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Objectives: Closing-wedge high tibial osteotomy (CWHTO) and opening-wedge high tibial osteotomy (OWHTO) are commonly used osteotomy techniques for the symptomatic knee osteoarthritis treatment. However, there is no consensus on which method provides superior outcomes. In this study, we compared the clinical outcomes, radiologic outcomes, and postoperative complications of these techniques. Methods: In a randomized controlled trial, 76 patients with medial compartment knee osteoarthritis and associated varus malalignment were randomized into the CWHTO and OWHTO groups (n=38). The primary outcome measures were knee function evaluated by Knee Injury and Osteoarthritis Outcome Score (KOOS) and knee pain assessed by a visual analog scale. The secondary outcome measures were posterior tibial slope (PTS), tibial bone varus angle, and postoperative complications. Results: Both techniques significantly improved the clinical and radiologic outcome measures. The mean improvement of total KOOS was not significantly different between the CWHTO and OPHTO groups (P=0.55). Moreover, the improvement in various KOOS subscales was not significantly different between the two groups. The mean improvement of Visual Analogue Scale (VAS) was not significantly different between the CWHTO and OWHTO groups (P=0.89). The mean PTS change was not significantly different between the two groups (P=0.34). The mean improvement of the varus angle was not significantly different between the two groups (P=0.28). The rate of postoperative complications was not remarkably different between the CWHTO and OWHTO groups. Conclusion: Considering no observed superiority of each osteotomy technique over the other one, two techniques could be used interchangeably and based on the surgeon's preference.

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BACKGROUND: We aimed to assess the efficacy of intra-articular remifentanil in relieving postoperative pain after knee arthroscopy. METHODS: We conducted a double-blind randomized clinical trial study on 60 patients. Patients were divided into two equal groups. The control group received 25 ml of intra-articular normal saline, and the intervention group received 200 µg of remifentanil dissolved in 25 ml of saline. We evaluated at rest postoperative pain at 1, 3, 6, 12, 18, and 24 h after the surgery using the Visual Analog Scale (VAS). Patients with VAS scores of 4 or more received meperidine (pethidine). The first time meperidine was requested and the total amount of meperidine consumed was recorded. RESULTS: Out of 60 patients, 49 were male (81.6%), and the mean age of participants was 32.71 (7.02) years. An hour after the surgery, the control group showed a mean VAS score of 8.66 (1.26), and decreased to 2.53 (1.67) at the end of 24 h. The intervention group started with a mean VAS score of 2.23 (1.81) and ended at 0.10 (0.305). All patients in the control group and 11 (36.7%) patients in the intervention group asked for analgesics during follow-up. The mean total meperidine dose in the control and intervention groups was 108.33 (23.97) mg and 13.33 (19.40) mg, respectively (P < 0.001; 95% confidence interval of the difference 83.72 to 106.27). CONCLUSIONS: Intra-articular remifentanil may decrease postoperative pain and analgesic requirements in patients undergoing knee arthroscopy.

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BACKGROUND: Arthroscopic intervention is very common for conducting orthopedic surgeries. After a knee arthroscopic surgery, different drugs are used through intra-articular administration to induce analgesia. The aim of this study was to evaluate analgesic effects of Bupivacaine (marcaine), Bupivacaine plus midazolam, and Bupivacaine plus fentanyl in reducing pain after knee arthroscopic surgery. METHODS: Frothy five patients who were candidate for knee arthroscopy were divided into three groups. Group A, B and C received Bupivacaine (50 mg), Bupivacaine (50 mg) plus midazolam (50 µg/kg), and Bupivacaine (50 mg) plus fentanyl (3 µg/kg), respectively. The analgesic solutions were diluted with normal saline up to 20 ml. The analgesic effects were evaluated by VAS during first 24 hrs after surgery. With the VAS > 4, extra analgesic (pethidine) was administrated for patient. RESULTS: The amount of induced analgesia and need for extra analgesic was different between groups; however, it was not statistically significant (p<0.109). The amount of administered analgesic (pethidine) in first 24 hours post-operatively was 275 mg for group A, while it was 150 mg for group B and 75 mg for group C. In group A, 46.67% of patients required further analgesic while this was 26.67% and 13.34% for groups B and C respectively (p<0.109). CONCLUSION: Intra-articular administration of studied drugs in all three groups reduced post-operation pain. The amount of induced analgesia was the highest for group C, while group B drugs induced better analgesia compared to group C.

