Cost-Effectiveness and Budget Impact of Comprehensive Anemia Management, The First Pillar of Patient Blood Management, on the Turkish Healthcare System.

Purpose: Patient blood management (PBM) is a patient-centered, evidence-based, multidisciplinary approach aimed at optimizing hemoglobin concentration, ensuring the continuity of hemostasis and minimizing blood loss in patients undergoing surgery. The aims of this study were: (1) to explore the cost-effectiveness of comprehensive anemia management, the first pillar of PBM, in non-cardiac and cardiac surgery from the Turkish Social Security Institution's (SSI's) perspective; and (2) to explore the potential budget impact of PBM for coronary artery bypass grafting (CABG) and hip and knee arthroplasty to the SSI. Methods: Cost-effectiveness and budget impact models were developed based on the avoided postoperative adverse events following implementation of the first pillar of PBM for non-cardiac and cardiac surgical patients. The probabilities of adverse events (sepsis with and without pneumonia, renal failure, myocardial infarction and stroke) were taken from a recent meta-analysis and the costs of treating these adverse events to the SSI were estimated through expert views and the use of SSI guidelines. Results: The PBM arm dominated the control arm for both non-cardiac and cardiac surgeries in terms of cost-effectiveness in the simulated cohort of patients and was associated with improved outcomes and lower costs (1768 and 1244 avoided adverse events, and incremental cost reductions for non-cardiac and cardiac surgery of 7504 Turkish lira [TRY] and 6102 TRY, respectively). The budget impact analysis showed that PBM is a potential cost-saving option for the SSI, with savings of up to 196,937,705 TRY (€12,841,697) for hip and knee arthroplasty and 24,642,504 TRY (€1,606,861) for CABG surgery. Conclusion: PBM is a cost-effective option with a potential of cost-saving for cardiac and non-cardiac surgery in Turkey.

Proinflammatory biomarkers' level and functional genetic polymorphisms in periprosthetic joint infection.

OBJECTIVE: The aims of this study were 1) to identify the level of inflammatory biomarkers interleukin (IL)-1α, IL-1ß, IL-6, IL-8, IL-17, C-reactive protein (CRP), granulocyte colony-stimulating factor (GCSF), ferritin, and tumor necrosis factor (TNF)-α in serum and synovial fluid samples of patients who underwent revision arthroplasty surgery; 2) to establish the relationship between serum and synovial fluid levels; 3) to determine if any of the 11 genetic polymorphisms of TNFα, IL-1, IL-6, IL-8, IL-17, and GCSF on the encoding genes was associated with periprosthetic joint infection (PJI). METHODS: Synovial fluid and serum was collected from 88 patients who underwent revision arthroplasty surgery. The Musculoskeletal Infection Society definition was used to classify these patients into 2 groups: 36 PJIs and 52 aseptic failures. Synovial fluid and serum samples were tested for 9 biomarkers using a micro enzyme-linked immunosorbent assay. Genetic polymorphisms were evaluated with polymerase chain reaction and restriction endonuclease analysis. RESULTS: Synovial fluid-derived IL-1α, IL-1ß, IL-8, IL-17, CRP, GCSF, TNFα, and serum-derived IL-6, IL-17, ferritin, CRP were found suitable to classify PJI and aseptic failure. In addition, IL-17 and CRP levels demonstrated a positive correlation between synovial fluid and serum. TNFα-238, IL6-174, GCSF3R, and IL1 RN-VNTR genetic polymorphisms occurred more frequently in individuals with septic failure. CONCLUSION: Significant differences between the two groups were observed in the functional polymorphisms of the genes encoding the cytokines investigated. These differences could be interpreted as indicating that there is an association between PJI and genetic polymorphisms. LEVEL OF EVIDENCE: Level III, diagnostic study.

Adult acetabulo - pelvic parameters in Turkish society: A descriptive radiological study.

