Iranian Journal of Orthopedic Surgery

Abstract Background: The tourniquet commonly uses in knee replacement surgery, but there is no consensus on the release time of the tourniquet. The aim of this study was the evaluation of tourniquet release time, on postoperative hemoglobin level in knee arthroplasty patients.
Material and Methods: During one year, patients undergoing complete knee arthroplasty were randomly divided into two groups according to the inclusion criteria, the early release tourniquet group (opening tourniquet after cementation) and the late release tourniquet group (opening tourniquet after wound dressing). Hemoglobin levels were measured and compared at preoperative, 24 hours and one week after surgery. Also, Duration of surgery, blood transfusion requirements and early wound complications were evaluated in two groups.
Results: The mean duration of surgery was 82 ± 11.2 minutes in the early release group and 73 ± 14 minutes in the late release group (P <0.001). Decrease of hemoglobin level at 24 hours and one week after surgery was 1.8±0.82 and 1.1±0.71 respectively in the first group, and 1.4 ±0.94 and 0.6 ±0.82 in the second group. In this study, the requirements for blood transfusion was more in the early release of the tourniquet group (4 cases in the first group and 2 cases in the second group), but this difference was not significant.
Conclusion: Late tourniquet release after wound dressing can reduce surgery time and reduction of hemoglobin level in total knee arthroplasty.

Abstract Background: In a total knee arthroplasty surgery the goal is to produce 90 degree angle between the knee articular lobe and the mechanical femoral line. Most orthopedic surgeons usually utilize a 5 to 7 degree for distal femoral cutting angle. In this study we will aim at clearing this question, that whether the” five-seven degree” distal femoral cutting angle supposed to be an equable spectrum?
Method: In this three year course of study, 123 candidate patients for knee arthroplasty with varus knee deformities underwent pre operatore radiologic assessment before joint replacement surgery. The femoral bowing angle, distal femoral cutting angle, neck shaft angle, angle between knee articular line and mechanical femoral angle were assessed and statistically analyzed.
Results: The mean varus angle was in 13.71±4.34 in male and 16.41±7.87 in female. The mean distal femoral cutting angle (DFCA) was 6.50±1.09 in male and 7.38±1.75 in female. In 48 patients (%39) the female DFCA was out of 507 degree range. In 32 (26%) of patients the DFCA was 7-9 degrees and in 8 (%6) it was over 9 degrees, and in 8 (%6) was less than 5. The angle differences had no sex-related variation. There was a good co-relation between DFCA and bowing angle (r=0.769). The co-relation between DFCA and NSA was moderator (r=0.523). The co-relation between DFCA and DFA (r=0.11) and varus angle with LDFA (r=0.28) was low. LDFA was also related to NSA (r=0.15). Therefore, the candidates for knee replacement who have varus deformity may need a distal femoral cutting angle over 7 degrees. Based on these results, the distal femoral cutting angle in patients in need of a knee arthroplasty and varus deformity might be more than seven degrees.
Conclusion: The distul femoral cutting angle in knee arthroplasty in face of severe varus does not have a constant value and maybe over 7 degrees. A long standing radiograph is needed to measure the mechanical and correlate with axis the anatomic axis of distal third of femur. When the bowing angle is high the DFCA will need to be higher.
 

Abstract Abstract Background: Hip fracture in the elderly is associated with a high mortality rate, imposing considerable burden to healthcare system. This study aimed to evaluate the functional score of Harris Hip Score (HHS) in elderly patients with intertrochanteric fracture treated by bipolar hemiarthroplasty. Methods: This study was conducted on 40 patients (mean age of 78.21 years) with unstable intertrochanteric fracture after surgery using cemented bipolar hemiarthroplasty. The cases were assessed in terms of radiographic and clinical evaluation. Harris Hip Score (HHS) questionnaire was filled for all the patients. Results: Four patients had incomplete follow-ups and 5 patients had deceased. The HHS score was excellent for 6, good for 14, fair for 7, and poor for 4 patients. The mean HHS was 85.12 (good). Conclusion: Performing surgery with cemented bipolar hemiarthroplasty in older patients with unstable intertrochanteric fracture would lead to acceptable clinical and functional results with earlier ambulation, and HHS score of 85.12 .

