Cercetare/Studii

Clinical Trials in Orthopedic Disordes, 2018

Total hip arthroplasty via the direct anterior approach versus lateral approach: study protocol for a randomized controlled trial.

Background and objectives: Total hip replacement is evolving to be more refined, especially through the development of muscle sparing approaches such as the direct anterior approach (DAA), bone preserving prosthesis, as well as the use of a fast tracking protocol. Despite the rising interest in the DAA, its attribute and benefits as a muscle sparing approach continue to be debated. While some advocates of this procedure report a faster recovery, lower postoperative pain levels and lower dislocation rates, there are some studies describing higher complication rates specific to the approach, longer setup and surgery time, as well as muscle damage similar to classic approaches, especially in complex cases. We aim to establish if the total hip replacement through the DAA results in lower muscle damage, faster recovery and better overall clinical outcomes when compared to the classic lateral approach.

Design: This will be a single-center, single surgeon, randomized controlled trial.

Methods: Two hundred patients diagnosed with end-stage primary degenerative hip arthritis confirmed on plain radiographs will be randomly assigned to undergo a primary total cementless hip arthroplasty via the direct anterior approach or the lateral approach. The primary goal of this study is to determine if the direct anterior approach is less invasive and if this yields superior clinical outcomes.

Outcome measures: The primary outcome is muscle damage assessment using Myoglobin and Troponin as biomarkers. Secondary outcomes include functional outcome measures Oxford Hip Score, Harris Hip Score and quality of life 36-Item Short-Form Health Survey, physical recovery tests, complication rates, postoperative pain levels (daily for the 1st week and weekly for the first 3 months, as well as 6, 12 and 24 months after surgery), rescue medication consumption, prosthesis component positioning evaluated on radiographs, as well as perioperative data (i.e., surgery and setup time, incision length, blood loss, length of hospital stay, time to cessation of walking aids) and other biomarkers for muscle damage and inflammatory responses (i.e., creatine kinase, lactate dehydrogenase, aspartate aminotransferase and C-reactive protein).

Discussion: This study represents a pursuit to provide an evidence based enquiry upon the muscle sparing benefits of the total hip replacement via the direct anterior approach relative to the lateral approach.

Ethics and dissemination: This study was approved by the University of Medicine and Pharmacy Cluj-Napoca Ethics Committee (517/2015) and it will be performed in accordance with the guidelines of the Declaration of Helsinki. Written informed consent will be obtained from all patients prior to recruitment in this study. The results of the trial will be published in a peer-reviewed journal and will be disseminated via various forms of media.

Trial registration: ClinicalTrial.gov identifier: NCT02719236.

Key words: total hip arthroplasty; direct anterior approach; lateral approach; degenerative hip arthritis; muscle sparing hip replacement

doi: 10.4103/2542-4157.227048

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Acta Ortopaedica et Traumatologica Turcica, 2017

Letter to the Editor,

Single or double anterior portal shoulder arthroscopy for Bankart repair? That is the question

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International Orthopaedics (2017)

Transitioning to the direct anterior approach in total hip arthroplasty. Is it a true muscle sparing approach when performed by a low volume hip replacement surgeon?

Abstract: Purpose We conducted this study to establish if the transition from a lateral approach (LA) to the direct anterior approach (DAA) for a low volume hip arthroplasty surgeon during the steep learning curve can be performed maintaining the muscle sparing approach of the DAA without increasing the complication rates.
Methods: In this controlled, prospective, randomized clinical study we investigated 70 patients (35 DAA, 35 LA) with similar demographics that underwent a total hip arthroplasty. Assessment of the two approaches consisted of determining the invasiveness through serum markers for muscle damage (i.e. myoglobin, creatine kinase and lactate dehydrogenase), the operative parameters such as post-operative pain and rescue medication consumption, the component positioning and complication rates.
Results: Post-operative myoglobin levels were higher (p < 0.001) in the LA group (326.42 ± 84.91 ng/mL) as compared to the DAA group (242.80 ± 71.03 ng/mL), but with no differences regarding other biomarkers for muscle damage. Pain levels were overall lower in the DAA group, with a statistical and clinical difference during surgery day (p < 0.001) associated with lower (p < 0.001) rescue medication consumption (median 1 (1; 3) mg morphine vs. 3 (2; 4)mgmorphine). Most patients in the LA group reported chronic post-operative pain throughout all three evaluated months, while the majority of patients in the DAA group reported no pain after week six. Component positioning did not differ significantly between groups and neither did complication rates.
Conclusion: The DAA can be transitioned from the LA safely, without higher complication rates while maintaining its muscle spearing advantages when performed by a low volume hip arthroplasty surgeon.
 Keywords: Direct anterior approach . Low-volume surgeon. Total hip arthroplasty . Learning curve . Lateral approach

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Knee Surgery, Sports Traumatology, Arthroscopy (KSSTA 2017)

LETTER TO THE EDITOR

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Acta Orthopaedica et Traumatologica Turcica, 2017

Abstract.

