Semih Aydogdu

Long-term evaluation of radioisotope synovectomy with Yttrium 90 for chronic synovitis in Turkish haemophiliacs: Izmir experience.

Summary.  Since 2001 we have performed 105 radioisotope synovectomy (RS) in 65 children and young adults, age ranging from 3 to 25 years with a average of 15 years in Ege University Hospital, Izmir, Turkey. One fourth of cases were below 10 years of age. All patients had severe haemophilia A and B. Ten patients (17 joints) had high responder inhibitor. We prefer to use Yttrium 90 for all joints (5 mCi for knees; 2 mCi for others). The knees were injected in 56 cases, elbows in 24 cases, ankles in 23 cases and shoulders in two cases. Steroid injections were not preferred as the principle drug of choice. Mean follow‐up period after procedure was 2 years (range: 6 months to 3.5 years). All inhibitor patients had satisfactory results. The best results were obtained in elbows than knees and ankles. Excellent rates (no bleeding) were observed in grade‐II synovitis 84% for knees, 93% for elbows and 50% for ankles. Because of the excellent and good response (bleeding reduction to 75%), rates were 100% for knees and elbows and 92% for ankles. In six cases, repeated injections were given at 6‐month interval and all of them had good results. The grading of synovitis seems to be an important parameter than the age of the patient. Even in patients below 10 years of age, outcomes are not satisfactory in all joints with grade‐III vs. grade‐II synovitis (12% vs. 73%). No serious complications were observed during and after procedure except two cases. A mild and transient inflammatory reaction was observed in the ankle. There was a minimal radioisotope leakage to superficial skin in the elbow. RS seems to be a safe and effective treatment for chronic synovitis causing recurrent joint bleedings.

Radioisotope synovectomy with rhenium186 in haemophilic synovitis for elbows, ankles and shoulders

Summary.  We have performed 221 radioisotope synovectomy (RS) in more than 150 children and young adults with haemophilia, age ranging 3–30 years (mean 15) in Ege Hemophilia Center, Izmir, Turkey for last 7 years. We always preferred to use Yttrium 90 (Y90) for knees; however, since 2005, we started using rhenium 186 (Re186) for medium‐sized joints with respect to safety. In this article, we have evaluated long‐term experience ranging from 6 months to 3 years (mean 18 months) with Re186 for elbows (n = 35), ankles (n = 26) and shoulders (n = 2) in total of 63 RS procedures for 49 patients. Their age range was 3–30 years and mean age was 15.5. Two mCi of Re186 intra‐articularly injected for treating target joints and chronical synovitis. After RS, joint bleedings were decreased for all patients. The best results were obtained for all joints in patients with grade‐II synovitis as like earlier experience with Y90. Excellent rates (no bleeding) were observed in grade‐II synovitis in 81% and 46% for elbows vs. 86% and 57% for ankles after 6 months and after 1 year follow‐up of patients, respectively. In grade‐III synovitis, excellent rates were 53% and 25% for elbows and 44% and 29% for ankles, respectively. In five joints for five patients, repeated injections were needed for better outcome. No adverse events such as radioisotope leakage, local inflamatory reactions or malignancy development were observed during and after RS. For medium‐sized joints, RS with Re186 seems to be either effective or safe treatment method. Our results confirm those previously published by others on the value of Re186 synoviorthesis in medium‐sized joints in haemophilia patients. After this experience, we changed our protocol and we use Re186 for all medium‐sized joints for treating chronical synovitis.

Surgery in patients with haemophilia and high responding inhibitors: Izmir experience

Summary.  This report evaluates the haemostatic efficacy of recombinant factor VIIa (rFVIIa) and activated prothrombin complex concentrate (APCC) in patients with haemophilia and high responding inhibitors who underwent major and minor surgery. Data pertaining to surgeries from 2001 to 2009 at a single centre were retrospectively analysed. During this period, 53 surgical procedures were performed in 30 haemophiliacs with high responding inhibitors. Mean age was 16.2 ± 9.4 years. Eleven major surgeries in 4 patients, 41 radioisotope synovectomies (RS) and one circumcision classified as minor surgery in 28 patients were performed. Among the major surgery procedures, four were treated with rFVIIa, five with APCC and two with sequential use of APCC and rFVIIa. We used rFVIIa at the dosage of 80–120 μg kg−1 every 2 h and APCC 100 IU kg−1 every 12 h for the major surgery. When performing RS, we used rFVIIa in 18 patients with 26 target joints and APCC in 9 patients with 15 target joints. Three consecutive doses of rFVIIa (90 μg kg−1) were used at 2‐h intervals followed by additional three doses at 6‐h intervals. The initial dose of APCC was 75 IU kg−1 followed by a second and third dose of 50 IU kg−1 at 12‐h intervals. APCC and rFVIIa demonstrated excellent efficacy in our major and minor surgical interventions [100% (22/22) and 94% (31/33), respectively]. We had only two bleeding complications with rFVIIa. There were no thromboembolic complications. APCC and rFVIIa provide an effective and safe first line haemostatic therapy for inhibitor‐positive haemophiliacs, allowing both major and minor surgery to be successfully performed.

