Skeletal complications in patients with hemophilia: a single-center experience.

BACKGROUND: Arthropathy is a common complication in patients with hemophilia. We examined the prevalence of this skeletal complication in patients with hemophilia who were registered at a Comprehensive Hemophilia Center in Shiraz, Southern Iran. MATERIALS AND METHODS: In this cross-sectional study, an orthopedic specialist visited 448 patients and conducted screenings for skeletal complications. The assessment included evaluating the type of hemophilia, disease severity, treatment modality, the presence of inhibitors, and the identification of skeletal complications. RESULTS: Ninety patients with hemophilia A, with a mean age (SD) of 31.6 (14.4) years, and 10 patients with hemophilia B, with a mean age of 30.5 (20.6) years, were assessed. The most frequently affected joints were the knee and ankle joints. In the univariate analysis, patients with severe disease were more likely to exhibit synovitis, a target joint, and bone disease compared to patients with non-severe disease. Additionally, a history of treated or active hepatitis and an annual bleeding rate showed significant associations with the target joint. In the multivariable logistic regression analysis, disease severity (OR 14.43, 95% CI 1.6-129.6) and a higher age at diagnosis (OR 1.06, 95% CI 1.00-1.13) increased the likelihood of developing osteoporosis. A history of hepatitis (OR 3.67, 95% CI 1.28-10.48) was identified as an independent risk factor for the target joint. CONCLUSION: Skeletal complications are a common occurrence in hemophilia. Regular consultations with orthopedic specialists, focusing on bleeding control and hepatitis prevention, are essential for reducing the impact of this debilitating complication.

Total Knee Arthroplasty with Non-Stemmed Tibial Components among Obese Patients: Clinical and Radiologic Evaluation and Review of Literature.

Objective: This study aimed to evaluate the radiologic and clinical outcomes of TKA with non-stemmed tibial components in relation to their body mass index (BMI). Methods: In this retrospective cohort study, the outcome of TKA with non-stemmed tibial components based on their BMI was evaluated (BMI<30 vs. BMI≥30). The patients' function was assessed using the International Knee Documentation Committee (IKDC) and Lysholm knee questionnaires. Radiologic evaluation for probable signs of loosening was performed using two quantitative scoring systems by Ewald and Bach et al. Moreover, we reviewed the current literature on the application of non-stemmed tibial components in obese patients. Results: Twenty-one patients (two men and 19 women) with BMI≥30 and a mean age of 65.1±9.5 years, and 22 patients (three men and 19 women) with BMI<30 and a mean age of 63.6±8.5 years were studied. The mean follow-up periods with BMI≥30 (47.0±19.8 months) and BMI<30 (49.2±18.7 months) were comparable (p=0.618). No patients in either group experienced clinical loosening. Besides, none of the patients had any kind of revision surgery. The patients in both BMI groups had comparable IKDC scores (both the total score and its sub-scores; p>0.05). Furthermore, the total Lysholm knee scores were similar in both groups (p=0.122). Using both scoring systems, the peri-prosthetic bone radiolucency near the tibial components was similar in both groups (p>0.999). Conclusion: The present study found no significant difference in the radiologic or clinical outcome of non-stemmed TKA in patients with BMIs under and over 30.

Is posterior knee arthroscopy using posterior portals necessary for orthopedic surgeons? The latest evidence on applications and techniques.

