Total Knee Arthroplasty in Patients with Ipsilateral Hip Fusion: Technical Notes and Literature Review.

Numerous studies report the success and outcomes of the total knee arthroplasty (TKA); however, few papers present patients with knee osteoarthritis and ipsilateral hip fusion. One controversy when treating patients requiring a TKA with prior ipsilateral hip fusion is whether to first perform a total hip arthroplasty (THA) of the fused hip, followed by the ipsilateral TKA, or to proceed with the TKA without replacing the hip; studies suggest that the position of the fused hip is a key factor when making this therapeutical decision. In addition, performing a TKA in patients with an ipsilateral fused hip may require modifications to the surgical technique generated by the lack of joint mobility in the hip. We identified 12 studies encompassing 30 patients with hip fusion and ipsilateral TKA in current orthopedic literature, but only six offered insights on patient positioning on the operating table during surgery. This study aims to review the current literature on patients with knee osteoarthritis and prior ipsilateral hip fusion and to present some technical considerations when performing a TKA on a 75-year-old patient with hip ankylosis who underwent a total ipsilateral knee arthroplasty in our clinic.

Patient specific instrumentation versus conventional knee arthroplasty: comparative study.

BACKGROUND: The key to a successful knee replacement is restoring normal kinematics with a neutral alignment, thus a hip-knee-ankle (HKA) angle of 180° (within 3° limits). Conventional TKR is proven to have excellent results but relies in extensive visual referencing of bony landmarks. Customised cutting blocks provide accurate bone cuts, also lowering the risk of fat embolism, blood loss and operating time. METHOD: We share our experience comparing two different TKA techniques using patient specific instrumentation (PSI) with the Visionaire knee and conventional instrumentation (CVI) from the same system (Genesis II Smith&Nephew). A total number of 80 knees were divided into two equal groups, 40 PSI and 40 CVI respectively, operated between April 2013 and August 2014. One female patient had bilateral TKR during this period, at six months interval, both with the PSI. RESULTS: All operated knees had varus deformity, with a mean HKA of 168° (PSI) vs 163° (CVI). We used tranexamic acid (double-dose scheme) and suction drains for 48 hours, with a mean blood drainage in the PSI group of 185 ml and Hb levels of 11.2 g/dl at three days post, compared to 260 ml and 10.7 g/dl in the CVI. Mean blood loss was 3.5 g/dl in PSI, and 4.2 g/dl in the CVI. On the long leg standing radiograph at six weeks, all knees were aligned in frontal plane, with simillar HKA values (178.9° PSI vs 178.6° CVI). Bone cuts measured intraoperatively proved to be accurate within a 1 mm limit. CONCLUSIONS: We cannot recommend PSI-TKR for a better outcome. It is an alternative to conventional and computer-assisted TKR, but further studies are needed to evaluate weather surgical or economic benefits may be achieved by choosing customised instruments.

EFFECT OF TRANEXAMIC ACID USE ON POSTOPERATIVE BLOOD LOSS IN TOTAL KNEE ARTHROPLASTY.

AIM: To monitor the effect of tranexamic acid use (Exacyl) on postoperative bleeding (aspiration), autologous blood transfusion (autotransfusion), allogeneic blood transfusion and postoperative anemia (difference between preoperative and immediate postoperative hemoglobin levels) in total knee arthroplasty. MATERIALS AND METHODS: This retrospective observational study was conducted on a sample of 457 patients who underwent endoprosthetic knee arthroplasty in the interval January 1, 2008-July 3O, 2014 at the Traumatology-Orthopedics Clinic of the Iasi Rehabilitation Hospital. The mean age of the study group was 66 years (range 32-84 years), 74.4% were female, 39.8% presented varus and 6.1% valgus malalignment. The study group was subdivided into two groups: Group 1 served as controls and underwent surgery without the administration of tranexamic acid and Group 2 received tranexamic acid. RESULTS: In group 1 the average amount of blood lost was significantly higher than in group 2, 1168.94 ml vs. 452.9 ml (p < 0.001). The use of a cell saver was required in 70% of group 1 patients with an average amount of auto transfused blood of 480.70 ml, significantly more frequent and in greater amounts than in group 2 (below 10%) with an average of 15.05 ml (p < 0.001). In this study tranexamic acid had not a statistically significant favorable effect on blood transfusion requirements and anemia syndrome. CONCLUSION: Tranexamic acid has a favorable effect on postoperative blood loss and its associated complications, with a favorable impact on both early clinical and functional recovery.

Pre-operative radiological measurement of femoral rotation for prosthetic positioning in total knee arthroplasty.

