Bilateral Knee Replacement Research Articles

Treatment of a High Titer Anti-Factor-VIII Antibody by Continuous Factor VIII Administration: Report of a Case

Daily administration of large doses of factor VIII concentrate in a hemophiliac with a high titer factor VIII inhibitor resulted in marked reduction in the titer and response of the inhibitor to factor VIII administration and made possible elbow and bilateral knee replacements under conventional factor VIII coverage. Studies performed during the course of treatment indicated that the reduction in the inhibitor was the result of specific tolerance to factor VIII.

One stage bilateral unicompartmental knee replacement: Similar early clinical outcome with shorter rehabilitation and better resources utilization compared with two stage

Introduction: There are a lot of debates on the advantages and safety profile of one stage bilateral knee arthroplasty. Most of the studies focus on total knee replacement, and it may not be applied directly to unicompartmental knee replacement (UKR). We would like to compare the early results of one and two stage bilateral UKR in our center. Methods: This is a retrospective review of all the bilateral medial UKR done in our center in 2018–2019. Patients’ demographic data, operative time, postoperative blood, length of stay (LOS) and complications were recorded. The number of admissions, pre-operative assessment sessions (PAS), and weeks of post-operative physiotherapy were analyzed. Clinical outcome was measured by Knee society knee score and range of motion (ROM). Results: Our center performed 97 UKR in 2018–2019, with 50 UKR performed in 25 patients, among which 16 received one stage while 9 received two stage bilateral UKR. Both groups had similar mean age, BMI, sex ratio, ASA grading, pre-operative knee score and ROM. Patient in the one stage group required only 1 PAS/admission/operation to treat both knees with a mean LOS of 7.3 days and 7.8 weeks of physiotherapy, while those in the two stage group required 2 PAS/admissions/operations with a mean cumulative LOS of 9.8 days and 14.1 weeks of physiotherapy. The mean cumulative operative time was similar for both groups but the one stage group only required 1 operative session. There was no difference in blood loss and there was no transfusion or complication. The post-operative knee score and ROM at 3 and 6 months were similar for both groups. Conclusion: In suitable patients with bilateral medial OA knee, one stage bilateral UKR offers simliar early clinical outcome with shorter rehabilitation duration but without increasing complications compared with two stage. Resources can therefore be better utilized.

Epidemiología, uso de recursos y costos de la artritis reumatoidea en Argentina

La presente revisión tiene como objetivo identificar información sobre parámetros epidemiológicos y estimar el costo de la artritis reumatoidea (AR) moderada a severa. Se llevó a cabo una búsqueda de la literatura en las principales bases de datos. Se recurrió a un consenso de expertos locales en reumatología para encontrar los parámetros más realistas, utilizando un método Delphi modificado. Se estimaron los costos médicos directos, utilizando información recopilada en la base de datos de costos unitarios del Instituto de Efectividad Clínica y Sanitaria de Argentina. Los costos indirectos se estimaron a través del enfoque del capital humano. Los costos se expresaron en dólares estadounidenses (USD) a noviembre de 2017. La prevalencia reportada de AR en Argentina fue 0,94% (IC95%: 0,86 a 1,02), con una tasa de incidencia anual de 19 cada 100 000 personas (IC95%: 17 a 20). El costo anual de las drogas modificadoras de la enfermedad fue de USD 33 936,10 por paciente. El costo atribuido a las infecciones serias fue de USD 2474,6. El costo del reemplazo bilateral de rodillas por paciente fue de USD 5276,8, y el del reemplazo total de cadera, de USD 9196,4. El costo por paciente por año de días de hospitalización y los costos indirectos de la AR se acrecentaron al aumentar el puntaje de discapacidad. La revisión reporta información útil acerca de parámetros epidemiológicos y de costos de la AR moderada a severa en la era de los agentes biológicos, con el fin de resultar de utilidad para la conducción de evaluaciones económicas de salud en Argentina.