Abstract Background: Knee arthroplasty has been traditionally based on mechanical alignment restoration. In the newer, “Kinematically aligned knee replacement”, the eroded bone and joint surfaces in addition to saw-blade thickness are removed and replaced by the components. This study compared the results of two techniques of knee arthroplasty. Methods: In a clinical trial study, 90 patients who were candidates for knee arthroplasty were divided into 2 groups: 45 cases received knee arthroplasty by “mechanically aligned” and 45 by “Kinematically aligned” technique. The two groups were compared after 1 year by Lysholm score, hospitalization period, subjective satisfaction, and period of need for ambulatory aid. Results: 73 patients referred for follow up: 37 patients in the kinematic and 36 in the mechanical group. The mean hemoglobin drop was not significantly different between the two kinematic and mechanical groups; while the post operation mean hemoglobin drop difference was significant (p < /em>=.001). No significant difference in the patient satisfaction of the operation was observed between two groups. The difference of mean Lyshlom score was different between two groups (p < /em>=.000). Conclusions: kinematically aligned” knee replacement is associated with less pain, earlier return to daily activity, lesser intra operative bleeding and more patient satisfaction.

Abstract Total hip arthroplasty (THA) is the replacement of the hip joint by artificial prosthesis.  This surgery is one of the most successful orthopaedic surgeries. The most important challenge to the THA is bearing surface of these implants, which is closely related to the survival of the prosthesis. Following the introduction of the first successful implant in THA, there has been great progress in implant production, by increasing the power and reducing the friability and wear of the bearing surfaces. The wear particles can remain in the host tissue, generate osteolysis and reduce the implant survival. These problems with bearing surfaces have led to creation of other bearing surfaces such as metal-on-polyethylene, metal-on-metal, ceramic-on-ceramic and ceramic-on-polyethylene with improved characteristics. Such types of implants can be used for young and more active patient, in addition to the elderly who is less active. In the present review, the different type of bearing surfaces with their advantages and disadvantages has been discussed.

Abstract Aseptic loosening in total hip arthroplasty (THA) is among the common reasons for failure and the need for revision surgery. There is no general consensus among the orthopaedic surgeons as to the true reason for this pathology. Some consider this a purely mechanical failure, related to the long-standing forces applied to the joint, causing fatigue failure, while others consider it purely biological response of the body to the particulate debris resulting from the wear in polyethylene or other components of the THA causing linear osteolysis. A combined pathology is probably a more logical explanation, i.e. osteolysis weakening the prosthetic bone in-growth, making it more susceptible to shear, and rotational forces and eventually causing the loosening. Here in, an overview of pathophysiology, prevention, diagnosis and treatment of hip aseptic loosening has been presented.

Abstract Alkaptonuria is a rare metabolic disorder. Symptoms include discoloration of tissues and degenerative joint disease and urinary stones. A 60-year-old man was admitted due to knee and hip pain. Brown lesions on the eye, ear, hand and fingers were visible. Limitation of motion of the hip and knee and elbow was present on both sides. He had history of kidney stones ad Achilles tendon rupture. During hip arthroplasty, black lesions on the greater trochanter and femoral head were visible.

Abstract Background: Destruction of pain receptors around patella by electrocauterization is commonly used during total knee arthroplasty. Its effect on cartilage was the goal of this survey.Methods: In a clinical trail study, 20 rabbits, divided into two equality sized groups (experimental-control) and experimental group underwent surgery via medial parapatellar arthrotomy of the knee joint. Electrocauterization denervation at a depth of 1 mm and a distance of 3 mm from border of patella performed in the cases animals. No patellar denervation was done in the control group. Range of motion of joint, macroscopic evaluation using modified outerbridge score, and histopathologic scoring were assessed after twelve weeks. Results: Finally, nine cases and eight control animals were included due to death of three animals. Full range of motion was seen in all rabbits. Statistically significant difference in outerbridge score (p < /em>=.002), cellularity (p < /em>=.016), loss of matrix (p < /em>=.004), and clustering of chondrocytes (p < /em>=.008) were obtained.Conclusions: Cartilage destruction may be the result of electrocauterization of patellar rim. So, routine electrocauterization should be discouraged.

Abstract Background: Preoperative onlay templating is prevalently used to determine the size and placement of acetabular and femoral components before total hip arthroplasty (THA). The purpose of this study was to determine the accuracy and reliability of preoperative onlay templating in uncemented THA. Methods: In a cross sectional study, 50 patients who underwent uncemented THA for hip osteoarthritis were selected in one teaching hospital, retrospectively. The study was done in a 4-month period. Using onlay templates, four surgeons determined the size of acetabular and femoral component on plain anteroposterior hip radiographs. Finally, the average percentage of agreement between template and implanted components were considered as the accurate representation. Kappa coefficient was utilized to determine the interobserver reliability.Results: The accuracy of templating for acetabular and femoral component size was 60% and 59.5%, and the interobserver reliability was 49% and 52%, respectively.Conclusions: Based on our findings, preoperative onlay templating cannot provide us with proper component selection and intraoperative determination of correct size is required for best outcome achievement.