OBJECTIVE: The aim of this study was to measure the prevalences of the acetabular index, collodiaphyseal angle, CE angle, articulo-trochanteric distance, cross-over sign and posterior wall sign in healthy Turkish people, in order to shed light on the production of orthopedic medical products. METHODS: In this study, both hips (a total of 3960 hips) of 1980 individuals (1178 males, 802 females) from nine different cities between the ages of 18 and 65 years were measured and statistically analyzed. RESULTS: The right articulo-trochanteric distance of all participants was 19.67 ± 4.52 mm and the left articulo-trochanteric distance was 19.10 ± 4.58 mm. The CE angle was 35.11°±7.41° in the right hip and 35.37°±6.76° in the left hip. The acetabular index was 37.58°±5.30° in the right hip and 37.80°±4.82° in the left hip. The collodiaphyseal angle was 138.60°±8.27° in the right and 137.84°±8.01° in the left hip. The prevalence of cross-over sign in the right hip was 6.46% and 6.66% for the left hip. The prevalence of posterior wall sign was 4.24% for the right hip and 4.19% for the left hip. CONCLUSION: This study has provided prevalence values of cross-over sign, posterior wall sign, acetabular index, collodiaphyseal angle, CE angle and articulo-trochanteric distances of a healthy Turkish population between the ages of 18 and 65 years.

Osseointegration in arthroplasty: can simvastatin promote bone response to implants?

Cementless fixation depends on bone ingrowth for long-term success. Simvastatin as a lipid lowering agent has been demonstrated to have osteoanabolic effects. This study was designed to measure the possible effect of simvastatin on implant osseointegration. Bilateral femoral implantation of titanium cylinders was performed in 20 rabbits. Blood lipid levels were measured pre- and postoperatively. Scanning electron microscopy (SEM) was used to measure the percentage of the surface of each implant in contact with bone and mechanical pull-out testing was performed. The blood lipid levels were significantly reduced in the simvastatin group. Histomorphometric examination revealed increased bone ingrowth and mechanical examination showed increased interface strength in the simvastatin group. Mechanical and histological data showed superior stability and osseous adaptation at the bone/implant interface for the simvastatin group. We conclude that simvastatin has potential as a means of enhancing bone ingrowth, which is a key factor in the longevity of cementless implants.

[Midterm results of total knee arthroplasty in degenerative knee joint diseases with severe deformity]. / Ileri derecede deformiteye yol açan dejeneratif diz eklemi hastaliklarinda total diz artroplastisinin orta dönem sonuçlari.

OBJECTIVES: We evaluated the midterm results of total knee arthroplasty in degenerative knee joint diseases with severe deformity. METHODS: Total knee arthroplasty was performed in 125 knees of 86 patients (75 women, 11 men; mean age 69 years; range 39 to 85 years) with degenerative knee joint diseases accompanied by severe deformity. Almost all the patients had osteoarthritis (100 knees, 80%) or rheumatoid arthritis (22 knees, 17.6%). Thirty-nine patients with bilateral involvement underwent single-stage (n=20) or two-stage (n=19) surgery. During surgery, the posterior cruciate ligament was sacrificed in 108 knees and retained in 17 knees. Pre- and postoperative assessments were made according to the Knee Society clinical scoring system. The mean follow-up was 53 months (range 24 to 96 months). RESULTS: The results were excellent or good in 80.2% of the knees. Nine knees (7.2%) required revision surgery, of which preoperative diagnosis was rheumatoid arthritis in five. The reasons for revision were infection-related problems (n=5), aseptic loosening (n=3), and periprosthetic fracture (n=1). Compared with preoperative values, the mean knee score increased by 60.9 (from 26.2 to 87.1), and the mean functional score increased by 42.6 (from 33.2 to 75.8) (p<0.05), with a mean range of knee joint motion of 93.2 degrees . The mean preoperative and postoperative alignments were 17.8 degrees of varus and 4.1 degrees of valgus (range 0 degrees to 6 degrees ), respectively. The number of knees with a flexion contracture decreased from 68 (mean 28.8 degrees ) to 8 (mean 8.4 degrees ), all of which had a flexion contracture angle below 10 degrees . CONCLUSION: Total knee arthroplasty performed in degenerative knee joint diseases with severe deformity significantly improves patients' complaints and functional results.