Various uses of posterior knee arthroscopy have been shown, including all-inside repair of posterior meniscal lesions, posterior cruciate ligament (PCL) reconstruction or PCL avulsion fixation, extensile posterior knee synovectomy for pigmented villonodular synovitis or synovial chondromatosis, posterior capsular release in the setting of knee flexion contractures, and loose bodies removal. Posterior arthroscopy provides direct access to the posterior meniscal borders for adequate abrasion and fibrous tissue removal. This direct view of the knee posterior structures enables the surgeon to create a stronger biomechanical repair using vertical mattress sutures. During PCL reconstruction, posterior arthroscopy gives the surgeon proper double access to the tibial insertion site, which can result in less acute curve angles and the creation of a more anatomic tibial tunnel. Moreover, it gives the best opportunity to preserve the PCL remnant. Arthroscopic PCL avulsion fixation is more time-consuming with a larger cost burden compared to open approaches, but in the case of other concomitant intra-articular injuries, it may lead to a better chance of a return to pre-injury activities. The high learning curve and overcaution of neuromuscular injury have discouraged surgeons from practicing posterior knee arthroscopy using posterior portals. Evidence for using posterior portals by experienced surgeons suggests fewer complications. The evidence suggests toward learning posterior knee arthroscopy, and this technique must be part of the education about arthroscopy. In today's professional sports world, where the quick and complete return of athletes to their professional activities is irreplaceable, the use of posterior knee arthroscopy is necessary.

Metformin attenuates symptoms of osteoarthritis: role of genetic diversity of Bcl2 and CXCL16 in OA.

OBJECTIVE: This study aimed to evaluate the effectiveness of metformin versus placebo in overweight patients with knee osteoarthritis (OA). In addition, to assess the effects of inflammatory mediators and apoptotic proteins in the pathogenesis of OA, the genetic polymorphisms of two genes, one related to apoptosis (rs2279115 of Bcl-2) and the other related to inflammation (rs2277680 of CXCL-16), were investigated. METHODS: In this double-blind placebo-controlled clinical trial, patients were randomly divided to two groups, one group receiving metformin (n = 44) and the other one receiving an identical inert placebo (n = 44) for 4 consecutive months (starting dose 0.5 g/day for the first week, increase to 1 g/day for the second week, and further increase to 1.5 g/day for the remaining period). Another group of healthy individuals (n = 92) with no history and diagnosis of OA were included in this study in order to evaluate the role of genetics in OA. The outcome of treatment regimen was evaluated using the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire. The frequency of variants of rs2277680 (A181V) and rs2279115 (938C>A) were determined in extracted DNAs using PCR-RFLP method. RESULTS: Our results indicated an increase in scores of pain (P ≤ 0.0001), activity of daily living (ADL) (P ≤ 0.0001), sport and recreation (Sport/Rec) (P ≤ 0.0001), and quality of life (QOL) (P = 0.003) and total scores of the KOOS questionnaire in the metformin group compared to the placebo group. Susceptibility to OA was associated with age, gender, family history, CC genotype of 938C>A (Pa = 0.001; OR = 5.2; 95% CI = 2.0-13.7), and GG+GA genotypes of A181V (Pa = 0.04; OR = 2.1; 95% CI = 1.1-10.5). The C allele of 938C>A (Pa = 0.04; OR = 2.2; 95% CI = 1.1-9.8) and G allele of A181V (Pa = 0.02; OR = 2.2; 95% CI = 1.1-4.8) were also associated with OA. CONCLUSION: Our findings support the possible beneficial effects of metformin on improving pain, ADL, Sport/Rec, and QOL in OA patients. Our findings support the association between the CC genotype of Bcl-2 and GG+GA genotypes of CXCL-16 and OA.

The functional impact of home-based self-rehabilitation following arthroscopic meniscus root repair.

