance than each component individually.

Retaining the medial collateral ligament in high tibial medial open-wedge osteotomy mostly results in post-operative intra-articular gap reduction.

PURPOSE: The current study aimed to evaluate how open-wedge high tibial osteotomy (OWHTO) without the release of medial collateral ligament (MCL) changes in vivo intra-articular joint space after the surgery. METHODS: Patients with varus malalignment of the knee with an indication for OWHTO were included in this study. The intra-articular gap was measured before and 30 min after OWHTO without MCL release using a series of calibrated nerve hooks. The association of post-operative gap size with varus angle, medial proximal tibial angle (MPTA), lateral distal femoral angle (LDFA) and joint line convergence angle (JLCA) was also assessed. RESULTS: A total of 42 knees from 38 patients were evaluated. The mean size of the intra-articular gap of the medial compartment was 5.2 ± 1 mm before the osteotomy and 3.1 ± 2.2 mm at 30 min post-osteotomy. The size of the intra-articular gap decreased post-operatively in 30 knees (71.5%), increased in eight knees (19%) and remained the same in the remaining four knees (9.5%). Smaller MPTA and more correction were associated with a decrease in gap size after the osteotomy (p = 0.01 and p = 0.03, respectively). A significant negative correlation was observed between the correction size and the gap size after osteotomy (r = - 0.317, p = 0.04). CONCLUSION: Intra-articular pressure of the medial compartment increases in the majority of cases following OWHTO without MCL release. Until the factors affecting this increased pressure are thoroughly identified, MCL release seems to be a wiser option during OWHTO. LEVEL OF EVIDENCE: III.

Diminished femoral head-neck offset and the restricted hip range of motion suggesting a possible role in ACL injuries.

PURPOSE: Femoroacetabular impingement may be associated with anterior cruciate ligament (ACL) injuries. The purpose of this study was to determine the head-neck offset, as measured by 45° Dunn's view alpha angles, in patients with ACL injuries compared to control subjects. METHODS: In this retrospective study, 140 consecutive non-professional athletes with primary ACL ruptures confirmed with knee arthroscopy and 100 consecutive patients with non-ACL injury were enrolled. Hip range of motion was assessed in lower extremities in all participants, and alpha angle was calculated according to 45° Dunn's view radiographs. RESULTS: There is not any difference in age, gender distribution, height, weight, and BMI between groups. Internal rotation, abduction, and adduction of the hip were significantly decreased in ACL-injured patients comparing with control subjects (p < 0.001). ACL-injured patients had also a significantly higher alpha angle comparing to the control individuals (p < 0.001). The mean of alpha angle in the ACL-injured patients was 56.1 (SD 10.1) and in the non-ACL-injured group was 49.3 (SD 9.4). CONCLUSIONS: The patients in ACL-injured group showed a significant restriction in hip range of motion and also a diminished femoral head-neck offset suggesting a possible role of these findings in the outcome assessed. LEVEL OF EVIDENCE: III.

Unusual Presentation of Synovial Sarcoma as Meniscal Cyst: A Case Report.

Periarticular cyst and cystic soft tissue lesion around the knee are common. Synovial sarcoma is a rare and malignant soft tissue tumor accounting for approximately 5% of soft tissue sarcoma. A case is presented where a lesion adjacent to the joint line of the knee was diagnosed clinically and on imaging as a meniscal cyst. MRI signal was homogenous and no concomitant meniscal tears were seen. The tissue diagnosis was monophasic synovial sarcoma.

The results of biplanar distal femoral osteotomy; a case series study.

BACKGROUND: Distal femur wedge osteotomies for varus or valgus alignment of the lower extremity could be done in either uniplanar or biplanar fashion.Union time and stability of the osteotomy site has been considered important in this anatomic region. In this study, clinical and radiographic findings of biplane distal femur osteotomy were reported. METHODS: Clinical, functional, and radiological findings of eight patients (10 knees) underwent biplane distal femur osteotomy were evaluated. Visual analogue score (VAS) and Lysholm-Tegner knee score were used for the assessment of pain and function before and three months after surgery. RESULTS: In this study, eight patients were included. All patients were female. The mean age was 28±6.3. The mean pre-operative mechanical angle was 8.7±2.2° and the post-operative angle was 1.4±0.53° in patients with valgus alignment whileit was 7.0±1.0°preoperatively and 0.66±1.2° postoperatively in patients with varus alignment. The mean lateral distal femoral angle (LDFA) was 85±8.0° before surgery and was 88±1.3° after surgery. According to Lysholm-Tegner knee score, in the post-operative visit, six knees were good and four were excellent. The mean union time was 9.2±2.3 weeks. CONCLUSIONS: Biplane distal femur osteotomy is a reliable technique that creates larger surfaces and more stability at the osteotomy site with further rapid union.

Arterial blood gas and spirometry parameters affect the length of stay in hospitalized asthmatic patients.