The safe distance for the superior gluteal nerve in direct lateral approach to the hip and its relation with the femoral length: a cadaver study.

INTRODUCTION: The most inferior branch (MIB) of the superior gluteal nerve (SGN) is vulnerable during direct lateral approach to the hip. A safe distance proximal to the tip of the greater trochanter varying from 3 to 5 cm has been reported in different studies. Anatomical studies defining safe zones and clinical studies reporting the results use various reference points, and the oblique course of the MIB contributes to the confusion. Numerous efforts have been made to standardize the safe zone using patient characteristics such as body height; however, contradictory results have been reported. The purpose of this study was to measure the safe distance in line to the gluteal split and also to determine the relationship of the safe distance with femoral length, as a stable component of body height. MATERIALS AND METHODS: Fifteen lower extremities of 12 formalin-fixed cadavers (M/F: 7/5) were dissected. The most prominent lateral palpable part of the trochanter major (TM) was determined and the dissection in the gluteus medius muscle (GMM) was performed starting from this point upwards in line of the muscle fibers. The distances between the MIB in the plane of dissection in the GMM to the TM and also to the trochanteric apex (TA) were measured. Femoral lengths were measured between the TM point and the lateral epicondyle. Spearman's correlation and Mann-Whitney U tests were used for statistical analysis. RESULTS: The SGN in 13 hips had spray pattern and neural trunk pattern in two. The plane of dissection was within the anterior third of the GMM in all hips. The average femoral length was 37.5 cm. Average distance between TM and MIB was 44 mm; in three hips, the distance was <30 mm. The average distance between TA and TM was 21 mm. There was no statistically significant correlation between femoral length and TM-MIB distance. CONCLUSION: The distance from the TM to the MIB is highly variable and independent from body height or femoral length. The so called "safe zone" in which damage of significant nerve damage is excluded can have a rather small dimension in some patients. Short patients are not at increased risk and tall patients are not risk free. Modern techniques in total hip replacement which try to minimize proximal interruption of the GMM are therefore justified.

[Venous thromboembolism prophylaxis in major orthopaedic surgery: A multicenter, prospective, observational study]. / Majör ortopedik cerrahilerde venöz tromboemboli profilaksisi: Cokmerkezli, prospektif, gözlem çalismasi.

OBJECTIVES: We investigated risk factors for venous thromboembolism (VTE), prophylaxis measures employed, and incidence of symptomatic deep venous thrombosis (DVT) and pulmonary embolism (PE) in patients undergoing major orthopaedic surgery (MOS). METHODS: An open, multicenter, prospective, observational study was conducted in 21 medical centers, comprising 899 patients. Of these, 316 patients (35.2%) underwent total hip arthroplasty (THA), 328 patients (36.5%) underwent total knee arthroplasty (TKA), and 255 patients (28.4%) underwent surgery for hip fractures (HF). Pharmacologic prophylaxis was employed in all the patients. RESULTS: Risk factors for VTE were seen in 73.2% of the patients, the most common being obesity (72%) and prolonged immobilization (36.3%). Low-molecular-weight heparin (91.1%) and fondaparinux (8.9%) were used for prophylaxis, which was short-term in 273 patients (30.4%) and long-term in 626 patients (69.6%). Mechanical prophylaxis was performed with compression stockings in 610 patients (67.9%) and by intermittent pneumatic compression in 67 patients (7.5%). During three-months of follow-up, symptomatic DVT and PE were seen in eight (0.9%) and four patients (0.4%), respectively. Mortality occurred in 10 patients (1.1%). Complications of major and minor bleeding were seen in eight (0.9%) and 40 (4.5%) patients, respectively. CONCLUSION: Effective VTE prophylaxis is associated with low risk of clinically apparent DVT and PE in MOS.