BACKGROUND: Corona virus infectious pandemic makes outdoors rehabilitation a potential hazard. Patient education to perform simple home-based exercises seems to be an interesting and sometimes a mandatory option. This study provides a comparison between the conventional and home-based virtual rehabilitation after surgical repair of medial meniscus root tears. METHODS: In this prospective study, all patients who underwent medial meniscus posterior root repair with a modified trans-tibial pull-out technique from March 2019 to March 2021 were evaluated. Those who underwent surgery after December 2019 were trained to perform self-rehabilitation. The rest had undergone outdoors specialized rehabilitation according to a unified protocol and these were used as a historical control group. All patients were followed up for a minimum of 2 year after surgery. Final Lysholm scores were utilized to compare functional outcomes after considering the effect of age, body mass index and time from surgery by multivariate linear regression analysis. RESULTS: Forty-three consecutive patients with medial meniscal root tears were studied. Thirty-nine (90.7%) were women and 4 (9.3%) were men. The mean age of participants was 53.2 ± 8.1 years. The total Lysholm knee score, and all its items were significantly improved in both groups at a two-year follow-up (p < 0.05), except the "Using cane or crutches" item (p = 0.065). Nevertheless, the final Lysholm knee score improvement was higher in patients who performed outdoors specialized rehabilitation and in patients with shorter time-to-surgery. CONCLUSION: Regardless of age and gender, home-based rehabilitation after meniscal root repair with the modified trans-tibial pull-out technique improved the patients' function at a two-year follow-up. Nonetheless, this effect was still significantly lower than that of the outdoors specialized rehabilitation. Future work is required to clarify basic protocols for home-based tele-rehabilitation programs and determine clinical, radiological and functional results. LEVEL OF EVIDENCE: Level IV, therapeutic, historically controlled study.

A Modified Semi-Lithotomy Position for Approach to Tibial Plateau Complex Fractures: A Technical Note.

There is no agreement on the best surgical strategy to manage multicolumnar tibial plateau fracture. The combined approach used by many investigators has been found to be an effective method. However, combined approaches call for repositioning the patient which lengthens the operation time. The sterility of the field of surgery might be jeopardized by repositioning. Intraoperative fluoroscopic imaging is hard to adjust to both parts of the combined positions. To tackle these problems without sacrificing the concept of three-column tibial plateau, we have started to use a combined medial and lateral approach without repositioning the patients using a modified semi-lithotomy position.

Determination of Normal Reference Values for Meniscal Extrusion Using Ultrasonography During the Different Range of Motion: A Pilot, Feasibility Study.

OBJECTIVES: It is essential to know the normal extrusion measures in order to detect pathological ones. In this study, we aimed to define some normal reference values for meniscal extrusion in the normal knees during different ranges of motion. METHODS: The amount of anterior and posterior portion of meniscal extrusion among 21 asymptomatic volunteers (42 knees) were tracked in 0, 45, and 90° of knee flexion using an ultrasound machine. The repeated measures analysis of variance (ANOVA) was used to show the interaction between the amounts of meniscal extrusion and the different degrees of knee flexion. RESULTS: The anterior portion of the lateral menisci at full knee extension (0.59 ± 1.40) and the posterior portion of the medial menisci during 90° flexion (3.06 ± 2.36) showed the smallest and the highest mean amount of extrusion, respectively. The normal average amounts of anterior extrusion were 1.12 ± 1.17 and 0.99 ± 1.34 mm for medial and lateral menisci, respectively. The posterior meniscal normal extrusions were significantly increasing in both medial and lateral menisci during the survey (F = 20.250 and 11.298; both P values <.001) as they were measured 2.37 ± 2.16 and 1.53 ± 2.18 mm in order. CONCLUSIONS: The medial meniscus can extrude 1.74 ± 1.84 mm normally while this amount was 1.26 ± 1.82 mm for the lateral meniscus. These measures commonly increased with the rising of knee flexion motion. Likewise, the posterior portion showed more extrusion than the anterior portion on both sides. These measures commonly increased with higher knee flexion.

A mechanobiological approach to find the optimal thickness for the locking compression plate: Finite element investigations.