SAT-376 Secondary Hyperparathyroidism, an Untoward Complication of High Dose Phosphate Supplementation in Hereditary Hypophosphatemic Rickets

Background: Hereditary hypophosphatemic rickets is a debilitating disease with multiple skeletal abnormalities. Children exhibit rickets and growth failure, while adults exhibit bone pain, enthesopathy, HTN, and arthritis. Gene mutations involving renal phosphate reabsorption(PHEX, FGF23, SLC34A3) leads to renal phosphate wasting. Modes of inheritance include X-linked dominant (most common), autosomal dominant, and autosomal recessive. High dose oral phosphate supplements along with calcitriol are the mainstay of treatment. This can lead to complications of secondary hyperparathyroidism. Clinical Case: An 81-year-old Caucasian woman with PMH of X-linked dominant hypophosphatemic rickets (XLH), secondary osteoarthritis of both knees, HTN, and neuropathy was seen in the Endocrinology clinic. She was diagnosed with XLH 47 years ago and was taking calcitriol 0.5 mcg daily along with a phosphate supplement of 250 mg, 2 tablets 5 times a day. She underwent multiple corrective orthopedic procedures and bilateral knee replacements. On exam, she had short stature (height of 149.9 cm), arthritic changes of bilateral hand joints, and dentures. Starting in 2015, there was a rise in PTH to 101 pg/ml (normal 18.4-80 pg/ml). Over the next 4 years her PTH continued to rise to 182.6 pg/ml, 244.4 pg/ml, 350.6 in 2016, 2017, and 2019 respectively. A 24-hour urine collection revealed a calcium level of 175 mg (normal 100-250 mg/24 hours) and a phosphorus level of 2191 mg (normal 900-1300 mg/24 hours). In December of 2018, she developed hypercalcemia with a serum calcium level of 10.9 mg/dl(normal 8.5-10.5 mg/dl). We then tapered off calcitriol and decreased the phosphate supplements to TID. Despite these measures, her PTH continued to rise, but phosphorus remained normal. A Sestamibi scan showed hyperplasia of all four parathyroid glands, and a DXA scan showed normal bone mineral density. Serum alkaline phosphatase was normal. We decreased her phosphate supplements to BID and started cinacalcet at 30 mg BID. Conclusion: This case illustrates the challenges of primary and secondary hyperparathyroidism when treating XLH. It is proposed that an increased oral phosphate load transiently lowers ionized calcium in serum, which then stimulates PTH secretion. Increased mineralization of bone is another possible explanation of this phenomenon. Persistent parathyroid stimulation can cause hyperplasia of parathyroid glands, nephrocalcinosis, hypertension, and renal failure. Early identification, temporary discontinuation of oral phosphate, and an increase of calcitriol will lower PTH. The FDA approved burosumab for the treatment of XLH in 2018. Future studies are needed to see if burosumab therapy prevents the above complications associated with traditional treatment.

Predictors of the use of analgesic drugs 1\u2009year after joint replacement: a single-center analysis of 13,000 hip and knee replacements

BackgroundPain persists in a moderate number of patients following hip or knee replacement surgery. Persistent pain may subsequently lead to the prolonged consumption of analgesics after surgery and expose patients to the adverse drug events of opioids and NSAIDs, especially in older patients and patients with comorbidities. This study aimed to identify risk factors for the increased use of opioids and other analgesics 1 year after surgery and focused on comorbidities and surgery-related factors.MethodsAll patients who underwent a primary hip or knee replacement for osteoarthritis from 2002 to 2013 were identified. Redeemed prescriptions for acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), and opioids (mild and strong) were collected from a nationwide Drug Prescription Register. The user rates of analgesics and the adjusted risks ratios for analgesic use 1 year after joint replacement were calculated.ResultsOf the 6238 hip replacement and 7501 knee replacement recipients, 3591 (26.1%) were still using analgesics 1 year after surgery. Significant predictors of overall analgesic use (acetaminophen, NSAID, or opioid) were (risk ratio (95% CI)) age 65–74.9 years (reference < 65), 1.1 (1.03–1.2); age > 75 years, 1.2 (1.1–1.3); female gender, 1.2 (1.1–1.3); BMI 30–34.9 kg/m2 (reference < 25 kg/m2), 1.1 (1.04–1.2); BMI > 35 kg/m2, 1.4 (1.3–1.6); and a higher number of comorbidities (according to the modified Charlson Comorbidity Index score), 1.2 (1.1–1.4). Diabetes and other comorbidities were not significant independent predictors. Of the other clinical factors, the preoperative use of analgesics, 2.6 (2.5–2.8), and knee surgery, 1.2 (1.1–1.3), predicted the use of analgesics, whereas simultaneous bilateral knee replacement (compared to unilateral procedure) was a protective factor, 0.86 (0.77–0.96). Opioid use was associated with obesity, higher CCI score, epilepsy, knee vs hip surgery, unilateral vs bilateral knee operation, total vs unicompartmental knee replacement, and the preoperative use of analgesics/opioids.ConclusionsObesity (especially BMI > 35 kg/m2) and the preoperative use of analgesics were the strongest predictors of an increased postoperative use of analgesics. It is remarkable that also older age and higher number of comorbidities predicted analgesic use despite these patients being the most vulnerable to adverse drug events.

