Alper Kaya

Treatment of Kienböck Disease by Lunate Core Decompression

PURPOSE Kienböck disease is characterized by avascular necrosis of the lunate bone, which is usually progressive without treatment. This study examined lunate core decompression for its treatment potential. METHODS We surgically treated 20 patients with stage 1 to 3b Kienböck disease with lunate core decompression. We evaluated pain, range of motion, functional disability, and radiographic indices in these patients at baseline and 5 years after surgery. RESULTS The mean age of the patients was 29 years; 16 were men. Ten patients had Lichtman stage 1 disease, 6 had stage 2 disease, 3 had stage 3a, and 1 had stage 3b disease. Range of motion scores showed meaningful improvement. Two patients did not improve with this technique and were revised with radial shortening procedures. CONCLUSIONS Lunate core decompression is a simple surgical procedure that is effective in the treatment of Kienböck disease. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Evaluation of the two bundles of the anterior cruciate ligament with 1.5 tesla magnetic resonance imaging

OBJECTIVES Studies on the anatomy of the anterior cruciate ligament (ACL) have shown that the normal ACL consists of two functional bundles named as anteromedial (AM) and posterolateral (PL) bundles. In this study, we evaluated the AM and PL bundles of the ACL using 1.5 tesla magnetic resonance imaging (MRI), which is routinely used in clinical practice. METHODS The study included 150 patients (96 females, 54 males; mean age 33.4+/-11.6 years; range 18 to 59 years) who did not have any signs of ACL insufficiency and whose knees were examined by MRI for other reasons. Standard magnetic resonance images (77 right, 73 left) were evaluated independently by an orthopedist and a radiologist in terms of distinguishable ACL bundles. The angle between the ACL (and each bundle) and the tibial plateau was measured on sagittal and coronal sections. Arthroscopic surgery was performed in 64 patients (42.7%) for primary diagnoses and arthroscopic and MRI findings were compared. RESULTS Magnetic resonance imaging showed an intact ACL in all the patients. The ACL was assessed as a single bundle in the axial, coronal, and sagittal planes in 93 patients (62%). A double-bundle appearance was noted in 57 patients (38%), involving all three planes in 14 patients (9.3%), axial and coronal planes in 41 patients (27.3%), coronal and sagittal planes in one patient (0.7%), and only coronal plane in one patient (0.7%). On MRI sections showing a single bundle ACL, the mean angle between the ACL and the tibial plateau was found as 55.3 degrees in the sagittal plane, and 70.3 degrees in the coronal plane. On sections with a double-bundle appearance, the mean angles between the AM bundle and the tibial plateau were 70.1 degrees and 55.1 degrees in the coronal and sagittal planes, respectively. The corresponding angles for the PL bundle were 81 degrees and 53.5 degrees . The incidence of double bundle ACL appearance in coronal, sagittal, and axial MRI sections was not influenced by sex and side (p>0.05). The number of bundles identified in each plane did not show a significant difference between the two observers (p>0.05). During arthroscopic surgery, both bundles were identified with normal integrity and function of the ACL in all the patients. Of these, MRI could depict a double-bundle appearance in one or more planes in only 42.2% of the patients. CONCLUSION Even though standard 1.5 tesla MRI, routinely used in clinical practice, has a very high success rate in demonstrating the ACL, it can visualize the two-bundle structure only in about one-third of the patients.

Minimum 5-year follow-up surgical results of post-traumatic thoracic and lumbar kyphosis treated with anterior instrumentation: comparison of anterior plate and dual rod systems.