Risk of superior gluteal nerve and gluteus medius muscle injury during femoral nail insertion.

BACKGROUND: Abduction weakness and limping is a well-recognized complication of closed antegrade insertion of femoral nails. Iatrogenic injuries to the superior gluteal nerve and the gluteus medius muscle are the most likely contributing factors. The purpose of this study of cadavers was to assess the risk of nerve and muscle injury with various lower-limb positions used during nail insertion. METHODS: We studied thirteen hips of ten formalin-fixed adult cadavers. With the cadaver in the full lateral position, a 9-mm reamer was introduced in a retrograde fashion from the intercondylar notch and passed through the gluteus medius muscle. The distance between the point of entry of the reamer into the undersurface of this muscle and the inferior main branch of the superior gluteal nerve (the nerve-reamer distance) and the distance between the entry and exit points of the reamer in the gluteus medius muscle (the intramuscle distance) were measured in three different hip positions: 15 degrees of flexion and 15 degrees of adduction (Position 1), 30 degrees of flexion and 30 degrees of adduction (Position 2), and 60 degrees of flexion and 30 degrees of adduction (Position 3). RESULTS: In Position 1, the average nerve-reamer distance was 7 mm and the average intramuscle distance was 24 mm. In three hips the reamer injured the nerve directly, and in two other hips the distance was

[Midterm results of total hip replacement in osteonecrosis of the hip joint]. / Kalça osteonekrozunda total kalça artroplastisinin orta dönem sonuçlari.

OBJECTIVES: We evaluated the midterm results of total hip arthroplasty (THA) for femoral neck osteonecrosis. METHODS: The study included 59 patients (23 females, 36 males; mean age 45.6 years; range 24 to 66 years) who underwent THA in 72 hips. Osteonecrosis was secondary to fracture in the femoral neck in 11 hips (15.3%), was associated with steroid use in 23 hips (31.9%), and was idiopathic in 38 hips (52.8%). Functional evaluations were made with the hip scoring system of D'Aubigne and Postel. Bone-implant relations were assessed radiographically using the Gruen's seven zones in the femur and Charnley's three zones in the acetabulum. The mean follow-up was 4.1 years (range 2 to 7 years). RESULTS: The mean D'Aubigne-Postel hip score was 11.8 (range 7 to 16), with good or excellent results in all hips. While no significant difference was found between cementless and hybrid systems (p>0.05), the mean hip score was significantly higher with press-fit acetabular systems compared to expansion cups (p<0.001). The effects of the following were found insignificant on the clinical outcome (p>0.05): etiology, metal-on-metal or metal-on-polyethylene surfaces, and development of stress shielding in the proximal femur or of varus-valgus angulation in the femoral stem. However, the results were significantly less favorable in cases in which complications arose (p<0.001). Intraoperative complications were fissure in five patients and isolated trochanteric fracture in five patients, all of which occurred in cementless THA. Heterotopic ossification was seen in six hips. At the end of 6.5 years, mild polyethylene wear was detected in eight hips, two of which also had focal osteolysis in Gruen zone 1. CONCLUSION: Thanks to improvements in implant technology and surgical techniques, the results of both cementless and hybrid systems are satisfactory in hip osteonecrosis, regardless of the etiology.

Safe zone for the descending genicular artery in the midvastus approach to the knee.

Minimally invasive total knee arthroplasty is performed using a modified version of the standard total knee arthroplasty without complete knee exposure. Traditional medial parapatellar arthrotomy has been criticized because it may disturb patellar blood flow and the extensor mechanism. Devascularization of the patella leading to osteonecrosis places the patella at risk for fracture. Alternative vastus-orientated approaches have the potential to preserve the descending genicular artery. Although this arterial supply to the patella potentially can be compromised throughout surgery, it is particularly vulnerable during deep dissection and arthrotomy. Knowledge of the anatomic course of the descending genicular artery would likely be helpful in its preservation. We investigated the course of the descending genicular artery and its entry angle to peripatellar network to determine the distance between the artery and superomedial patella during medial parapatellar arthrotomy and proximal capsular release. We dissected the descending genicular artery in 15 cadaveric knees. The average entry angle was 32.6 degrees , and the average distance between the descending genicular artery and superomedial pole of the patella during parapatellar arthrotomy was 13.5 mm. The safest distance for splitting the vastus medialis during median parapatellar arthrotomy was 15 mm from the superior pole of the patella because of the course of the descending genicular artery.