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BACKGROUND: Posterior tibial slope (PTS) is an important factor in the knee joint biomechanics and one of the bone features, which affects knee joint stability. Posterior tibial slope has impact on flexion gap, knee joint stability and posterior femoral rollback that are related to wide range of knee motion. During high tibial osteotomy and total knee arthroplasty (TKA) surgery, proper retaining the mechanical and anatomical axis is important. The aim of this study was to evaluate the value of posterior tibial slope in medial and lateral compartments of tibial plateau and to assess the relationship among the slope with age, gender and other variables of tibial plateau surface. METHODS: This descriptive study was conducted on 132 healthy knees (80 males and 52 females) with a mean age of 38.26±11.45 (20-60 years) at Imam Reza hospital in Mashhad, Iran. All patients, selected and enrolled for MRI in this study, were admitted for knee pain with uncertain clinical history. According to initial physical knee examinations the study subjects were reported healthy. RESULTS: The mean posterior tibial slope was 7.78± 2.48 degrees in the medial compartment and 6.85± 2.24 degrees in lateral compartment. No significant correlation was found between age and gender with posterior tibial slope (P≥0.05), but there was significant relationship among PTS with mediolateral width, plateau area and medial plateau. CONCLUSION: Comparison of different studies revealed that the PTS value in our study is different from other communities, which can be associated with genetic and racial factors. The results of our study are useful to PTS reconstruction in surgeries.

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BACKGROUND: The prevalence of neglected developmental dysplasia of the hip (DDH) has been decreasing. Nowadays, the disease is rarely seen in walking age children. The purpose of this study is to assess the results of simultaneous osteotomy of femur and pelvic bones in such children. METHOD: We performed a retrospective study on 30 children aged 3.8±0.9 (range: 1.5-7) years old, with DDH who underwent surgical operation in our hospital from August 2001 to September 2006. Tönnis and Severin grading systems were used to classify the radiographic status of the hip in pre- and postoperative era, respectively. Improvement in function and limp was also evaluated by the modified McKay's classification. RESULTS: From the 30 cases, six patients excluded in the course of the study and among the remaining patients, 12 had bilateral involvement. The mean follow-up period was 7.6±0.8 (range: 5.1-11.3) years. During the last visit, radiographic status of the operated joints, according to Severin classification was as follows: Class I: 12 patients; Class II: 20 patients; Class III: 3 patients; Class IV: 1 patient; and Class VI: 1 patient. CONCLUSION: Although through the follow-up, two hips subluxated, necrosis happened in three and one joint was re-dislocated, simultaneous femoral and innominate osteotomy in the walking age children with DDH has relatively good clinical outcomes.

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PURPOSE: The purpose of the present research was to translate the original English version of International Knee Documentation Committee (IKDC) Subjective Short Form to Persian and to assess validity and reliability of it in Iranian patients with ACL injury. METHOD: The Persian version of the IKDC Subjective Short Form was administered to 145 patients including 111 men (76 %) and 34 women (24 %) with the clinical diagnosis of knee ACL tear that were referred to our Knee and Shoulder Center at Mashhad University of Medical Sciences, Mashhad, Iran. The Persian IKDC Subjective Short Form and Persian SF-36 questionnaire were completed by patients in the clinic before beginning any treatment intervention. Patients filled out the Persian IKDC 72 h again before receiving a major treatment; we were then able to use the test-retest method to calculate reliability. RESULTS: The average age of the subjects was 30.9 ± 10.4 years. The calculated ICC with 95 % confidence interval was 0.845. In this study, Cronbach's alpha was 0.845. There were significant correlations between mean total score of the Persian IKDC and all items of the SF36 (P < 0.05) except for MCS (P = 0.055). CONCLUSION: Cronbach's alpha and correlation of IKDC Subjective Short Form and SF-36 demonstrated that the Persian version of IKDC has both strong reliability and validity. The Iranian version of IKDC has favourable validity and reliability and therefore can be used to assess Persian-speaking patients with cruciate ligament injuries. LEVEL OF EVIDENCE: Level II.