Study Design. A retrospective follow-up study of post-traumatic thoracic and lumbar kyphosis after anterior instrumentation with anterior plate and dual rod systems. Objective. To investigate the outcome of anterior vertebrectomy, anterior strut grafting, and anterior instrumentation in patients with >30° sagittal contour deformity. Summary of Background Data. Post-traumatic kyphosis may lead to mechanical pain due to the impairment of physiologic sagittal contours as well as cosmetic complaints. Methods. Forty patients with post-traumatic kyphosis were followed for a minimum of 5 years. Mean age was 44.7 ± 12.4 years (range, 18–65 years); 18 were female and 22 were male. All patients underwent anterior vertebrectomy and decompression; anterior fusion was carried out with costal or iliac ala grafts. Patients were randomly assigned into 2 treatment groups: correction and internal fixation was performed by using either plate-screw (n = 20) or double rod-screw (n = 20). Patients were also evaluated clinically by using Pain and Functional Assessment Scale (PFA) and SRS-22 questionnaire. Results. Before surgery, the mean value for local sagittal contours was 51.4° ± 13.8°; after surgery, it was reduced to 7.0° ± 7.6°, resulting in an 88.7% ± 11.3% correction (P = 0.00). At the last follow-up visit, a mean correction loss of 1.4° ± 1.8° was found. A statistically significant improvement in local kyphosis angles and PFA scores was found after surgery and at the last visit. In 92.5% of the patients (n = 36), pain completely resolved; and in the remaining 3 patients, it is markedly reduced. Neurologic improvement was achieved in all of the 24 patients with neural claudication and other neurologic findings. Solid fusion mass was obtained in all patients. The type of instrumentation system did not differ significantly in terms of kyphotic deformity correction rates, correction losses, PFA scores, and SRS-22 scores. Final PFA scores showed a statistically significant correlation with SRS-22 scores (r = −0.918, P < 0.01). Final pain, function, mental status, self image and satisfaction domain scores and total SRS-22 score were ≥4. The time from trauma to operation and the severity of kyphotic deformity were inversely correlated with postoperative correction rates. On the other hand, these 2 parameters were positively correlated with both final PFA and final SRS-22 scores (P < 0.01). Conclusions. In light of the present studys findings, we suggest that the technique of anterior decompression, strut grafting, and anterior instrumentation is an effective method for the treatment of post-traumatic kyphotic deformity and that the success of the technique depends on the time from trauma to operation and the severity of baseline deformity, regardless of the type of instrumentation.

Cemented versus Uncemented Oxford Unicompartmental Knee Arthroplasty: Is There a Difference?

Purpose. The use of uncemented unicompartmental knee prostheses has recently increased. However, few studies on the outcomes of uncemented unicompartmental knee prostheses have been performed. The purpose of this study was to compare the outcomes of cemented and uncemented Oxford unicompartmental knee arthroplasty. Materials and Methods. This retrospective observational study evaluated the clinical and radiological outcomes of 263 medial Oxford unicompartmental prostheses (141 cemented, 122 uncemented) implanted in 235 patients. The mean follow-up was 42 months in the cemented group and 30 months in the uncemented group. Results. At the last follow-up, there were no significant differences in the clinical results or survival rates between the two groups. However, the operation time in the uncemented unicompartmental knee arthroplasty group was shorter than that in the cemented unicompartmental knee arthroplasty group. In addition, the cost of uncemented arthroplasty was greater. Conclusion. Despite the successful midterm results in the uncemented unicompartmental knee arthroplasty group, a longer follow-up period is required to determine the best fixation mode.

Outcomes for revision total knee replacement after unicompartmental knee replacement

OBJECTIVE The aim of this retrospective, observational study was to describe the outcomes of total knee replacement (TKR) after failed Oxford phase 3 medial unicompartmental knee replacement (UKR). METHODS The study included 24 revision TKRs (20 females, 4 males; mean age: 61 years) performed following failed aseptic UKR. Outcomes were assessed using the Knee Society Score (KSS). RESULTS The most common causes for revision were mobile bearing dislocation and unexplained pain. Mean preoperative KSS was 50.3 (range: 37 to 66) and 82.2 (range: 58 to 97) after TKR. There were 17 excellent, 4 good, 2 fair and 1 poor results. CONCLUSION The type of UKR performed (cemented versus uncemented) had no effect on TKR success. Revision for failed UKR with TKR appears to be a technically straightforward procedure with satisfactory early clinical results.

Cementless total hip arthroplasty in developmental dysplasia of the hip with end stage osteoarthritis: 2-7 years' clinical results.

Between 2006 and 2011, 102 hips of 78 patients with end-stage osteoarthritis secondary to developmental dysplasia of the hip (DDH) underwent cementless total hip arthroplasty (THA). According to the Crowes classification, 22 hips (21%) were type 1, 19 hips (18%) were type 2, 22 hips (21%) were type 3 and 39 hips (38%) were type 4 respectively. Functional and clinical analyses were performed by Harris Hip Scores (HHS). There were 73 (71%) excellent or good results according to HHS. The postoperative HHS was significantly lower in patients who underwent femoral shortening (p<0.01). We observed 25 (24.5%) complications in total, 15 (14.7%) of which required revision surgery. The authors concluded that THA for DDH is a safe and a reliable procedure with good clinical outcomes.

Osteochondritis dissecans occurring in the patella and medial femoral condyle in the same knee

Osteochondritis dissecans (OCD) is a condition in which a portion of articular cartilage separates from the bone together with the underlying subchondral bone. Its classical localization is the medial femoral condyle. We presented a 14-year-old boy who had OCD lesions in both the medial femoral condyle and patella in the same knee joint. He presented with complaints of pain, swelling, and locking following sports activities. Magnetic resonance imaging showed completely detached loose bodies causing instability. Arthroscopic treatment was performed including in situ fixation of the condylar lesion and debridement of patellar lesions. At six-month follow-up, he had full range of motion of the knee joint, with some pain in the patellar grind test.