Texas Heart Institute Medal and the Ray C. Fish Award for Scientific Achievement in Cardiovascular Diseases.

Ray C. Fish (1902–1962) was a leading figure in Houston's natural gas industry and a philanthropist. He believed in the American dream of “opportunity for success.” The Ray C. Fish Foundation was established so that others might be encouraged to broaden man's self-knowledge and to keep the American dream alive. After its founder's death from heart disease, the Fish Foundation granted $5 million to make the Texas Heart Institute a reality. For this reason, the Institute's highest professional award is given in honor of this extraordinary man. The award recognizes those whose innovations have made significant contributions to cardiovascular medicine and surgery. The 1st Texas Heart Institute Medal and the Ray C. Fish Award for Scientific Achievement in Cardiovascular Diseases were presented in 1972 to Dr. Norman Shumway. Since 1972, 25 other highly deserving recipients have been so honored by the Institute. The complete Roll of Recipients appears at the end of this article. In 2004, the faculty and staff of the Institute were extremely pleased to honor James L. Cox, MD. Dr. Cox received his award at a dinner held in conjunction with the Fifth Symposium on Cardiac Arrhythmias (New Pharmacologic and Interventional Strategies), on 14 February 2004, at the Houstonian Hotel, Club and Spa. James L. Cox, MD Dr. James L. Cox was honored for his seminal work in atrial fibrillation, a condition that affects up to 2 million people in the United States and is responsible for about 300,000 strokes every year. This disorder is characterized by spiraling electric signals that cause the heart to beat out of control. Dr. Cox has spent his career unraveling the mechanism behind this disorder and devising surgical techniques to cure it. In 1987, Dr. Cox performed his first Maze procedure. The Maze procedure definitively curbs the electrical, atrial chaos with a maze of incisions on the surface of the atria. The incisions block the signals, stopping the atrium from fibrillating. The Cox-Maze procedure has proved highly successful in long-term follow-up of patients. In 1967, Dr. Cox received his medical degree from the University of Tennessee, where he earned the Alpha Omega Alpha Distinguished Graduate Award as the outstanding student in his graduating class. He spent the next 11 years in surgical training under Dr. David Sabiston, Jr., at Duke University, except for a 2-year stint on active duty in the U.S. Army, which earned him a personal commendation from Brigadier General George S. Patton III. Dr. Cox was appointed an NIH Scholar in Academic Surgery for the remainder of his surgical training. After completing his residency, he remained at Duke for 5 years before leaving to become chief of the Division of Cardiothoracic Surgery at Washington University School of Medicine in St. Louis. In 1997, he left St. Louis for Washington, D.C., and the chairmanship of the Department of Cardiothoracic Surgery at Georgetown University. Not long thereafter, simultaneous bilateral knee replacements forced him to give up the clinical practice of surgery, but he has remained very active in the field. Currently, he is chairman and chief executive officer of The World Heart Foundation and a member of the board of directors of The Cardiothoracic Surgery Network (CTSNet). In addition, Dr. Cox was editor-in-chief of 2 of the 3 official journals of the American Association for Thoracic Surgery. Dr. Cox has trained more than 100 residents and fellows, delivered over 150 peer-reviewed scientific presentations, given over 180 invited lectures, and served as visiting professor at 79 institutions nationally and internationally and as invited operating surgeon at 40 international institutions. Dr. Cox has been a director of the American Board of Thoracic Surgery, a board member of the Thoracic Foundation for Research and Education, a member of the NIH Study Section on Surgery and Bioengineering, and chairman of the Residency Review Committee for Thoracic Surgery; in 2001, he was president of the American Association for Thoracic Surgery.