PURPOSE: This study outlines the benefits of the seated view radiograph of the knee in evaluation of the pre-operative individual distal femoral torsion (DFT) and for the follow-up of the post-operative rotational positioning of the femoral component in total knee arthroplasty. METHODS: Study on 20 patients who underwent total knee arthroplasty and the correlation between the DFT measured before surgery with this radiology view, the intra-operative external rotation (ER) necessary for the parallel positioning of the femoral component with the transepicondylar axis (TEA) and the post-operative femoral rotational alignment of the prosthesis on the same view. RESULTS: In 90 % of cases the values of internal DFT were between -1(0) and -8(0), while the mean value of the internal rotation (IR) was -4.45(0). The mean value of the ER applied to the posterior bone resection was 4.25(0) (0(0)-7(0)), showing a statistically significant correlation between the pre-operative measurement and the intra-operative one of the posterior condylar angle (PCA) (r = 0.890, p = 0.000). Residual internal femoral malrotation has been identified in four cases, its mean value being 0.4(0). In three patients the pre-operative value of the PCA was higher than the intra-operative one and an internal malrotation of the post-operative femoral component was observed. CONCLUSIONS: The results are encouraging for the further use of this pre-operative view with the premises of increasing the accuracy of prosthetic positioning and reducing the mechanical complications.

Stem cells derived from osteoarthritic knee mesenchymal tissues: a pilot study.

Regenerative medicine is a promising approach for addressing musculoskeletal disorders. Successful implementation of regenerative therapies is based upon existence of reliable, easy accessible cell sources. Mesenchymal tissues removed during total knee replacement (TKR) were investigated as a potential autologous stem cell source. Materials and methods Samples were collected from patients undergoing primary TKR mononuclear cells from adipose and synovial tissue; subchondral trabecular bone and osteoarthritic cartilage were isolated and assessed in terms of mesenchymal stem cells (MSC) content. Results MSCs obtained from all the investigated tissue types and from all donors showed proliferative, differentiation and surface markers characteristic of stemness. Important number of MSCs could be obtained in the first passage (P0). Mesenchymal tissues removed during TJR can qualitatively and quantitatively function as autologous MSC sources to be considered for regenerative therapies.

Adult multifocal pigmented villonodular synovitis--clinical review.

Pigmented villonodular synovitis (PVNS) is a rare, benign proliferative disease of the synovial tissue that affects a single joint or a tendon sheath. Data from the literature present only a few cases of multifocal PVNS. This paper presents multifocal PVNS in the adult. This disease can affect bilateral shoulders, hips and knees. The diagnosis may be delayed by the slow evolution of the disease (up to ten years); some patients may be seen with late-stage degenerative joints, serious complications, painful and functionally uncompensated, with significant locomotion deficit. PVNS requires a radical treatment with prosthetic arthroplasty associated with synovectomy. Complex imaging (X-Rays, magnetic resonance imaging (MRI), ultrasound) and macroscopic appearance of the lesions during surgery confirms the clinical diagnosis of multifocal PVNS with secondary bone lesions. Histology marks the final diagnosis of multifocal PVNS. The postoperative results are good, with recovery in functional parameters of the joints with endoprosthesis.

Isolation and phenotypic characterisation of stem cells from late stage osteoarthritic mesenchymal tissues.

INTRODUCTION: Osteoarthritis (OA) represents an increasing health issue worldwide. Regenerative medicine (RM) has raised the hope for introducing revolutionary therapies in clinical practice. Detection of autologus cell sources can improve accessibility to RM strategies. OBJECTIVES: To assess the presence and biological potential of mesehchymal stem cells in three tissues (subchondral bone, synovial layer, periarticular adipose tissue) in late stages osteoarthritic patients. MATERIAL AND METHODS: Samples were collected from subjects undergoing total knee replacement (TKR). MSCs were isolated and cultured in complete αMEM with ß FGF. Cell morphology and growth potential was assessed. Flow cytometry was used for detection of several relevant cell surface markers. Quantitative and qualitative assessment of differentiation potential towards three mesenchymal lineages (osteogenesis adipogenesis chondrogenesis) was performed. Time lapse life cell imaging of nondiferentiated cells over 24 hours period was used to determine cell kinetics. RESULTS: Mesenchymal cells derived from all donors and tissue types showed morphology, growth and surface cell markers associated with stemness. All cell types underwent differentiation toward three mesenchymal lineages with significant differences between tissues of origin, not between donors. Cell kinetics, as derived from life imaging records, was variable with tissue of origin, significant higher for adipose derived MSCS. CONCLUSION: Human late stage OA mesenchymal tissues, contain progenitors with proliferative and differentiation potential of MSCs. These populations can be used for research and autologus regenerative therapies. Further comparative studies with age matched non OA samples has the potential of contributing to deepening knowledge about disease occurrence and progression.