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BACKGROUND: The Oxford Knee Score (OKS) is a short patient-reported outcome instrument that measures pain and physical activity related to knee osteoarthritis. The purpose of this study is to evaluate, construct validity and consistent reliability of the Persian version of the OKS. METHODS: The case series consisted of 80 patients who were clinically diagnosed with having knee osteoarthritis. All patients were requested to fill-in the Persian OKS and Short-Form 36 Health Survey (SF-36). Correlation analysis between the Persian versions of these two instruments was then carried out. The scores of the Persian SF-36 were used to evaluate convergent and divergent validity of the 12-item Persian OKS. RESULTS: From a total of 80 patients, 63 were female (79%) and the remaining 17 were male (21%) with a mean age of 52.2 years. In the present study, high Cronbach's alpha of 0.95 confirms excellent internal consistency of the Persian OKS scale similar to previous investigations. The results confirm that the Persian version of this instrument is valid and reliable, similar to its English index and its subsequent translations in different languages. CONCLUSION: The Persian OKS is a reliable instrument to evaluate knee function in patients with knee osteoarthritis and is a useful tool for outcome measurement in clinical research.

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BACKGROUND: Various drugs are administered intra-articularly to provide postoperative analgesia after arthroscopic knee surgery. The purpose of this study was to assess the analgesic effects of intra-articular injection of a dexmedetomidine following knee arthroscopy. METHODS: Forty six patients scheduled for arthroscopic knee surgery under general anaesthesia, were randomly devided into two groups. Intervention group received 1µg/kg dexmedetomidine (D) and isotonic saline. Control group received 25ml isotonic saline (P). Analgesic effects were evaluated by measuring pain intensity (VAS scores) and duration of analgesia. RESULTS: There was no significant difference between the two groups in terms of age, sex and weight. The mean of post-operation pain severity in 1, 3, 6,12, and 24 h was significantly lower in the intervention group (D) in comparison with the control group (P). the mean of the total dose of tramadol consumption was significantly lower in the intervention group in comparison with the control group (P<0.001). CONCLUSIONS: Intra-articular injection of dexmedetomidine at the end of arthroscopic knee surgery, alleviates the patients' pain, reducing the postoperative need for narcotics as analgesics, and increase the first analgesic request after operation.

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BACKGROUND: Osteoarthritis of the knee is the most common chronic joint disease that involves middle aged and elderly persons. There are different clinical instruments to quantify the health status of patients with knee osteoarthritis and one example is the WOMAC score that has been translated and adapted into different languages. The purpose of this study was cultural adaptation, validation and reliability testing of the Persian version of the WOMAC index in Iranians with knee osteoarthritis. METHODS: We translated the original WOMAC questionnaire into Persian by the forward and backward technique, and then its psychometric study was done on 169 native Persian speaking patients with knee degenerative joint disease. Mean age of patients was 53.9 years. The SF-36 and KOOS were used to assess construct validity. RESULTS: Reliability testing resulted in a Cronbach's alpha of 0.917, showing the internal consistency of the questionnaire to be a reliable tool. Inter-correlation matrix among different scales of the Persian WOMAC index yielded a highly significant correlation between all subscales including stiffness, pain, and physical function. In terms of validity, Pearson`s correlation coefficient was significant between three domains of the WOMAC with PF, RP, BP, GH, VT, and PCS dimensions of the SF-36 health survey (P<0.005) and KOOS (P<0.0001) . CONCLUSIONS: The Persian WOMAC index is a valid and reliable patient- reported clinical instrument for knee osteoarthritis.