Preventive Epidural Analgesia in Bilateral Single-Stage Knee Arthroplasty: A Randomized Controlled Trial

IntroductionAlthough controversial, pre-emptive analgesia has shown some promise in preventing altered pain perception and reducing pain amplification after surgery. Hence, it has the potential to be more effective than a similar analgesic regimen started after surgery with an appropriate combination of patient category and analgesic modality. Hence, the present study was undertaken to evaluate the effect of preventive epidural analgesia in reducing pain severity and duration after bilateral single-stage knee arthroplasty.MethodsFifty patients, 18–70 years, with American Society of Anesthesiologists physical status class I & II posted for bilateral single-stage knee replacement under regional anesthesia were randomly allocated into preventive versus postoperative epidural analgesia group to compare severity of post-operative pain, analgesic consumption, day of mobilization, C-reactive protein (CRP) levels, and hospital stay.ResultsThe pain score after surgery [2.0 (1.5, 2.0); 3.0 (1.5, 3.0), p = 0.005] and day of mobilization [(2. 92 ± 0. 28; 3. 31 ± 0. 48; p value 0.02)] were significantly lesser in the preventive epidural group. However, there was no difference in the hospital stay (9.92 ± 3.71 and 9.00 ± 2.12, p = 0.95) and analgesic consumption (65.38 ± 37.55 and 73.08 ± 43.85, p = 0.30). The preventive group had a larger drop in CRP and experienced a lesser number of days with pain after surgery as compared to the controls [(64.29 ± 21.29); (142.37 ± 80.04), p = 0.0001]. Six patients in the preemptive group (24%) and 13 of the control group (24 vs. 56.5%; p = 0.02) had chronic postsurgical pain.ConclusionsPreventive epidural analgesia reduces the severity and number of chronic pain days after bilateral single-stage knee replacement.Trial RegistrationThe study was registered in the Indian national registry (CTRI/2017/03/008240 on 28/03/2017).

A Structural Equation Model of Health-Related Quality of Life among Older Women Following Bilateral Total Knee Replacement

This study aimed to develop and test a structural equation model of health-related quality of life among older women following bilateral total knee replacement based on a literature review and Wilson and Cleary's model of health-related quality of life. One hundred ninety three women who were diagnosed with osteoarthritis, were older than 65 years, and were between 13 weeks and 12 months of having a bilateral total knee replacement were recruited from an outpatient clinic. Data were collected from July 2017 to April 2018 using a structured questionnaire and medical records. Data were analyzed using SPSS/WIN 22.0, AMOS 22.0, and Smart PLS 3.2.4. The fitness of the hypothetical model was good, with coefficients of determination (R²) ranging between .28 and .75 and predictive relevance (Q²) between .26 and .73. The standardized root mean square residual of the model fit indices for the hypothetical model was .04; which explained 64.2% of physical and 62.5% of mental health-related quality of life. Self-efficacy, symptom status, functional status, and general health perceptions had a significant direct effect on physical health-related quality of life, while social support, symptom status, and general health perceptions had a significant direct effect on participants' mental-health-related quality of life. To improve the physical and mental quality of life of older women who receive bilateral knee replacement, nursing-based intervention strategies that reduce symptoms, improve functional status, and increase health perceptions, self-efficacy, and social support are needed. The most important factor is the symptom status.

PMS11 EPIDEMIOLOGY, USE OF RESOURCES AND COST OF MODERATE TO SEVERE RHEUMATOID ARTHRITIS IN ARGENTINA: AN EXTENSIVE REVIEW WITH EXPERT ELICITATION

Rheumatoid arthritis (RA) is a disabling disease associated with a high use of resources for treatment (e.g. biologic drugs) and with costs related to productivity losses. There is scarce information on the epidemiology and economic burden of rheumatoid arthritis (RA) in Argentina. The objective was to collect information about key epidemiological parameters and estimate the cost of moderate to severe RA. We conducted a literature search on PUBMED and LILACS. In addition to this, we resorted to a consensus of experienced local rheumatologists using a modified Delphi panel method to find actual parameters for Argentina. We estimated resource usage rates and direct medical costs, based on the database of unit costs of the Institute for Clinical Effectiveness and Health Policy in Argentina, and indirect costs through the human capital approach. Costs were expressed in United States Dollars (USD), November 2017. The reported prevalence of RA in Argentina was 0.94% (95%CI: 0.86 – 1.02) with an estimated yearly incidence rate of 19 new cases every 100,000 persons/year (95%CI: 17 - 20). In 2017 the estimated cost of disease-modifying drugs was USD 54,405 per patient per year. The cost attributed to serious infections associated with the disease was nearly USD 2474. The per-patient cost of bilateral knee replacement exceeded USD 5276, and the cost of total hip replacement was USD 9196. Both types of costs increased with higher Health Assessment Questionnaire band. HAQ is a widely used disability assessment tool. We provide useful information on epidemiological and cost parameters of moderate to severe RA in the era of biologic agents in Argentina.