Objective: The objective of this study was to compare the pain levels and analgesic consumption after single bundle ACL reconstruction with free quadriceps tendon autograft versus hamstring tendon autograft.
Patients and methods: A total of 48 patients scheduled for anatomic single-bundle ACL reconstruction were randomized into two groups: the free quadriceps tendon autograft group (24 patients) and the hamstring tendons autograft group (24 patients). A basic multimodal analgesic postoperative program was used for all patients and rescue analgesia was provided with tramadol, at pain scores over 30 on the Visual Analog Scale. The time to the first rescue analgesic, the number of doses of tramadol and pain
scores were recorded. The results within the same group were compared with the Wilcoxon signed test.
Results: Supplementary analgesic drug administration proved significantly higher in the group of subjects with hamstring grafts, with a median (interquartile range) of 1 (1.3) dose, compared to the group of subjects treated with a quadriceps graft, median ¼ 0.5 (0.1.25) (p ¼ 0.009). A significantly higher number of subjects with a quadriceps graft did not require any supplementary analgesic drug (50%) as compared with subjects with hamstring graft (13%; Z-statistics ¼ 3.01, p ¼ 0.002). The percentage of subjects who required a supplementary analgesic drug was 38% higher in the HT group compared with the FQT group.
Conclusion: The use of the free quadriceps tendon autograft for ACL reconstruction leads to less pain and analgesic consumption in the immediate postoperative period compared with the use of hamstrings autograft.
Level of Evidence: Level I Therapeutic study

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Arthroscopy Technique, 2016

Abstract:

Anatomic double-bundle anterior cruciate ligament (ACL) reconstruction aims to restore the 2 functional bundles of the ACL in an attempt to better reproduce the native biomechanics of the injured knee and promote long-term knee health. However, this concept is not fully accepted and is not performed on a standard basis. In addition, the superiority of this technique over the conventional single-bundle technique has been questioned, especially the long-term clinical results. One of the down sides of the double-bundle reconstruction is the complexity of the procedure, with increased risks, operative time, and costs compared with the single-bundle procedure. Also, the revision procedure, if necessary, is more challenging. We propose a technique that has some advantages over the traditional double-bundle procedure, using a single femoral tunnel, 2 tibial tunnels, and a free quadriceps tendon autograft.

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Arthroscopy Technique, 2016

Abstract:

Arthroscopic partial medial meniscectomy is a very common orthopaedic procedure performed for symptomatic, irreparable meniscus tears. It is usually associated with a very good outcome and minimal complications. In some patients with tight medial compartment, the posterior horn of the medial meniscus can be difficult to visualize, and access in this area with instruments may be challenging. To increase the opening of the medial compartment, after valgusextension stress position of the knee, different techniques of deep medial collateral ligament release have been described. The outside-in pie-crusting technique shown in this technical note has documented effectiveness and good outcomes with minimal or no morbidity.

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Arthroscopy Technique, 2016

Abstract:

The most commonly used autografts for anterior cruciate ligament reconstruction are the bone-patellar tendon-bone and hamstring tendons. Each has its advantages and limitations. The boneepatellar tendonebone autograft can lead to more donor-site morbidity, and the hamstring autograft can be unpredictable in size. The quadriceps tendon, with or without a bone block, has been described as an alternative graft source and has been used especially in revision cases, but in recent years, it has attracted attention even for primary cases. We report a technique for harvesting a free bone quadriceps tendon graft and attaching an extracortical button for femoral fixation for anterior cruciate ligament reconstruction.

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Clujul Medical, 2014

Abstract.

The aim of the study is to retrospectively review the patients admitted and treated in the “Alexandru Rădulescu” Orthopedics and Traumatology Clinic, Cluj-Napoca for an anterior cruciate ligament tear over a 2-year period and document the intra-articular lesions found at arthroscopy as well as the treatment used for these associated lesions.

Patients and methods. The case records of 88 patients operated for anterior cruciate ligament tear over a period of 2 years were reviewed. There were 67 males and 21 females with a mean age of 28.9 years, ranging from 14 to 49 years. After recording the patient demographics, we documented all the intra-articular lesions found during knee arthroscopy, as well as all procedures undertaken concomitant with the ACL reconstruction.

Results. 50 of the 88 patients (56.8%) had associated intra-articular lesions at the time of anterior cruciate ligament reconstruction. The most common injury found was a meniscus tear, 48 patients (54.5%) had a meniscal pathology at the time of ligament reconstruction, medial meniscus being the most frequent injured one, found in 37 patients. Meniscectomy and meniscus suture were the procedures performed for these lesions, meniscectomy being more frequent. Chondral defects were the next associated injuries found with an incidence of 15.9% of the cases. The medial side of the knee was the most common site of chondral pathology.

Conclusions. ACL tears are frequently associated with other intra-articular lesions, especially medial meniscus tears and chondral defects affecting the medial compartment. Such pathology most often needs surgical attention during the anterior cruciate ligament reconstruction.

Keywords: anterior cruciate ligament, associated lesions, meniscus tear, chondral defect.

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Clujul Medical, 2012

Abstract.

The aim of the study was to evaluate the results of minimally invasive treatment of trochanteric fractures with the use of intramedullary nails.

Patients and methods. From September 2010 to September 2012 we treated 21 patients with pertrochanteric fractures by a minimally invasive technique using the Gamma 3 (Stryker, Howmedica) nail. There were 13 females and 8 men with a mean age of 74.1 years, ranging from 58 to 88 years. Fractures were classified as being stable (AO type 31-A1) in 5 cases and unstable (AO type 31-A2 and A3) in the rest of 16 cases. Patients were reviewed at 6 weeks and 3 months postoperatively.

Results. Mean surgery time was 46.8 minutes and mean hospital stay was 14.9 days. No patients required blood transfusions. During the hospital stay all the patients were mobilized with weight bearing as tolerated. All patients were available for review at 6 weeks, and 2 were lost to the 3 months follow up. 16 patients regained the previous level of activity.

Conclusions. This minimally invasive technique using a gamma nail device for pertrochanteric fractures gives reliable good results with excellent preservation of hip function.

Keywords: trochanteric fractures, minimally invasive, gamma nail.

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