Total hip arthroplasty in developmental high dislocation of the hip.

In total hip arthroplasty for developmental high dislocations, placement of the implant cup in the true acetabulum and femoral-shortening osteotomy can produce satisfactory results. We performed total hip arthroplasties in 25 high dislocated hips (22 patients) between 1992 and 2000, placing all cups in the true acetabula and using noncemented components and performing a femoral-shortening osteotomy in 22 hips. The overall complication rate was 36%. At follow-up evaluation at an average of 5 years later, patients' mean scores had improved as follows: pain, from 2.3 to 5.7; function scores, from 2.3 to 4.5; mobility scores, from 2.3 to 4.4; Harris hip scores, from 37.8 to 95. We recommend both placing the cup in the true acetabulum to maximize host-bone contact with the implant and preserve as much host bone as possible and femoral-shortening osteotomy for a lower incidence of nerve injury than with aggressive soft-tissue release.

A new approach to the treatment of osteoporosis.

Osteoporosis remains a significant clinical problem despite the availability of effective therapies. The main therapy still needed is an anabolic agent for the treatment of osteoporosis. This study examined the in vivo effect of the enzyme 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitor simvastatin, which controls the first step in the biosynthesis of cholesterol, on bone formation in rats. Histologic specimens were collected 7, 14, and 21 days after administration of 1 mg of simvastatin for 5 days and compared with control specimens for changes in bone tissue. The observed effects on the bone in a healthy animal model included advancement of the blood supply, acceleration of the proliferation and differentiation of osteoprogenitor cells, and formation of osteoid tissue.

[An evaluation of the methods used for removal of components and cement in revision hip arthroplasty]. / Revizyon kalça artroplastisinde komponentlerin ve çimentonun çikartilmasinda kullanilan yöntemlerin degerlendirilmesi.

OBJECTIVES: This study was designed to evaluate the methods that we used for removal of components and cement in revision hip arthroplasty (RHA). METHODS: Thirty-seven patients (mean age 65.6 years; range 18 to 78 years) who underwent RHA were retrospectively evaluated. Arthroplasty had been cementless, hybrid, cemented, and partial in 13, 16, 5, and 3 hips, respectively. Revision included only acetabular cup in four patients, femoral component in three, and all components in the remaining patients. Of the acetabular cups revised, five were cemented, 28 were cementless (10 expanded, 18 porous-coated); of the femoral components, 22 were cemented and 11 were cementless. The mean time to revision was 7.3 years (range 1.5 to 13 years). Extended proximal femoral osteotomy (EPFO) was performed in 28 hips (84.9%), of which 10 hips (35.7%) required the use of high speed cutting heads. All the patients were evaluated before and after revision according to the criteria of Merle d'Aubigne and Postel which were modified by Charnley. The mean follow-up period was 36.3 months (range 2 to 48 months). RESULTS: There were no difficulties in the removal of cemented acetabular cups. Expanded cementless cups were readily removed by bending their expanded leaves. However, high speed cutting heads were used to resolve the bone-cup integration in eight porous-coated cups (44.4%); of these, two cups (25%) even required the use of high speed metal cutting heads to split several parts apart. In one patient, a spiral fracture occurred extending to the distal end of EPFO. On final follow-ups, the results were evaluated as perfect or good in 92% of the hips. CONCLUSION: The removal of components and cement during RHA may require the use of more complex methods and device in addition to standard ones.