Transtibial repair in medial meniscus root avulsions; 2 years clinical results:

Introduction: Medial meniscus posterior root avulsion injuries exhibited a similar extent of increasing contact pressure and decreasing contact area, as that in the total meniscectomized knee and resulting articular cartilage loss in medial compartment of the knee joint. Although partial meniscectomy is the traditional treatment in symptomatic posterior root avulsions, this method can not restore cartilage loss. The recommended surgical treatment for posterior root avulsions is repair in non degenerated knees. Patients and methods: Arthroscopic transtibial repair was performed in 11 patients who were diagnosed as symptomatic posterior root avulsions with clinical examination and magnetic resonance imaging findings and minimum 2 years results were evaluated. There were 8 women and 3 men, and the mean age of the patients were 51 (46-58). The mean time interval between injury and surgery was 4 weeks (5 days and 8 weeks). Conservative treatment was given to all of patients except one, and surgical treatment was performed for patients whose mechanical sypmtoms and pain weren’t relieved at the end of conservative treatment. The repair method was arthroscopic pull-out technique with fixation of the posterior attachment area through a tibial tunnel. Walking 4-6 weeks non-weight bearing with two crutches and physical treatment was given that includes muscle strengthening and range of motion exercises. Patients were evaluated with preoperative and 2 years postoperative Lysholm knee scores, clinical examination and radiographic changes. Results: Mean Lysholm scores were increased preoperative from 55 to postoperative 86 that was found statictically significant. In ten patients complaints were resolved after surgical treatment and daily living began normally after surgery. In one patient arthroscopic partial meniscectomy was done due to rerupture after five months from index surgery. In two patients medial joint space narrowing was found radiologically at the end of two years but there were no clinical complaints. Conclusions: Repair must be considered in symptomatic medial meniscus posterior root avulsions also in older age if there is no degenerative osteoarthritis. The root tear that has similar effects as total meniscectomy will cause cartilage loss if not treated.

The triangle between the anterior and posterior cruciate ligaments: an arthroscopic anatomy study.

OBJECTIVE The goal of anterior cruciate ligament (ACL) reconstruction is to place the graft in closest proximity to the native ACL anatomy. This study aims to examine the angular relation between intact anterior and posterior cruciate ligaments (PCL) from an arthroscopic perspective. METHODS Forty patients (20 male, 20 female) with a mean age of 35.12 (range: 18-40) years that underwent knee arthroscopy for reasons other than ACL rupture were included in the study. Following diagnostic examination and repair of the primary pathology, the triangle between ACL and PCL was seen at different flexion degrees of the knee joint (120, 90, 60, and 30°) through standard anterolateral (AL) and anteromedial (AM) portals. The narrow top angle of the triangle between the long intersecting axes of ACL and PCL was measured using recorded images by 3 blind observers. RESULTS The average ACL-PCL angle was 61°, (standard deviation±2°) at 90°of knee flexion. The angles were narrower when viewed through the AM portal. The degree of the angles was not affected by age, sex, body mass index (BMI), or the side (right or left) on which the procedure was performed. There was good-to-excellent intra- and interobserver reliability. CONCLUSION The angular relation between intact ACL and PCL has the potential to provide a better view of the anatomy during arthroscopic ACL surgery. To perform better anatomic reconstructions, it is important to create a 60° angle between the ACL graft and PCL (as viewed through AL portal) at 90°of knee flexion.

Arthroscopic Repair of Horizontal Meniscus Tears by Vertical Sutures With Packing Technique

Objectives: The aim of this study is to report short term results of arthroscopic repair of horizontal meniscus tears by vertical sutures with packing technique Methods: Seventeen patients with an average age of 33 years were treated. Repair was performed to the patients that horizontal component of the tear extends into the capsular zone of the meniscus after excision of the unstable, central or flap components of the tears. The repair was performed after rasping and trephination, with vertical sutures that one leg of the suture is on the superior surface of the menisci and the other leg of the suture is under the inferior surface of the menisci by inside-out technique using the zone-specific curved canulas and all-inside technique using all inside meniscal devices. 9 medial and 8 lateral meniscus tears were treated. Results: Evaluation was performed by Lysholm functional knee scores. All patients were followed clinically and radiological by means of MRI to assess meniscus integrity at the repair site with an average follow-up of 12 months. MRI showed a healed meniscus at the repair sites in only five cases (29%) but with no further disruption of the tear components and osteoarthritic changes in all cases. Mean of Lysholm scores improved from 58 preoperatively to 92 postoperatively that was found statistically significant. Conclusion: Repairing of horizontal meniscus tears that extend into capsular zone instead of resection improves activity level and prevents meniscal loss.