Burak Beksaç

Minimally invasive total knee replacement through a mini-midvastus incision : an outcome study

Total knee replacement traditionally has been done through an anterior incision approximately 18 cm long, using a capsular incision that separates the interval between the rectus femoris and vastus medialis musculature. Although giving excellent exposure, this incision also disrupts the suprapatellar pouch and may lead to adhesions and difficulty with rapidly regaining flexion. It is hypothesized that, by using a more minimally invasive incision, there will be a more rapid return of flexion and the patient will require fewer narcotic medications postoperatively. This retrospective review compared 32 total knee replacements done through a minimally invasive mini-midvastus approach with 26 total knee replacements done through the standard medial parapatellar approach. Preoperative Knee Society scores and postoperative functional outcomes were compared. Postoperative flexion was measured daily during hospitalization and at a 6-week and 3-month followup. Pain was assessed by a visual analog scale and the amount of pain medication used during hospitalization. Implant position was measured. The MIS group had an average skin incision length of 12.8 cm. Passive flexion on a daily basis was significantly higher in the MIS group compared with the standard group. At 6 weeks postoperatively, the change in Knee Score was statistically higher in the MIS group and the average visual analog pain score and the total amount of pain medication was lower. The radiographic alignment and position of all the components was normal in all patients in both groups. The limited disruption of the extensor mechanism results in more rapid restoration of the quadriceps muscle control.

Minimally invasive total knee replacement through a mini midvastus approach: a comparative study.

Between September 2001 and September 2002, forty consecutive minimally invasive total knee replacements were done. A modified midvastus approach was used and the patella was subluxed, but not everted. We compared the results of this group with an age-matched and sex-matched cohort of total knee replacements done between June 2000 and September 2001 with a standard technique. A posterior-stabilized knee (Genesis II) was used in both groups. Patients achieved motion considerably faster in the minimally invasive total knee replacement group. Mean flexion for minimally invasive total knee replacement at 6 and 12 weeks was 114° (range, 90–132°) and 122° (range, 103–135°) respectively, compared with 95° (range, 65–125°) and 110° (range, 80–125°) for the control group. Improved range of motion was also seen at one year postoperatively. The average range of motion at one year postoperatively in the minimally invasive total knee replacement was 125° (range, 110–135°) compared with 116° (range, 95–130°) in the Control Group. Postoperative Knee Society scores were also higher in the minimally invasive total knee replacement group. There was no difference in xray alignment. There were no infections, extensor mechanism or neurovascular complications. The mini midvastus approach without patella eversion combined with a small incision was associated with a more rapid functional recovery and improved range of motion in total knee replacement without compromising implant positioning.

Aspirin Decreases the Prevalence and Severity of Heterotopic Ossification After 1-Stage Bilateral Total Hip Arthroplasty for Osteoarthrosis

Heterotopic ossification (HO) is a frequent complication after total hip arthroplasty (THA). We retrospectively evaluated the prevalence and severity of HO in patients with osteoarthrosis who underwent 1-stage bilateral THA (OSBTHA) and compared those who received aspirin with those who received Coumadin for postoperative chemothromboprophylaxis. The aspirin group consisted of 66 patients (132 hips), with a mean age of 64 years (SD, 8.5). The Coumadin group consisted of 67 patients (134 hips), with a mean age of 60 years (SD, 10.2). Overall, HO was detected in 124 hips (46.6%). There were 43 hips (32.5%) with HO in the aspirin group and 81 (60.4%) in the Coumadin group (P < .00005). Aspirin significantly decreases the prevalence and severity of HO in comparison to Coumadin after OSBTHA.

Delayed Acute Sciatic Nerve Palsy as a Complication of Bridging Chemothromboprophylaxis Following Hip Hemiarthroplasty

Sciatic nerve palsy is a recognized complication of hip arthroplasty1,2. The prevalence is low, ranging from 0% to 3.7%1. Delayed-onset acute sciatic nerve palsy due to hematoma formation is rarely seen. Recently, with the increased use of strong anticoagulants for thromboprophylaxis, an increase in the prevalence of sciatic nerve palsy secondary to local hematoma formation has been reported3. We report the case of a patient who developed complete sciatic nerve palsy over the course of a few hours on the fifth day after hip arthroplasty as a result of local bleeding secondary to bridging chemoprophylaxis with use of low-molecular-weight heparin. The patient discussed in this report was informed that data concerning her case were to be submitted for publication, and she provided consent. A seventy-year-old woman presented to our emergency department with a right intertrochanteric hip fracture. The orthopaedic examination revealed external rotation posture of the lower extremity, painful and limited range of motion of the right hip, and weakness on the right side of the body. The patient had a height of 1.65 m (65 in) and a weight of 70 kg (154 lb). Medical conditions included atrial fibrillation, mild hypertension, and cerebrovascular embolism. The patient had been followed by a cardiologist for three years because of a history of thromboembolism and was taking Coumadin (warfarin), amlodipine besylate, and metoprolol succinate. She was not taking any other antithrombotic medications, such as aspirin or clopidogrel, for the treatment of vascular disease. The preoperative neurological examination revealed weakness of the right upper and lower extremities. The international normalized ratio was 2.23. The Coumadin was stopped, and low-molecular-weight heparin (enoxaparin sodium, 60 mg; two times per day) was started, as recommended by the consulting cardiologist. When the international normalized ratio was decreased to 1.55 …