This study aimed at finding the acceptable range, and the optimal value for the locking compression plate (LCP) thickness (THK), through simulating the osteogenic pathway of bone healing, and by checking bone-plate construct's strength and stability. To attain the goals of this research, a multi-objective approach was adopted, which should trade-off between some conflicting objectives. A finite element model of the long bone-plate construct was made first, and validated against an experimental study. The validated model was then employed to determine the initial strength and stability of the bone-plate construct, for the time right after surgery, for various thicknesses of the LCP. Afterward, coupling with a mechano-regulatory algorithm, the iterative process of bone healing was simulated, and follow up was made for each LCP thickness, over the first 16 post-operative weeks. Results of this study regarding the sequence of tissue evolution inside the fracture gap, showed a similar trend with the existing in-vivo data. For the material and structural properties assigned to the bone-plate construct, in this study, an optimal thickness for the LCP was found to be 4.7 mm, which provides an enduring fixation through secondary healing, whereas for an LCP with a smaller or greater thickness, either bone-implant failure, unstable fixation, impaired fracture consolidation, or primary healing may occur. This result is in agreement with a recent study, that has employed a comprehensive optimization approach to find the optimal thickness.

Two-stage Total Knee Arthroplasty for Treatment of Surgical Failure of Septic Arthritis in Degenerative Knee Joints.

BACKGROUND: The ultimate goal of the treatment of infectious knee arthritis is to protect the articular cartilage from adverse effects of infection. Treatment, however, is not always hundred percent successful and has a 12% failure rate. Persistent infection is more likely to happen in elderly patients and those with underlying joint diseases, particularly osteoarthritis. Eradication of infection and restoration of function in the involved joint usually are not possible by conventional treatment strategies. There are few case series reporting two-stage primary knee arthroplasty as the salvage treatment of the septic degenerative knee joint; however, the treatment protocol remains to be elucidated. METHODS: Based on a proposed approach, patients with failure of common interventions for treatment of septic knee arthritis and underlying joint degeneration were treated by two-stage TKA and intervening antibiotic loaded static cement spacer. Suppressive antibiotic therapy was not prescribed after the second stage. RESULTS: Complete infection eradication was achieved with mean follow up of 26 months. All cases were balanced with primary total knee prosthesis. The knee scores and final range of motions were comparable to other studies. CONCLUSION: The two-stage total knee replacement technique is a good option for management of failure of previous surgical treatment in patients with septic arthritis and concomitant joint degeneration. Our proposed approach enabled us to use primary prosthesis in all of our patients with no need for suppressive antibiotic therapy.

Loop-Post Construct, A Novel Technique for Medial Meniscus Root Repair.

Surgical reattachment of medial meniscus posterior root tear (MMPRT) with transtibial sutures can delay the presence of medial knee joint compartment osteoarthritis. Most suture configurations are placed five mm away from the torn margin in the meniscal substance which is already degenerated and may decrease the pull out strengths of repair construct. The number of meniscus penetration may also be important considering meniscus tissue damage with more complex suture techniques impose the risk of suture cut out through the meniscus substance. We introduce our loop postsuture construct technique which is simple, cheap and reproducible.

Comparison of Accuracy in Expert Clinical Examination versus Magnetic Resonance Imaging and Arthroscopic Exam in Diagnosis of Meniscal Tear.

BACKGROUND: Many clinical tests and diagnostic studies have been developed to increase the clinician's ability to accurately diagnose disorders of the knee. Torn menisci or ligamentous structures within the knee cause significant pain and disability and thus require expeditious management. This study was conducted to evaluate the accuracy of clinical examination in comparison with MRI examination and with the help of arthroscopic examination as the gold standard in the diagnosis of meniscal tears. METHOD: All of the arthroscopic surgery candidates, presenting symptoms of meniscal or cruciate ligament lesions, referring to Namazi and Chamran hospitals, Shiraz, Iran, were included in this study. Clinical examination (including McMurray test, Apley test, and 20 Thessaly test) was performed before the arthroscopy, and the results were recorded in special forms. Magnetic resonance imaging (MRI) results were also added. Then, arthroscopy was performed, declaring the definite diagnosis, and the results were compared to the results obtained from both tests and MRI. Statistical analysis was performed using SPSS software. RESULTS: 86 patients with a mean age of 27 years old, including 63 (73%) male and 23 (27%) female, were studied. 57 (66%), 19 (22%), and 10 (12%) injuries were caused by sports, twisting, or trauma, respectively. Arthroscopic results showed 32 meniscal tears, of which 28 (87%) and 4 (13%) were in medial and lateral menisci, respectively, including 10 bucket handle, 17 longitudinal, and 5 of other types (transverse, oblique, radial) of injuries. Comparing MRI results to arthroscopic results, we had 2 false-positive and 2 false-negative cases. 62 cases of McMurray test results were accurate; 15 and 9 cases were reported false positive and false negative, respectively. 60 cases of Apley test results were accurate; 16 and 10 cases were reported false positive and false negative, respectively. 78 cases of Thessaly test results were accurate; 5 and 3 cases were reported false positive and false negative, respectively. Comparing Thessaly test results to McMurray and Apley showed statistical significance (P < 0.05). Comparing Thessaly test results to MRI showed no statistical significance (P = 0.151), while comparing McMurray and Apley test results to MRI showed statistical significance (P < 0.01). CONCLUSION: Clinical examination, performed by an experienced examiner, can have equal or even more diagnostic accuracy compared to MRI to evaluate meniscal lesions. In this study, the Thessaly test has been approved as a reliable clinical test in the diagnosis of meniscal tears.