Hemofili A Hastalarındaki Diz Artropatisi ve Bilateral Total Diz Artroplastisi Oranı

Objective: This epidemiological study was co nducted in the joint haematology- orthopaedics clinic of a university hospital. The aim was to analyse the data in terms of age and radiolo gy of patients with moder ate or severe haemophilia A and knee involvement. Materials and Method: This was a retrospective stu dy 49 patients with knee problems out of 130 haemophilia A and musc u loskeletal problems . Kellgren-Lawrence (KL) classification was used for radiological assessments of osteoarthritis degree. Results: KL degree was 3 or 4 for most patients (27/39, 69.23%) in the group. There was statistically a meaningful correlation between KL degree and patients’ age (Spearman’s: r s = 0.512, p = 0.001). There were 7 patients with KL degree 4 at the age of 50 or younger (14.29%). 25 patients in 49 (51.0 2%) had total knee arthroplasty(TKA) and 10(40%) of those was bilateral . Mea n age for bilateral TKA (56.3 5 ) was higher than unilateral(49.87 ). There was a statistically mea ningful correlation between patient age and the patients with TKA (Spearman’s : r s = 0.338, p = 0.017 ). There were 2 revision surgeries out of 35 TKA (5.7 1 %). Most of the patients had prophyl actic factor treatment (43, 87.75 %). Conclusion: Our study signify the high ratio of bilateral knee replacements in haemophilia A patients and how early age they progressed to KL stage 4 comparing to normal population. These results show the importance of patient care in this group of patients, close follow-up and prophylactic treatment. They should be managed in experienced centres by an experience team to decrease the risks and complications.

HOW MANY REVISION ARTHROPLASTIES DO WE UNDERTAKE PRIOR TO ARTHRODESIS? (CASE REPORT OF A PATIENT WITH RHEUMATOID KNEE ARTHRITIS)

The authors present a clinical case of a female patient with seropositive rheumatoid polyarthritis mainly affecting the knee joints. The patient underwent a primary total bilateral knee replacement. Surgical site infection required multiple revisions including replacement of extensive bone defects of AORI type 3 by structural femur and tibia allografts as well as allografting of extensor mechanism. Repeated attempts to eliminate infection, to gain support ability of extremities and joints motion were not successful. Long-term staged surgical treatment resulted in removal of prostheses and bilateral knee arthrodesis to restore support function of the extremities.

European guidelines on perioperative venous thromboembolism prophylaxis: Surgery in the elderly.

: The risk for postoperative venous thromboembolism (VTE) is increased in patients aged more than 70 years and in elderly patients presenting with co-morbidities, for example cardiovascular disorders, malignancy or renal insufficiency. Therefore, risk stratification, correction of modifiable risks and sustained perioperative thromboprophylaxis are essential in this patient population. Timing and dosing of pharmacoprophylaxis may be adopted from the non-aged population. Direct oral anti-coagulants are effective and well tolerated in the elderly; statins may not replace pharmacological thromboprophylaxis. Early mobilisation and use of non-pharmacological means of thromboprophylaxis should be exploited. In elderly patients, we suggest identification of co-morbidities increasing the risk for VTE (e.g. congestive heart failure, pulmonary circulation disorder, renal failure, lymphoma, metastatic cancer, obesity, arthritis, post-menopausal oestrogen therapy) and correction if present (e.g. anaemia, coagulopathy) (Grade 2C). We suggest against bilateral knee replacement in elderly and frail patients (Grade 2C). We suggest timing and dosing of pharmacological VTE prophylaxis as in the non-aged population (Grade 2C). In elderly patients with renal failure, low-dose unfractionated heparin (UFH) may be used or weight-adjusted dosing of low molecular weight heparin (Grade 2C). In the elderly, we recommend careful prescription of postoperative VTE prophylaxis and early postoperative mobilisation (Grade 1C). We recommend multi-faceted interventions for VTE prophylaxis in elderly and frail patients, including pneumatic compression devices, low molecular weight heparin (and/or direct oral anti-coagulants after knee or hip replacement) (Grade 1C). : This article is part of the European guidelines on perioperative venous thromboembolism prophylaxis. For details concerning background, methods, and members of the ESA VTE Guidelines Task Force, please, refer to:Samama CM, Afshari A, for the ESA VTE Guidelines Task Force. European guidelines on perioperative venous thromboembolism prophylaxis. Eur J Anaesthesiol 2018; 35:73-76.A synopsis of all recommendations can be found in the following accompanying article: Afshari A, Ageno W, Ahmed A, et al., for the ESA VTE Guidelines Task Force. European Guidelines on perioperative venous thromboembolism prophylaxis. Executive summary. Eur J Anaesthesiol 2018; 35:77-83.