Long-term evaluation of chromosomal breakages after radioisotope synovectomy for treatment of target joints in patients with haemophilia

Summary.  Radioisotope synovectomy (RS) is defined as the intra‐articular injection of radioisotopic agents with the aim of fibrosis on hypertrophic synovium in the target joint. The aim of this study was to investigate genotoxic effects on lymphocytes and malign transformation induced by Yttrium90 (Y90) and Rhenium186 (Re186) in children with haemophilia undergone RS. Forty haemophilia patients were enrolled. The mean age was 16.4 ± 6.2 years (range: 8–40). Y90 was used for knees, Re186 was used for other joints. For safety, cytogenetic analysis was performed to determine potential chromosomal changes after RS procedure at three different time points as prior to procedure, 3rd day and 90th day. For the stimulation of chromosomal breakages, diepoxybutane was used (DEB test). Chromosomal breakages (CBs) were found in 23 patients (67.6%) prior to RS. We have found CBs additionally in nine of 11 patients who had no CBs prior to RS after 3 days of radioisotope exposure. At that time, the patients who had CBs were 29 (85.2%). At day 90, only 21 patients revealed (61.7%) CBs. The mean frequency of CBs slightly but not significantly increased in the 3rd day. However, there was a significant decreasing trend between 3rd and 90th days. Radioisotope synovectomy with Y90 and Re186 does not seem to induce the genotoxic effects significantly on peripheral blood lymphocytes. However, CBs even after one year in the re‐evaluation of four patients, significant decrease in the number of CBs between the 3rd and 90th days and de novo CBs after exposure may be accepted as warning signals for young population. It should also be pointed out that families and patients be informed properly related with historical and potential dangers of radioisotopic agents.

The pelvi-femoral incomplete bone bridge in a patient with mild haemophilia

A 15‐year‐old boy with mild haemophilia who regularly participates in contact sports presented with right hip pain radiating to the groin and buttock areas and difficulty in walking. Conventional radiography disclosed a heterotopic new bone formation in the adductor region. The reformatted and three‐dimensional reconstructed images of computerized tomography (CT) scans detailed an incomplete pelvi‐femoral bone bridge formation in the quadratus femoris muscle, which was located very close to the sciatic nerve but did not cause any clinical symptoms. Postural exercises and clinical survey were selected as the primary treatment.

The effect of 2 adhesive products on skin integrity used for fixation of hip and knee surgical dressings: a randomized controlled trial.

PURPOSE: The aim of this study was to compare effects of 2 adhesive products, a nonwoven porous adhesive bandage (NPAB) and transparent film adhesive bandage (TFAB), on skin integrity for fixation of hip and knee surgical dressings. MATERIALS AND METHODS: A prospective, randomized study was conducted on 300 patients who underwent hip and knee surgery (arthroplasty, fixation of fractures, tumor operations, etc). Participants were randomized into 2 equal groups according to the applied surgical dressing fixation product (NPAB or TFAB). Skin changes (edema, erythema, blister, peeling of blister, mechanical peeling, and maceration), drying of incision, serous discharge, and early infection symptoms were evaluated. RESULTS: The skin integrity was found to be impaired in 4.0% (n = 6) of the 150 NPAB patients and in 10.7% (n = 16) of the 150 TFAB patients (P = .02). Logistic regression analysis showed that the risk of impaired skin integrity increased 2.5-fold when TFAB was applied (P = .03). CONCLUSION: The NPAB was associated with a reduced likelihood of impaired skin integrity following hip and knee surgery.

Effect of tibial tubercle elevation on patellofemoral compressive force in patellofemoral arthrosis.

Abstract In this study, the effect of tibial tubercle elevation on the patellofemoral compressive force (PFCF) was investigated in patients with patellofemoral arthrosis. Fifteen (11 women and 4 men) patients who had undergone tibial tubercle elevation were included in the study. The average follow-up was 4.5 years. The mean age of the patients was 59 years (range 34–71 years). They were able to maintain a normal pain-free daily life. Maximal isometric quadriceps force (Q) was calculated by equating the moment generated by this force to the moment of the force measured at the ankle by a modified hand dynamometer. PFCF was calculated from the quadriceps and patellar tendon forces. Statistical analyses were then applied to the measured and calculated quantities. The mean quadriceps force in the operated knee decreased by 20%. Likewise, the mean PFCF was found to be reduced by 30% in the operated knees as compared with the asymptomatic contralateral knees. The above differences in Q and PFCF between the operated knee and the asymptomatic knee were statistically significant (P < 0.05). Therefore, the results of this study do not agree with the previously held view that Q and PFCF increase due to the removal of pain after the elevation operation. It is our contention that comparison of the forces measured preoperatively in a painful joint with the forces that can be attained postoperatively in the pain-free joint can lead to errors in biomechanical evaluations.

