Bülent Atilla

Scintigraphic evaluation of impaction grafting for total hip arthroplasty revision

Abstract To determine the fate of an impacted allograft after a minimum follow-up of 1 year, we examined 9 of 40 patients who underwent revision arthroplasty with the impaction grafting technique. The allograft used in this study was morselized cancellous freeze-dried allograft. We examined these 9 patients with technetium-99 m methylene diphosphonate bone scintigraphy at an average of 14 (range 12–20) months after surgery. All of them had a good clinical outcome, with an average postoperative Hip Society Score of 89 (range 65–98) and no evidence of radiolucency or subsidence on direct radiography. Scintigraphic examination demonstrated that the area corresponding to the allograft had a remarkable radioactivity accumulation suggesting new bone formation. The allograft in total hip revision using the impaction grafting technique undergoes a significant neovascularization and new bone formation. This study suggests than when vigorous impaction is used, freeze-dried cancellous allograft can be used for impaction grafting.

Comparison of extraarticular leakage values of radiopharmaceuticals used for radionuclide synovectomy

ObjectivesRadionuclide synovectomy is a reliable therapy in patients with chronic synovitis. However, radiation doses delivered to non-target organ systems due to leakage of radioactive material from the articular cavity are an important disadvantage of this procedure. In this study we compared extraarticular leakage values of the 3 commonly used radiopharmaceuticals;90Y-citrate,90Y-silicate and186Re-sulfide colloid.Materials and MethodsThirty-five patients with persistent synovitis were enrolled in the study. Twenty-two hemophilic, 8 rheumatoid arthritis and 5 patients with pigmented villonodular synovitis were studied.90Y labeled silicate and citrate were used for knee joints and186Re-sulfide for intermediate sized joints. Radiocolloid leakage values were evaluated using a gamma camera with 20% window centered over the bremsstrahlung photopeak of90Y and a respective window over the 137 keV photopeak of186Re. Regions of interest were drawn over the injection site, the regional lymph nodes and the background areas. Leakage of radiocolloid was calculated by dividing the counts/pixel in the regional lymph node area to the counts/pixel in the injection site.ResultsNo visible leakage was observed. The median leakage values calculated for90Y-citrate,90Y-silicate and186Re-sulfide were found as 1.9%, 2.4% and 2.7%, respectively. The difference between the variability of leakage values was not statistically significant (p > 0.05).Conclusion: There was no significant difference in terms of extraarticular leakage between90Y-citrate,90Y-silicate and186Re-sulfide radiocolloids.

Is corticosteroid coinjection necessary for radiosynoviorthesis of patients with hemophilia

Purpose: Radiation synovectomy is frequently combined with intraarticular corticosteroid injection in the treatment of rheumatoid arthritis to reduce local inflammation and lymphatic clearance of radiocolloid. However, this practice is not universally accepted because corticosteroids have local and systemic toxicity such as osteonecrosis and cartilage damage and whether simultaneous corticosteroid injection together with radiocolloids is necessary in other forms of chronic synovitis like patients with hemophilia remains to be determined. Materials and Methods: In this study, we performed radiosynoviorthesis in 14 joints of 12 patients with hemophilia with chronic knee synovitis without corticosteroid coadministration and measured radiocolloid leakage from the joint space. Five mCi Y-90 radiocolloid was injected under local anesthesia and the needle was flushed with additional lidocaine injection instead of corticosteroid. The joint was then manipulated through a full range of extension and flexion to distribute the particles homogeneously throughout the joint space. The joint was then splinted for 48 hours to minimize leakage from the joint space. After the immobilization period, radiocolloid leakage was evaluated using a gamma camera with a 20% window centered over the maximum Bremsstrahlung photopeak of Y-90. Regions of interest were drawn to the injection site on the knee joint and to the ipsilateral inguinal lymph node area. Leakage of radiocolloid was calculated by dividing the background-corrected counts/pixel at the inguinal region by the counts/pixel at the injection site. Results: One of 12 patients who had knee arthroplasty was previously found to have a high amount of leakage. In this patient, 70% of radiocolloid at the injection site drained into the pelvic lymph nodes. In the remaining 11 patients, no lymph nodes were visualized in the groin area and the measured average leakage for these patients was 2.3% (range, 0–13). Conclusion: We concluded that in cases of appropriate particle size and strict immobilization of knee joints, leakage of radiocolloid was minimal and steroid coinjection might not be necessary for radiosynoviorthesis of patients with hemophilia with chronic knee synovitis.