Dual-mobility bearings for patients with abductor-trochanteric complex insufficiency

Introduction: The purpose of this study was to summarise the performance of dual-mobility cup systems for revision total hip arthroplasty in patients with abductor-trochanteric complex deficiency. Methods: We prospectively followed 17 patients (20 hips) with a mean age of 64.5 years (range 33-89 years) who underwent acetabular reconstruction with dual-mobility cups for aseptic loosening in 12 hips, infection treatment as second or single stage in 6 hips, and instability in 2 hips. All of the patients had abductor insufficiency. We evaluated the clinical Harris Hip scores (HHS) and radiographs for migration, loosening, and osteolysis. The survival of the components was calculated according to Kaplan-Meier survivorship analysis, and failure was defined as any dislocation, acetabular component or total hip revision for any reason. Results: The mean duration of follow-up was 38.1 months (range 24-98 months). There were 2 (12.5%) revisions for cemented cup migration after 11 months and 19 months respectively. There were no dislocations. At the last follow-up, the mean HHS increased from 42 points preoperatively to 86 points. The cumulative survival rate of the dual-mobility cup system was 93% (95% confidence interval 88-98.7%) at 5 years, with any revision as the end point. Conclusion: Dual-mobility cups may provide excellent stability in patients with abductor-trochanteric complex insufficiency.

CORR Insights(®): Can Vascular Injury be Appropriately Assessed With Physical Examination After Knee Dislocation?

T raumatic knee dislocation is a rare but catastrophic injury that carries with it a high risk of neurovascular damage. The challenge in the management of traumatic knee dislocation is making a prompt and accurate diagnosis. Dislocations often reduce spontaneously, which can result in delayed or missed diagnoses [2], and these can result in ischemia, permanent nerve damage, compartment syndrome, or even amputation. Although generally a consequence of high-velocity trauma, some research suggests that traumatic knee dislocation can occur following even lowenergy injuries like sprains [1]. Patients with morbid obesity have an increased likelihood of a traumatic knee dislocation following such low-velocity trauma. This adds to the diagnostic dilemma, as sedentary patients with knee sprains are likely to be last in line in the emergency department. The current study by Weinberg and colleagues highlights the use of vigilant clinical examination parameters to diagnose vascular injuries [4]. These parameters include palpable dorsalis pedis, posterior tibial pulses, and the presence of an ankle-brachial index (ABI) of 0.9 or greater. No single physical examination was sensitive enough to diagnose vascular injury. However, when combined, these parameters could rule out vascular injury. Weinberg and colleagues also found that increased BMI and the presence of open dislocation were associated with a greater risk for vascular injury following traumatic knee dislocation.

Hindfoot Valgus following Interlocking Nail Treatment for Tibial Diaphysis Fractures: Can the Fibula Be Neglected?

Purpose. We evaluated whether intramedullary nail fixation for tibial diaphysis fractures with concomitant fibula fractures (except at the distal one-third level) managed conservatively with an associated fibula fracture resulted in ankle deformity and assessed the impact of the ankle deformity on lower extremity function. Methods. Sixty middle one-third tibial shaft fractures with associated fibular fractures, except the distal one-third level, were included in this study. All tibial shaft fractures were anatomically reduced and fixed with interlocking intramedullary nails. Fibular fractures were managed conservatively. Hindfoot alignment was assessed clinically. Tibia and fibular lengths were compared to contralateral measurements using radiographs. Functional results were evaluated using the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Foot and Ankle Disability Index Score (FADI). Results. Anatomic union, defined as equal length in operative and contralateral tibias, was achieved in 60 fractures (100%). Fibular shortening was identified in 42 fractures (68%). Mean fibular shortening was 1.2 cm (range, 0.5–2 cm). Clinical exams showed increased hindfoot valgus in 42 fractures (68%). The mean KOOS was 88.4, and the mean FADI score was 90. Conclusion. Fibular fractures in the middle or proximal one-third may need to be stabilized at the time of tibial intramedullary nail fixation to prevent development of hindfoot valgus due to fibular shortening.