BACKGROUND: Asthma is a common condition in general medical practice, and it accounts for about 1% of all ambulatory hospital visits. Nowadays, hospitalization rates for asthma have actually been increased in some demographic subgroups despite recent advances in treatment. Understanding the underlying factors that contribute to hospitalization and especially duration of the hospitalization of asthmatics could help elucidate the recent rise in morbidity and also reduce the high demand on health care systems of the disease. The aim of this study was to evaluate factors affecting the duration of hospitalization for Iranian patients with asthma. METHODS: This study was conducted on 55 asthmatic patients (diagnosis of asthma was in accordance with the criteria of the American Thoracic Society). The study was performed on patients hospitalized in Rasoul-e-Akram hospital in Tehran, Iran during the period 2005-2006. During hospitalization, the patients' most common complaints were recorded as the symptoms and signs of the medical condition, results of physical examinations, spirometry, arterial blood gas analysis (ABG), and ICU admission. RESULTS: There were 18(32.7%) male and 37(67.3%) female patients with a mean age of 54.96 (SD=17.54) years. The mean duration of hospitalization was 8.31(SD=4.69) days that ranged between 2 and 23 days. The mean baseline arterial PH (p=0.039, RPearso = -0.362), baseline arterial [HCO3] (p=0.042, RPearson = 0.361), changes of FEV1 after bronchodilator (p=0.041, RPearson= -0.363) and patient's age (p=0.002, RPearson=0.0433) were determined as factors affecting duration of hospitalization. CONCLUSION: Our results showed that more attention needs to be given to the findings of arterial blood gas and spirometry which can potentially affect the duration of hospitalization of asthmatic patients.

Aneurysmal bone cyst of the capitate: a rare case report.

Primary aneurysmal bone cyst (ABC) in the hands is rare. It occurs more commonly in metacarpal bones and involvement of carpal bones is very uncommon. We report the third case of ABC in the capitate, its clinical presentation, imaging findings and treatment.

Chondromyxoid fibroma of calcaneus.

BACKGROUND: Chondromyxoid fibroma is a rare benign primary bone tumor composed of immature myxoid mesenchymal and cartilaginous tissue. Its occurrence in calcaneus is very rare and few cases of calcaneal involvement have been reported in literature. We report five cases of CMF in calcaneus. METHODS: Five cases, with the final diagnosis of chondromyxoid fibroma of the calcaneal bone are included in this report. Preoperative tumor workup was performed for our patients. We reviewed and recorded demographic data and the sign and symptoms of patients at presentation to our center. Mode of treatments, postoperative complications and recurrence were also studied. Curettage, high speed burring and bone grafting was performed in 4 of our patients and in the remaining case we only carried out curettage and burring. RESULTS: Of the five patients, 3 were male and 2 were female. The mean age at presentation was 21. Two of our cases had previous surgery in other centers and had been referred to our clinic because of recurrence. The chief complaint in all of our patients was heel pain. The mean follow up period was 25.2 months. All of our patients had a delay in the diagnosis of tumor. We did not have any recurrence in our patients during follow up period. CONCLUSIONS: This case series shows that chondromyxoid fibroma is not necessarily as exceedingly rare as generally reported in the current literature. This tumor should be considered in the differential diagnosis in patients with ankle and heel pain.

Pulmonary hypertension in hemodialysis patients.

The aim of this study was to evaluate the prevalence of primary pulmonary hypertension (PHT) among hemodialysis patients and search for possible etiologic factors. The prevalence of PHT was prospectively estimated by Doppler echocardiogram in 62 long-term hemodialysis patients on the day post dialysis. PHT (> 35 mm Hg) was found in 32 (51.6%) patients with a mean systolic pulmonary artery pressure of 39.6 +/- 13.3 mmHg. The hemoglobin and albumin levels were significantly lower in the PHT subgroup (11.1 +/- 1.86 vs 9.8 +/- 1.97 g/dL and 3.75 +/- 0.44 vs 3.38 +/- 0.32 g/dL, p = 0.01 and 0.02, respectively). Our study demonstrates a surprisingly high prevalence of PHT among patients receiving long-term hemodialysis. Early detection is important in order to avoid the serious consequences of the disease.

Pulmonary hypertension and predisposing factors in patients receiving hemodialysis.

INTRODUCTION: The aim of this study was to evaluate the frequency of unexplained pulmonary hypertension (PHT) among patients on hemodialysis at 2 centers and to evaluate possible predisposing factors. MATERIALS AND METHODS: In this cross-sectional study, PHT was screened by Doppler echocardiography on the day after dialysis in 62 patients with end-stage renal disease receiving maintenance hemodialysis via arteriovenous access. Pulmonary hypertension was defined as a systolic pulmonary arterial pressure (PAP) higher than 35 mm Hg, and the systolic PAP was calculated using the modified Bernoulli equation. Clinical variables were compared between patients with and without PHT. RESULTS: A PAP higher than 35 mm Hg was found in 32 patients (49.3%) receiving hemodialysis, with a mean systolic PAP of 39.58 +/- 13.27 mm Hg. Blood hemoglobin level was significantly lower in the patients with PHT than those without PHT (9.8 +/- 1.97 g/dL versus 11.07 +/- 1.86 g/dL; P = .01). In addition, serum levels of albumin was lower in these patients (3.38 +/- 0.32 g/dL versus 3.75 +/- 0.44 g/dL; P = .02). CONCLUSIONS: This study demonstrates a surprisingly high prevalence of PHT among patients with end-stage renal disease receiving hemodialysis. We concluded that the best approach to this unrecognized complication that is associated with reduced survival is keeping it in mind and looking for it in the management of patients on dialysis.