Pre‐operative flexion contracture determines the functional outcome of haemophilic arthropathy treated with total knee arthroplasty

Summary.  End‐stage haemophiliac arthropathy can be successfully treated with total knee arthroplasty. However, the functional results may not be as good as anticipated and certain pre‐op knee characteristics may alter the functional results. The purpose of this study was to evaluate the functional outcome of TKA in haemophilic patients with specific attention to final range of motion and residual flexion contracture of the joint. Twenty‐one consecutive patients were retrospectively reviewed. The average age was 34 years with an average follow‐up of 5.7 years. Functional status was evaluated with Hospital for Special Surgery Knee Score. Receiving Operating Characteristics analysis was used to determine the threshold of pre‐operative flexion contracture degree to avoid residual knee contracture. The range of motion was increased in 16 joints and unchanged in three joints and decreased in the remaining two. Preoperative average range of motion was 37.6°, improved to 57.1° post‐operatively. The average knee score increased from 27.85 (15–30) points pre‐operatively to 79.42 (12–94) points at the last follow‐up. The degree of pre‐operative flexion contracture was found to be a good predictor for residual flexion contracture. (Specificity: 85.7%, sensitivity: 100%, cut‐off: 27.5°). Total knee replacement improves the quality of life in patients with advanced haemophilic arthropathy. Statistical analysis revealed that pre‐op flexion contracture of 27.5° is an important threshold. Patients should be operated before that stage to gain maximum benefit with minimal gait abnormalities.

Implantation of vancomycin microspheres in blend with human/rabbit bone grafts to infected bone defects

In orthopaedic applications, allografts are used for restoration of bone defects. In order to combine the effects of bone repair and to prevent the infection, antibiotic-impregnated bone grafts are under current investigation with promising early results. In this study, to preserve the stability of antibiotics and to provide appropriate release profiles for 4–6 weeks, antibiotic-loaded microspheres were administered in combination with allografts and vancomycin was the antibiotic loaded to microspheres. Particle size, surface characteristics, loading capacity and in vitro release characteristics of the microspheres with and without allografts were determined. In vivo studies were performed on rabbits and antibiotic amount was determined by a fluorescence polarization immunoassay (FPIA) method from synovial fluid sample aspirated. According to the results, although the in vitro study demonstrated effective antibiotic release of vancomycin from antibiotic-impregnated allografts for 5 weeks, in vivo conditions led to an early instability of the antibiotic (in powder form) and contrary to the high initial loading dose an effective release could not be obtained from the allografts after the first week. Following these studies, it was determined that antibiotic release over a minimum inhibitory concentration (MIC) for 6 weeks was realized from vancomycin-loaded microspheres which were implanted in a blend with allografts in bone defects. In conclusion, preservation of the antibiotic in microspheres maintained the bioactivity and provided the controlled antibiotic release, thus implantation of microspheres in a blend with allografts seemed to be a promising carrier system for the orthopaedic applications.