Abstract Background: Cementless total hip replacement is an accepted alternative to total hip replacement with cement in younger patients, but it remains controversial for elderly patients. This study evaluated the functional results and complications of cemented and cementless methods in old patients. Methods: In this cross-sectional study, all the patients aged 65 years or older who had been hospitalized for total replacement of hip joint because of femoral neck fracture or osteoarthritis of hip were studied during a 3-year period in three educational hospitals in Iran. "Harris hip score" was used to assess the functional consequences. The early complications -thrombophlebitis of lower limbs, dislocation, hematoma and infection - and late complications - aseptic loosening, dislocation, and reoperation, were documented. Results: 209 eligible patients, including 96 (45.9%) cemented and 113 (54%) cementless were studied. Patients were followed for a mean period of 5 years and 2 months (51-82 months). The overall rate of early complication was 8 cases (3.8%): five in the cemented and three in cementless group, respectively. Late complications were seen in two cases -one loosening in cemented group and one dislocation in cementless group. The final Harris hip score at the final follow-up was 84.01±4.71 in cemented and 85±5.02 in the cementless groups (p≥.05). Conclusion: Cementless hip replacement can have a satisfactory functional result like cemented hip replacement procedure in the elderly patients over 65 years of age.

Abstract Background: The posterior of acetabular cup in total hip replacement can be affected by the central osteophytes in the acetabular fovea. We are proposing a classification of such osteophytes based on direct observation and CT scan of osteoarthritis hips.Methods: This study was composed of two sections: first, 276 cases with all clinical and radiographic evidence of osteoarthritis of hip–with no history of fracture or pelvic bony surgery – were studied by radiographs and CT Scans. The changes in the acetabular osteophytes were evaluated and categorized. Secondly, 57 cases of hip osteoarthirites who were undergoing hip arthroplasty received direct observation of the acetabular osteophytes and categorization of the acetabular fovea in accordance with the above classification system. The relation of primary etiology of hip osteoarthritis with the osteophyte classification was also studied.Results: According to radiographs, CT Scans and direct visualization, four types of acetabular osteophytes were identified. Type I: Normal acetabular with 5mm distance from rim to the floor type IIa: Evidence of sclerosis around fovea type IIb: Sclerosis forming a ceiling, like an umbrella over the fovea type IIc: The foveal osteophytes are almost touching in the center type III: Osteophytes have fully covered the fovea, making the acetubular look very shallow.Conclusion: Study and categorization of acetabular osteophytes with radiographs and CT scan would be a helpful pre-operative tool for more accurate reaming of the acetabular cavity and cup positioning in hip osteoarthrties.

Abstract Background: Dislocation of total hip arthroplasty may happen for different reasons. Abnormal acetabular orientation is a common reason for such occurance. We would like to report the effect of acetabular inclination on incidence of dislocation.Methods: In a cross-sectional study all cases of total hip arthroplasty performed in a 2-yaer interval in one educational hospital in Tehran, were followed and assessed for possible dislocation in a 18.1 months (3-25 months) of follow-up. The inclination angles of acetabular components were measured, and the relationship of dislocation with gender, age and this angle was evaluated.Results: 132 cases entered the study. 4 patients (3%) encountered dislocation and all 4 had inclination angles of over 50 degrees. Gerder did not seem to play an important role. Older age, however, was probably contributing to risk of dislocation.Conclusion: Inclination angle of over 50 degree in acetabular component position is one of the factors making it more likely for the hip arthroplasty to dislocate.

Abstract Background: The role of a mobile-bearing knee arthroplasty is still not clear. This study was designed to compare the mobile and fixed-bearing prosthesis.Methods: In 30 knees a fixed-bearing and in 38 knees a mobile-bearing prosthesis was used. The results were compared using the "Knee Society Scoring System".Results: The mobile-bearing group of patients had an average age of 65 and 34 months average follow-up. The fixed-bearing group had an average age of 69 years and a mean follow-up of 30 months. The average knee score, functional score and overall score in the mobile-bearing group rose from 29, 45, 73 to 64, 67, 128 and in the fixed-bearing group from 31.7, 34, 65.9 to 68, 57, 125 prospectively. The difference between two groups was not significant statistically.Conclusion: Although in both groups the average knee scores increased after the operation, there were, however, no significant difference between knee scores in the two types in short-term, and no preference between two types of prosthesis.