European Guidelines on perioperative venous thromboembolism prophylaxis: Executive summary.

European Guidelines on perioperative venous thromboembolism prophylaxis: Executive summary.

Тотальне ендопротезування колінного суглоба у лікуванні гонартрозу з вальгусною деформацією

Aim.&nbsp;To find effective solution for the treatment of osteoarthrosis of the knee with valgus deformity in advanced stages. Material and Methods.&nbsp;In our study 67 patients with degenerative osteoarthrosis of the knee with valgus deformity were treated surgically, using total knee replacement. Fifteen patients had localized rheumatoid arthritis at the knee; 52 patients had primary osteoarthrosis of the knee; bilateral knee replacement was performed in 7 cases. The results of the treatment have been evaluated by the International Knee Score System. Results and Discussion.&nbsp;The results of the treatment have been evaluated using the International Knee Score System with average score of 32 points preoperatively and 84 points postoperatively during 2-4 years. Conclusions.&nbsp;Total knee arthroplasty is an argued and effective solution in the treatment of osteoarthrosis of the knee with valgus deformity in advanced stages. Careful selection of patients, proper preoperative planning, and adherence to the surgical techniques according to the algorithm allows us to achieve good functional outcomes in the majority of cases. Total knee arthroplasty allows correction of deformity, alleviation of pain, improvement of joint mobility, relatively rapid resumption of function in the postoperative period, and considerably improves the quality of life in these patients. In patients with valgus deformities with an angle over 20°, the use of suprastabilized revision prostheses is recommended.&nbsp

Mediation effect of psychological resilience between social support and quality of life in the postoperative patients with total knee replacement surgery

Objective To understand the quality of life of the elderly patients with the total knee replacement three months after the surgery and to analyze the mediation effect of psychological resilience on the relationship between the social support and the quality of life among the postoperative patients. Methods Two hundred and eight patients who first received the bilateral artificial total knee replacement in some Harbin class Ⅲ grade A hospital from October 2014 to October 2016 were included. They were investigated by the general situation questionnaire, the social support scale (SSRS) , the psychological resilience scale (CD-RISC) and the health status questionnaire (SF-36) . Results Three months after surgery, the total score of the psychological resilience, the social support, the quality of life of the included patients was (51.29±11.70) , (35.78±7.12) and (69.13±4.96) , which were all significantly lower compared to the domestic norm (t=-14.876, -17.418, -26.317; P<0.05) . The psychological resilience played a partial intermediary role between the social support and the quality of life of physical health. The mediation effect was 0.053, accounting for 11.30% of the total effect. The psychological resilience played a partial intermediary role between the social support and the quality of life of mental health. The mediation effect was 0.066, accounting for 27.73% of the total effect. Conclusions The quality of life was reduced in the postoperative patients with the total knee replacement surgery. The social support can predict the quality of life of the patients positively and it has an indirect influence which is mediated by the psychological resilience on the patients' quality of life. The psychological resilience mediates the positive effect of the social support on the postoperative patients' quality of life. A good social support system should be established for patients and the psychological resilience level should be enhanced, in order to improve the postoperative patients' quality of life. Key words: Total knee replacement surgery; Quality of life; Psychological resilience; Social support

Bilateral total knee replacement in severe knee osteoarthritis with large bone defect using autologous bone graft augmentation