Potential Role of Local Estrogen in Enhancement of Fracture Healing: Preclinical Study in Rabbits.

BACKGROUND: Effects of estrogen on bone metabolism and its protective role on prevention of osteoporosis are well documented. However, the efficacy of estrogen treatment on bone healing is not well investigated. The drug can be delivered both systemically or locally to the bone with differences in concentrations and side effects. The aim of this study was to investigate the effect of local and systemic administration of estrogen on the fracture healing process. METHODS: Standardized tibial fractures with 4 millimeter gaps were created in twenty four adult male Dutch rabbits. Fractures were fixed using intramedullary wires and long leg casts. Rabbits were randomly divided into three groups. Group A was treated with twice a week administration of long acting systemic estrogen; group B was treated with a similar regimen given locally at the fracture gap; and group C received sham normal saline injections (control). Fracture healing was assessed at six weeks post fracture by gross examination, radiographic and histomorphometric analysis. RESULTS: Group B had significantly higher gross stability, radiographic union and gap reduction than the two other groups. Histomorphometric analysis showed higher cartilaginous proportion of periosteal callus area in the control group. CONCLUSIONS: Our results showed that estrogen may enhance fracture healing of long bone in rabbits. Furthermore, local estrogen treatment might have better effect than systemic treatment.

Management of Deep Vein Thrombosis (DVT) Prophylaxis in Trauma Patients.

Deep vein thrombosis (DVT) and pulmonary embolism (PTE) are known as venous thromboembolism (VTE). DVT occurs when a thrombus (a blood clot) forms in deep veins of the body, usually in the lower extremities. It can cause swelling or leg pain, but sometimes may occur with no symptoms. Awareness of DVT is the best way to prevent the VTE. Patients with trauma are at increased risk of DVT and subsequent PE because of coagulopathy in patients with multiple trauma, DVT prophylaxis is essential but the VTE prophylaxis strategy is controversial for the trauma patients. The risk factors for VTE includes pelvic and lower extremity fractures, and head injury.

A simple and sensitive HPLC method for determination of gliclazide in human serum.

A simple, rapid and specific method for analysis of gliclazide in serum by a sensitive high-performance liquid chromatographic method is described. Only 100 microl of serum and a little sample work-up is required. A simple procedure of extraction by toluene followed by evaporation to dryness under a gentle stream of air and dissolving the dried residue in mobile was used. The gliclazide peak was separated from endogenous peaks on a C(8) column by a mobile phase of acetonitrile-water (45:55, v/v), pH 3. Gliclazide and internal standard (phenytoin) were eluted at 6.8 and 3.8 min, respectively. The limit of quantitation (LOQ) for gliclazide in serum was 75 ng/ml at 230 nm. The method was linear over the range of 75-10,000 ng/ml with r(2) of 0.999. Mean recovery for gliclazide and internal standard was 84.5 and 87%, respectively.