Position of the acetabular component determines the fate of femoral head autografts in total hip replacement for acetabular dysplasia

We have reviewed 54 patients who had undergone 61 total hip replacements using bulk femoral autografts to augment a congenitally dysplastic acetabulum. There were 52 women and two men with a mean age of 42.4 years (29 to 76) at the time of the index operation. A variety of different prostheses was used: 28 (45.9%) were cemented and 33 (54.1%) uncemented. The graft technique remained unchanged throughout the series. Follow-up was at a mean of 8.3 years (3 to 20). The Hospital for Special Surgery hip score improved from a mean of 10.7 (4 to 18) pre-operatively to a mean of 35 (28 to 38) at follow-up. The position of the acetabular component was anatomical in 37 hips (60.7%), displaced less than 1 cm in 20 (32.7%) and displaced more than 1 cm in four (6.6%). Its cover was between 50% and 75% in 34 hips (55.7%) and less than 50% in 25 (41%). In two cases (3.3%), it was more than 75%. There was no graft resorption in 36 hips (59%), mild resorption in 21 (34%) and severe resorption in four (6%). Six hips (9.8%) were revised for aseptic loosening. The overall rate of loosening and revision was 14.8%. Overall survival at 8.3 years was 93.4%. The only significant factor which predicted failure was the implantation of the acetabular component more than 1 cm from the anatomical centre of rotation of the hip.

Bilateral Peroneal Tubercle Osteochondroma of the Calcaneus: Case Report

A case of bilateral symmetric osteochondroma of the peroneal tubercle in a 24-year-old woman is presented. This lesion is discussed along with its etiology and related findings.

Acute fracture of the acetabulum secondary to a convulsive seizure 3 years after total hip arthroplasty.

While aseptic loosening, osteolysis, and infection are the most common causes of failure after total hip arthroplasty (THA), late hip pain can also be the result of acetabular fracture related to trauma and resultant prosthetic failure. However, atraumatic fracture of the acetabulum around a well-fixed acetabular component is unusual. We present a patient with an acetabular fracture resulting from a generalized convulsive attack 3 years after an uncomplicated primary THA. A 33-year-old man presented with acute left hip pain. He had chronic renal insufficiency and had undergone bilateral THA due to avascular necrosis. The night prior to his admission, he suffered a generalized convulsive attack with severe extremity contractions. Afterwards, he had acute left groin pain and had difficulty walking. Physical examination revealed moderate left hip pain as well as a 1-cm shortening of the affected limb. Radiological examination demonstrated an acetabular fracture with medial wall comminution. The acetabular component had migrated medially and rotated horizontally. Revision of the acetabular component with a reinforcement ring and implantation of a cemented acetabular component was realized. Severe muscle spasms during generalized seizures are known to lead to various musculoskeletal injuries (fractures of the proximal humerus, femur, acetabulum, and dislocation of the shoulder). Seizures could also lead to acute periprosthetic fracture of the acetabulum in patients with osteopenia. Therefore careful reaming is required to avoid overmedialization of the acetabular component in those patients.

Radiosynovectomy: current status in the management of arthritic conditions.

Departments of Nuclear Medicine, Orthopedics and Traumatology, Faculty of Medicine, Hacettepe University, Ankara, Turkey and Department of Medicine Service-PET Unit, ‘S. Maria della Misericordia’ Hospital, Istituto Oncologico Veneto (IOV) – IRCCS, Rovigo, Italy Correspondence to Dr Ömer Uğur, Department of Nuclear Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey Tel: + 90 312 305 1336; fax: + 90 312 309 3508; e-mail: ougur@hacettepe.edu.tr

The Effect of Collar on Aseptic Loosening and Proximal Femoral Bone Resorption in Hybrid Total Hip Arthroplasty

This study compared proximal femoral bone resorption in hybrid total hip arthroplasty cases that had poor or good contact between the collar and proximal medial femoral neck. A total of 94 patients (102 hips) comprised the study group. Mean patient age was 52 years, and mean follow-up was 4.86 years. Bone resorption of the proximal femur was evaluated with immediate postoperative and follow-up anteroposterior and lateral radiographs. Statistical analysis using the Mann-Whitney test showed no significant difference between the groups that had good or poor contact. The collar did not prevent calcar resorption even when ideal contact was achieved.