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BACKGROUND: The spinal cord injury quality-of-life questionnaire (SCIQL-23) is an instrument that has been developed for clinical follow-up as well health related quality-of-life (QOL) measurement in people with spinal cord injury (SCI). The purpose of this study was to assess the validity and reliability of the Persian version of SCIQL-23 in individuals with chronic SCI. MATERIALS AND METHODS: Medical outcomes study 36 item short-form health survey (SF-36) as well as the Persian version of the SCIQL-23 questionnaires applied to be used in 52 veterans with spinal cord injuries in the Orthopedic Research Center, Mashhad University of Medical Sciences from January 2011 to August 2011. Cronbach's alpha co-efficient computed to test the reliability of the survey. In order to assess the convergent validity the correlation of each item of the SCIQL-23 done with each dimension of the SF-36 by applying the Pearson correlation co-efficient. Independent samples t-test used to test power of discrimination. RESULTS: All of veterans were male and married. The mean age of individuals at the time of interview was 49.3 years (standard deviation = 7.9); in a range between 38 and 80 years. Most of them (88.5%) had incomplete paraplegia. Cronbach's alpha test revealed strong reliability in questions of SCI QOL (Total Cronbach's alpha = 0.764). A negative significant correlation occurred between physical function and functioning (FUNC) (r = -0.412**), bodily pain and problems related to injury (PROB) (r = -0.313*), vitality (VT) and mood state (MOOD) (r = -0.327*), social function and PROB (r = -0.309*), mental health (MH) and MOOD (r = -0.406**). Furthermore, the Mental component summary (MCS) of SF-36 had a negative significant correlation with MOOD (r = -0.312*). Similar to MCS, physical component summery (PCS) had a negative significant correlation with MOOD (r = -0.276*) in addition to FUNC (r = -0.324*) and PROB (r = -0.318*). Instead, GH (r = 0.455**), VT (r = 0.322*), MH (r = 0.276*) and PCS illustrated a positive significant correlation with global quality of life. CONCLUSION: The Persian version of the SCQL-23 discovered to be competent in terms of its valuable psychometric properties in assessing the QOL of SCI people by showing excellent internal consistency and no floor or ceiling effect.

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BACKGROUND: To compare the results of two different ways of distal femoral osteotomy stabilization in patients suffering from genuvalgum: internal fixation with plate, and casting. METHODS: In a non-randomized prospective study, after distal femoral osteotomy with the zigzag method, patients were divided into two groups: long leg casting, and internal fixation with blade plate. For all patients, questionnaires were filled to obtain data. Information such as range of motion, tibiofemoral anatomical angle and complications were recorded. RESULTS: 38 knees with valgus deformity underwent distal femoral supracondylar osteotomy. (8 with plaster cast and 30 with internal fixation using a blade plate). Preoperative range of motion was 129±6° and six months later it was 120±14°. The preoperative tibiofemoral angle was 32±6°; postoperative tibiofemoral angles were 3±3°, 6±2°, and 7±3° just after operation, six months, and two years later, respectively. Although this angle was greater among the group stabilized with a cast, this difference was not statistically significant. In postoperative complications, over-correction was found in five, recorvatom deformity in one, knee stiffness in three and superficial wound infection was recorded in three knees. CONCLUSIONS: There is no prominent difference in final range of motion and alignment whether fixation is done with casting or internal fixation. However, the complication rate seems higher in the casting method.

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INTRODUCTION: Some studies have proved that Tranexamic acid infusion is associated with a decrease in blood loss during and after surgery. Due to the availability of an oral form of the drug, the rapid and complete absorption of it and ease of administration without need for specific instruments, we evaluated the effectiveness of the oral form in decreasing blood loss after total knee arthroplasty. MATERIALS AND METHODS: In this double-blind, randomized, parallel clinical trial study, we evaluated 53 patients undergoing knee arthroplasty admitted to Ghaem hospital, Mashhad in 2012. Patients with any history of severe ischemic heart diseases, renal failure, cirrhosis, history of bleeding disorders or thromboembolic events, were excluded from the study. The patients were randomly allocated into 27 patients with and 26 patients without Tranexamic acid. Blood loss (mL) at 12 and at 24h and hematocrit at 24h were measured postoperatively. The results were analyzed with SPSS software (11.5 version) using independent and paired sample t-tests. A p-value ≤ 0.05 was considered to be significant. RESULTS: The average blood loss after 12h of surgery in the control and Tranexamic acid groups were 462.9 (± 147.4) and 274.6 (± 139)mL, respectively (p<0.001) and after 24h of surgery they were 588.8 (± 193)and 364 (± 165.1)mL, respectively (p<0.001). The mean decrease in the hematocrit after surgery was 4.7% in the Tranexamic acid group and 6.8% in the control group (p=0.016). CONCLUSION: Prescription of oral Tranexamic acid before knee arthroplasty can cause remarkable decrease in blood loss after surgery and also less decrease in hematocrit. The advantages of the oral route of the drug versus the intravenous form is that it can be used routinely as a safe and effective way to decrease bleeding after surgery.