40 years old malay gentleman with underlying gout presenting with severe pain in both knees for 10 years, analgesic dependant and wheelchair ambulation. Examination of right knee shows fixed flexion at 10 degrees, range of movement 10-100 degree flexion, lateral collateral laxity and varus deformity. Left knee had fixed flexion at 10 degrees, range of movement 5-100 degree and varus deformity. Blood investigation showed uric acid. X-ray of bilateral knee showed severe tricompartmental arthritis with large medial tibial defect. The patient has undergone bilateral knee replacement in 5 months interval started with left knee. Surgical technique is the same for both knees, intraoperative shows a large posteromedial bone defect. We used 5mm metal augmentation on the right knee, but due to limited financial resources, we have to use the bone graft from the osteotomized bone for the augmentation on the left side. The bone augmentation was fixed with cancellous screw. The patient was referred to physiotherapy for range of motion exercises. 1 year post operatively patient able to ambulate without aid. Pain score improved. The patient does not require analgesia. Functional and knee score is excellent. Range of movement, bilateral knee are 0-100 degree. Radiological finding shows no evidence of construct failure in both metal block and bone graft construct. Severe arthritis with bone defect is common due to late presentation. Using autologous bone graft can provide good result as using expensive meta block for reconstruction.

Quadriceps Tendon Rupture and Contralateral Patella Tendon Avulsion Post Primary Bilateral Total Knee Arthroplasty: A Case Report

Background: Extensor mechanism failure secondary to knee replacement could be due to tibial tubercle avulsion, Patellar tendon rupture, patellar fracture or quadriceps tendon rupture. An incidence of Patella tendon rupture of 0.17% and Quadriceps tendon rupture of around 0.1% has been reported after Total knee arthroplasty. These are considered a devastating complication that substantially affects the clinical results and are challenging situations to treat with surgery being the mainstay of the treatment.Case Description: We report here an interesting case of a patellar tendon rupture of one knee and Quadriceps tendon rupture of the contralateral knee following simultaneous bilateral knee replacement in a case of inflammatory arthritis patient. End to end repair for Quadriceps tear and augmentation with Autologous Hamstring tendon graft was done for Patella tendon rupture.OUTCOME: Patient was followed up for a period of 1 year and there was no Extension lag with a flexion of 100 degrees in both the knees.DISCUSSION: The key learning points and important aspects of diagnosing these injuries early and the management techniques are described in this unique case of bilateral extensor mechanism disruption following knee replacements.

Compare Between the Complication of Simultaneous and Staged Bilateral Knee Replacement at King Abdulaziz Medical City (KAMC) - Riyadh

Introduction: Total Knee replacement is a procedure commonly performed for degenerative joint disorder, e.g. osteoarthritis and rheumatoid arthritis. It is considered to be the most common and successful joint replacement. There will be an increase demand for the bilateral total knee replacement in the future due to increase of aging population and the indication to perform the surgery. There are controversies in the post surgical complication following simultaneous and staged bilateral total knee replacement; many studies have shown an increase in the mortality rate with simultaneous bilateral knee replacement. Other studies are showing evidence that suggest that there is no difference in the complication between simultaneous and staged bilateral total knee replacement. Methods: The study included 84 simultaneous BTKR, 110 staged BTKR (with time interval between the two 3 to 6 months) and 51 UTKR whom performed the surgery between January 2000 and August 2014. The collected data included demographic data, surgical data, complications and length of stay. We also have collected some variables of interest; Demographic (Gender, Age and Weight), Type of surgery (study groups), Hospital stay, Duration of procedure, Amount of bleeding, hemoglobin level before and after the operation and type of anesthesia. Results: We have a total of 245 patients. 110 (44.9%) underwent staged bilateral total knee replacement (BTKR), 84 underwent simultaneous bilateral total knee replacement (BTKR), and 51 of did the surgery on only one. The results showed that out of the 245, 194(79.18%) have not developed any complications, 62(73.81%) were simultaneous BTKR, 89(80.91%) of the staged BTKR and only 43(84.31%) were bilateral TKR. 43(17.55%) have developed minor complications which includes, Infection, UTI, Infected knee post operation or pulmonary complication other than pulmonary embolism. 18(21.43%) underwent simultaneous BTKR, 17(15.45%) for the staged BTKR and 8(15.69%) for the unilateral TKR. Only 8 patients have developed major complication (3.27%) of the general population. 4(4.76%) of the simultaneous BTKE and 4(3.64%) of the staged BTKR. None of the unilateral has developed major complication. We found a mean ± SE of the total days of hospital stay for all the groups was 12.58±. 52, for the simultaneous BTKR patients, the mean ± SE of hospital stay was 11.05±0.39 days, and for the staged was 16.19±1.31 days and 9.96±0.58 days, with a p value <.0001. Conclusion: We can say that simultaneous TKR is a save procedure to be performed especially in hospital where there is long waiting list as well difficulty of having elective bed as in our hospital. And we found out that patients whom underwent staged BTKR stayed at the hospital more than patients whom underwent simultaneous BTKR.