Abstract Background: Antifibrinolytic drugs are used to minimize the potential risks of bleeding and blood transfusion. Studies showed the effect of tranexamic acid on decreasing blood loss in cemented THA. We would like to report its effect on cementless hip arthroplasty.Methods: A prospective double blind randomized controlled study was conducted on 64 candidates for cementless THA under epidural anesthesia between 2006 and 2008. The patients were randomly divided into study and control groups. 32 patients received tranexamic acid (15 mg/kg) and 32 received normal saline immediately before surgery.Results: The comparison of two groups showed less drop in 6 hour (p < /em>=0.035) and 24 hour (p < /em>=0.043) post-operative hemoglobin levels, less intra-operative bleeding (p < /em>=0.024), and less need for allogenic blood transfusion (p < /em>=0.017) in the tranexamic acid group. Although the mean of 6 and 24 hour hematocrit level was higher and hospital stay was shorter in the tranexamic acid group, but the differences were not significant.Conclusion: administration of tranexamic acid before cementless THA under epidural anesthesia can reduce intra-operative and post-operative bleeding as well as need for blood transfusion.

Abstract Background: Avascular necrosis (AVN) of femoral head, with resultant joint destruction, is a common disabling disease of fourth and fifth decades of life. Metal-on-metal resurfacing is a relatively newer treatment modality for this disease. The aim of this study is to compare the result of resurfacing for osteonecrosis with that of resurfacing for other causes.Methods: Twenty eight patients with stage III or IV (Ficat & Arlet) osteonecrosis who underwent metal-on- metal hip resurfacing were compared with 24 cases of grade IV or V (Croft’s) osteoarthritis (OA) who had undergone the same kind of arthroplasty during a 2 year period in Akhtar hospital in Tehran. These cases were matched in terms of gender and age, and were assessed by Harris hip score with 41(±22) months follow-up.Results: The AVN cases had 30.86 (±7.5) and OA cases 47.88 (±12.6) years at surgery. Three patients from each of the above groups had sustained complications of either femoral neck or acetabular cup fracture and had required revision surgery. The average Harris hip score was 94(±7.2) in AVN and 91.2(±9.4) in OA group. The collective hip range of motion was 216(±6.2) in AVN and 196±(5.6) in AO patients.Conclusions: Metal-on-metal hip resurfacing gives similar satisfactory results in avascular necrosis and in osteoarthritis of hip joint in short-term, with no statistically significant difference.

Abstract Background: The association between wound drainage and subsequent periprosthetic infection is well known. However, the most appropriate treatment of wound drainage is not well understood. Methods: We retrospectively reviewed the records of 10325 patients (11785 procedures), among whom 300 patients (2.9%) developed persistent (greater than 48 hours postoperatively) wound drainage. Wound drainage stopped spontaneously between 2 and 4 days in 217 patients treated with local wound care and oral antibiotics. The remaining 83 patients (28%) underwent further surgery.Results: A single débridement resulted in cessation of drainage without subsequent infection in 63 of 83 patients (76%), whereas 20 (24%) patients continued to drain and underwent additional treatment (repeat débridement, resection arthroplasty, or long-term antibiotics). Timing of surgery and the presence of malnutrition predicted failure of the first débridement. There were no differences between the success and failure groups with regard to all other examined parameters, including demographic or surgical factors.Conclusions: We found patients who underwent débridement at a mean of 5 days following the onset of drainage were more likely to be infection free at one year postoperatively compared to patients who underwent debridement at a delayed time (mean, 10 days). Our data confirmed that malnourished patients (serum transferrin less than 200 mg/dL, serum albumin less than 3.5 g/dL, or total than 1500/mm3) undergoing total joint arthroplasty are lymphocyte count less more likely to develop deep infection and require further treatment after irrigation and débridement. Based on these findings, we recommend early (within 7 days) surgery for persistent wound drainage in general, and particularly for those with malnutrition

Abstract Background: Knee replacement is one of the final remedies for severe, symptomatic knee destruction. The results of this surgery are usually excellent. The number of reports from Iran on this subject is very few. We would like to report our experience with knee replacement in Kerman.Methods: In a clinical trial and prospective study, 54 patients (11 males, 43 females) with knee disease who underwent joint replacement from 2001 to 2006 in a Teaching hospital in Kerman, were studied. Mean age was 65 years (41-80) and mean follow-up 34.4 months (3 months to 5 years). 46 cases had osteoarthritis and 8 rheumatoid arthritis. The pre and post operative findings were assessed using the ‘Knee Society’ evaluation system. The opposite knees were used to compare the patients’ satisfaction from the procedure.Results: In a study on 54 cases, the pain score of ‘Knee Society’ improved from 33 to 77 and the functional score improved from 41 to 72. Ninety six percent of the cases were satisfied with their surgeries. The complications included 1 deep and 1 superficial infection, 2 wound healing problem and one patellar dislocation. Three revisions become necessary: 2 due to infection, one for loosening and deformity in tibial component.Conclusions: Knee replacement in Kerman is associated with high satisfaction rate in short-term. Early failure is mostly related to infection or technical errors in surgery.