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BACKGROUND: The prevalence of DDH ranges from 1 per1000 to 3.4 per 100 live- births. One- and-one-half hip spica cast is the conventional technique of immobilization after the open reduction with or without osteotomy. OBJECTIVES: In this study, we evaluated the preference of bilateral one-half spica cast over the one-and-one-half spica cast. MATERIALS AND METHODS: Eight hips in five patients with developmental dislocation of the hip have undergone open reduction. Salter osteotomy, Pemberton osteotomy and femoral shortening were done on two, two and six hips, respectively. Bilateral one-half spica cast with trochanteric molding was applied for all of the hips. RESULTS: The patients' age ranged from 1.5 to 7 years old. The only complications consisted of two osteonecrosis of the head and one superficial infection. No dislocation, graft displacement, nonunion and device failure was occurred. CONCLUSIONS: Bilateral one-half spica cast is sufficient after the open reduction with or without osteotomy in DDH patients and we can substitute the bilateral one-half spica cast above the knee cast for the conventional one and one-half spica cast.

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BACKGROUND: The knee joint is prone to injury because of its complexity and weight-bearing function. Anterior cruciate ligament (ACL) ruptures happen in young and physically active population and can result in instability, meniscal tears, and articular cartilage damage. The aim of this study is to evaluate the accuracy of Lachman and anterior drawer tests in ACL injury in compare with arthroscopy. METHODS: In a descriptive, analytical study from 2009 to 2013, 653 patients who were suspected to have ACL rapture were entered the study. Statistical analysis was performed by the usage of SPSS 16. Multiple comparison procedures were performed for comparing data between clinical examination and arthroscopic findings and their relation with age and sex. RESULTS: Mean age of patients was 28.3±7.58 years (range from 16 to 68 years). From 428 patients, 41.2% (175 patients) were between 26 and 35, 38.8% (165 ones) between 15 and 25 and 20% (85 patients) out of 36 years. 414 patients were male (97.2%) and 12 were female (2.8%). Sensitivity of anterior drawer test was 94.4% and sensitivity of Lachman test was 93.5%. CONCLUSION: The diagnosis of the ACL injury and the decision to reconstruct ACL could be reliably made with regards to the anterior drawer and Lachman tests result. The tests did not have privilege to each other. The test accuracy increased considerably under anesthesia especially in women.

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BACKGROUND: The treatment of recurrent anterior shoulder dislocation in patients who failed a supervised rehabilitation program is operative stabilization. Anatomical repair addressing the underlying pathology is the preferred method. We hypothesize that Bristow-Latarjet procedure is effective in all types of traumatic recurrent anterior shoulder dislocations, although in cases with Bankart lesion, Bankart operation is certainly preferred. METHODS: Thirty-five shoulders on which a Bristow-Latarjet operation had been performed on account of traumatic recurrent anterior shoulder instability were followed up for an average of 24.6 months (range: 18 - 51). The clinical outcome was measured according to Walch-Duplay Rating Sheet for Anterior Instability of the Shoulder at the latest follow-up. RESULTS: The clinical outcome was excellent in 11 (317%) patients and good in 24 (69%) patients. Two patients had redislocation that were treated nonoperatively and remained symptom-free at the latest follow-up. Radial nerve palsy occurred in one patient that spontaneously recovered after nine weeks. CONCLUSION: Although the treatment of anterior shoulder instability in patients with Bankart lesion and intact capsular material (without excessive laxity) is certainly Bankart operation, we claim that in almost all types of anterior shoulder instability, especially in patients with large Hill-Sachs lesions, glenoid bone loss, or excessive capsular laxity, the Bristow-Latarjet operation is associated with good or excellent results and can make the patient satisfied.

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