Efficacy and safety of intravenous tranexamic acid drips at different time points in bilateral primary total knee replacement

Objective To investigate the effects of intravenous tranexamic acid (TA) drips at different time points on perioperative hemorrhage and postoperative venous thromboembolism (VTE) following bilateral primary total knee arthroplasty (TKA). Methods We reviewed 52 patients who had undergone primary bilateral TKA from February 2012 to February 2014. They were 25 men and 27 women, 50 to 75 years of age. They were divided into 4 even groups (n=13) according to timing of medication. Group A received a dose of 15 mg/kg TA intravenously 30 minutes preoperation and 30 minutes before wound closure; group B received a dose of 15 mg/kg TA intravenously 15 minutes preoperation; group C received 15 mg/kg TA intravenously 30 minutes before wound closure; group D received an equal volume of normal saline before surgery. The following indexes were recorded: 24 h postoperative drainage volume; total drainage volume; blood transfusion rate; postoperative haemoglobin (Hb) levels at 24 h, 72 h and 7 d; postoperative prothrombin time (PT); activated partial thromboplastin time (APTT); fibrinogen (FIB); visual analogue scale (VAS) at 24 h & 36 h postoperation; level of bilateral knee passive movement 3 days after surgery and VTE incidence. Patients' lower limbs were examined with Doppler ultrasound 2 weeks postoperatively. Results The 24h postoperative drainage volume and total drainage volume in groups A, B & C were significantly lower than in group D with group A being significantly less than groups B & C (P 0.05). No VTE occurred in any of the 4 groups. Conclusions In bilateral primary total knee arthroplasty, intravenous TA drips can reduce postoperative hemorrhage and blood transfusion rate but may not increase the risk of VTE or hinder passive movement rehabilitation of the knee early after the surgery. The intravenous infusion of 15 mg/kg of TA 30 minutes preoperation and 30 minutes before wound closure may lead to optimal efficacy. Key words: Tranexamic acid; Arthroplasty, replacement, knee; Postoperative hemorrhage; Embolism and thrombosis

A study on the anomalies associated with the human sterna in south Indian population

Chondrocalcinosis (CC) is a common cause of joint pain and arthritis that is caused by the deposition of calcium-containing crystals within articular cartilage. Although most cases are sporadic, rare familial forms have been linked to human chromosomes 8 (CCAL1) or 5p (CCAL2) (Baldwin et al. 1995; Hughes et al. 1995; Andrew et al. 1999). Here, we show that two previously described families with CCAL2 have mutations in the human homolog of the mouse progressive ankylosis gene (ANKH). One of the human mutations results in the substitution of a highly conserved amino acid residue within a predicted transmembrane segment. The other creates a new ATG start site that adds four additional residues to the ANKH protein. Both mutations segregate completely with disease status and are not found in control subjects. In addition, 1 of 95 U.K. patients with sporadic CC showed a deletion of a single codon in the ANKH gene. The same change was found in a sister who had bilateral knee replacement for osteoarthritis. Each of the three human mutations was reconstructed in a full-length ANK expression construct previously shown to regulate pyrophosphate levels in cultured cells in vitro. All three of the human mutations showed significantly more activity than a previously described nonsense mutation that causes severe hydroxyapatite mineral deposition and widespread joint ankylosis in mice. These results suggest that small sequence changes in ANKH are one cause of CC and joint disease in humans. Increased ANK activity may explain the different types of crystals commonly deposited in human CCAL2 families and mutant mice and may provide a useful pharmacological target for treating some forms of human CC.