The Structure, Function, and Healing of the Meniscus

The menisci have indispensable functions in the knee joint such as load bearing, shock absorption, articular nutrition, and joint lubrication, along with roles in maintaining joint stability and proprioception. Meniscal tissue loss results in early degenerative changes in the knee joint because of alterations in the loading pattern of articular cartilages. With the improved understanding of the fundamental roles of the menisci and the detrimental effects of their absence, repair of torn menisci, instead of amputation, is supported today. Its healing potential is directly related to its vascularization. The tears of the less-vascularized zone are suggested to be not only repaired but also augmented with various techniques. If it is indicated to perform a segmental meniscectomy in a knee without arthritic changes, it is possible to replace the removed part with a synthetic matrix graft. In patients who had a total meniscectomy, meniscal allograft transplantation can be regarded as a treatment option.

Management of Patellofemoral Problems in Adolescents

Patellofemoral problems are frequently encountered in adolescents. A wide range of problems in changing severity may be seen. They may affect daily activities and even block athletic activities. The two most common forms of these problems are patellofemoral instability and pain syndrome without instability. Not isolated but interchanging nature of problems, immature skeleton, and relatively high activity demand increase the complexity. All kinds of treatment modalities including surgery deserve meticulous clinical evaluation. Imaging modalities have an important role in decision making, but sometimes they may be misleading by overvaluing some incidental minor abnormalities. Whatever the modality chosen, these problems may have long-lasting effects jeopardizing working and/or athletic activities in adulthood.

Changes of ankle inclinations after total knee arthroplasty

Aim: To evaluate the changes in ankle joint line inclination in patients who had total knee arthroplasty due to degenerative osteoarthritis. Material/Method: Sixty-two knees (with a mean age of 71,66±6,78 years, follow-up 52,34±27,42 months) which had undergone total knee arthroplasty between November 1996 and May 2014 were included in this retrospective study. The knee joint line orientations (KJLO) of the prosthesis and ankle joint line inclination (AJLI) relative to the floor were evaluated on postoperative standard standing long-leg X-rays. The AJLI relative to the floor was defined as the angle between the tangent to the subchondral plate of the talus and the horizontal grid line on radiographs. In order to determine the effects of KJLO and high varus on AJLI, patients were divided into two each groups that were pre-operative mechanical axes (MA) as <20° (n=35, group1) and >=20° (n=27, group2) and post-operative MA <3° (n=32, group a) and >=3° (n=30, group b). In addition, the changes in AJLI were compared between each group. The patients were regrouped as either <=3° (n=28, group i) or >3° (n=34, group ii), in terms of the postoperative KJLO. Inclination angles of the prosthesis were compared between each groups. Statistical analysis was performed with SPSS v18. Results: Mean MA of pre-operative and post-operative were 16,35±6,56° and 3,92±3,35°, respectively. All ankle inclinations were lateralized. AJLI, were significantly decreased from pre-operative mean 7,37°±3,19° to post-operative mean 3,71°±2,22° (p<0,0001). The mean of change was 3,65°±3,03°. However, pre-operative AJLIs were significantly increased in high varus group (group1: 6,34°±2,54°, group2: 8,70°±3,48°, p=0,003); post-operative AJLIs did not differ significantly (group1: 3,55°±2,36°, group2: 3,92°±2,05°, p=0,516) with respect to the MA. The changes in preop-postop AJLI’s were significantly higher in high varus group again (p=0,009). When the KJLO groups were compared, pre-operative AJLIs were significantly different (group i: 6,25°±2,33°, group ii: 8,29°±3,53°, p=0,004) while post-operative AJLIs did not differ significantly (group i: 3,46°±2,38°, group ii: 3,92°±2,08°, p=0,489). Conclusion: Pre-operatively high varus knees also had high ankle varus, hence ankle deformity was corrected by the restoration of the optimal lower limb aligment. Obtaining parallel orientation of the components relative to the ground, restored the AJLI. Pre-operative planning and convenient implantation of the components lead to achieve optimum knee orientation which restored the ankle joint line orientation independent from mechanical axes. Not only the goal of optimum mechanical axes but also optimum knee joint line orientation’s importance was demonsrated.