Archives of Bone and Joint Surgery
Year:2020 | Volume:8 | Issue:5|Papers Count:13

Knee arthroscopy to carry out partial removal of the meniscus and reconstruction of the anterior cruciate ligament (ACL) is common and efficacious, albeit a potential adverse event is intraarticular bleed after surgery. When this adverse event takes place, besides the concomitant pain, the patient commonly needs a joint aspiration (arthrocentesis) to avert loss of range of motion (ROM). Occasionally this problem leads to a poor result of surgery as a result of loss of ROM. That is why the utilization of tranexamic acid (TXA) has been taken into account with the aim of diminishing postoperative hemarthrosis and its potential associated adverse events (1– 3). Some reports have advised the utilization of intravenous TXA (IV-TXA) or intraarticular TXA (IA-TXA) in arthroscopic reconstruction of the ACL, considering it appears to diminish the level of bleeding after surgery and its adverse events: pain, swelling and loss of ROM (1– 3). But, some authors have published that IA-TXA could damage the chondrocytes (4). Besides, good outcomes have been obtained after using IV-TXA in arthroscopic partial removal of the meniscus (5). The objective of this editorial is to try to elucidate whether TXA must be employed in arthroscopic reconstruction of the ACL and arthroscopic partial removal of the meniscus and by what technique (IA-TXA or IV-TXA)...

Mesenchymal Stem Cell (MSC) therapy in osteoarthritis has been hailed as a promising treatment for osteoarthritis due to their unlimited potential of healing and regeneration. Existing literature regarding their proper name, optimal sources, mechanisms of action, dosage, and route of administration, efficacy, and safety is debatable. This index review article has tried to connect these puzzling pieces of available information and brought clarity on some of these crucial issues. The author believes that Maintenance Stem Cells (MSC) may be a more suitable term than mesenchymal stem cell or medicinal signaling cells as their origin might not be limited to mesodermal tissue. Also, they have been shown capable of self-renewal, differentiation, and maintaining a cascade of healing & possibly regeneration at the implanted site. Only a small percentage of implanted MSC survive and rest undergo apoptosis after releasing growth factors, cytokines, and extracellular vesicles. These surviving MSC become active due to conformational changes induced by anti-environment stimuli and undergo limited self-renewal, proliferation, and differentiation, but only a few of them might incorporate into the host tissues. These cells generate & maintain a momentum of series of regenerative activities to improve the function of joint, stabilize or possibly enhance the cartilage quality. More randomized studies with long term follow-up are required to bring clarity on their ideal source, expansion, culture technique, optimum dosage, and route of administration and longterm safety issues.

An increasingly popular method for post-operative rehabilitation of an ACL reconstruction, as a substitute for traditional therapy, is blood flow restriction therapy (BFR). BFR therapy utilizes a pneumatic cuff to simulate strenuous exercise in an effort to stimulate muscle recruitment, mitigate atrophy, and promote hypertrophy in patients with load-bearing limitations. Because this is a relatively new form of therapy, there is a lack of established literature and protocol that is preventing widespread use of the therapy. This article will seek to confirm the value and validity of the utilization of BFR therapy. In order to validate the utilization of BFR, an evaluation of the science underlying BFR will be discussed as well as the technique and exercises preformed during therapy. Furthermore, analysis of other BFR literature will be utilized to lend further credence to the obtained conclusions. Based on the literature, BFR therapy mitigates atrophy through type II muscle recruitment while also stimulating hypertrophy in patients, supporting its use post-operatively. Moreover, positive results from BFR case series also lend credence to its value as a substitute for traditional therapy in patients who have weight-bearing limitations, specifically those who are recovering from anterior cruciate ligament reconstructions.

Background: Successful repair of a torn rotator cuff may prevent progression to rotator cuff arthropathy. However, previous studies have shown a substantial rate of failure after rotator cuff repair and characteristics of surgically repaired rotator cuffs that go on to shoulder arthroplasty have not been fully elucidated. The purpose of this study was to determine the patient characteristics and rate at which patients who underwent rotator cuff repair progressed to shoulder arthroplasty. Methods: This was a retrospective study of patients who underwent rotator cuff repair in a large, closed healthcare system in 2008. The EMR was queried for rotator cuff repair CPT with ICD-9 codes for rotator cuff. The resultant dataset was then cross-referenced with a separate internal shoulder arthroplasty registry to determine which patients went onto shoulder arthroplasty. Demographic variables, descriptors of tear pathology and repair characteristics were collected and compared between patients who subsequently underwent shoulder arthroplasty and those that did not. Results: A total of 882 rotator cuff repair patients were included within this study. Of the initial 882 cuff repairs, there were 12 patients (1. 4%) that went on to have arthroplasty. Patients who underwent shoulder arthroplasty after rotator cuff repair were significantly older at time of surgery and had greater comorbidity burdens. Patients who ended up with shoulder arthroplasty had the procedure an average of 4. 77 ± 3. 28 (SD) years after rotator cuff repair, with 11 of 12 patients having a diagnosis of rotator cuff arthropathy at the time of shoulder replacement. Conclusion: In a closed system, tracking rotator cuff repairs over 9. 1 years revealed a small number that went on to subsequent shoulder arthroplasty. Patients who underwent shoulder arthroplasty were significantly older and had greater comorbidity burdens than those who did not. Patients who underwent shoulder arthroplasty usually either had shoulder arthroplasty within 1 year or after 5 years. Enhanced understanding of which patients may progress to arthroplasty may provide a better initial choice of operative intervention in those patients.

Background: We compared the amount of variation in Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS PF) Computer Adaptive Test (CAT) accounted for by The Tampa Scale for Kinesiophobia (TSK) and its short form (TSK-4) independent of other factors. Questionnaire coverage, reliability, and validity were compared for both TSK and TSK-4 using mean scaled scores, internal consistency, floor and ceiling effects, interquestionnaire correlations, and collinearity with other measures as the Pain Catastrophizing Scale short form (PCS-4), PROMIS Depression CAT, and PROMIS Pain Interference (PROMIS PI) CAT. Methods: One hundred forty eight consecutive new or return patients were enrolled. Patients were seen in an outpatient setting in several orthopaedic clinics in a large urban area. All patients completed the TSK, PROMIS PF CAT, PROMIS PI CAT, PROMIS Depression CAT, and PCS-4. Results: Greater fear of movement (higher TSK) was associated with worse physical function (lower PROMIS PF CAT) and the full TSK explained more variation in physical function than the short form (TSK-4). In contrast to prior studies PCS-4 was not independent of TSK. Flooring and ceiling effects were seen with TSK-4. Worse physical function was associated with older age, traumatic condition, and more symptoms of depression. Conclusion: The short form of the Tampa Scale for Kinesiophobia can be used as a brief screening measure in patient care and research in order to identify an independent influence of kinesiophobia on lower extremity specific limitations. Additional study is needed to determine whether there is utility in screening for both TSK and PCS or if one or the other provides sufficient information about cognitive biases regarding pain to guide treatment with cognitive behavioral therapy and related techniques.

Background: Proximal humeral fracture-dislocations (PHFD) are a special entity in proximal humeral fracture treatment. The aim of this study is to present our minimally invasive plate osteosynthesis (MIPO) technique through an anterolateral deltoid split approach. In addition, we performed a retrospective cohort study analyzing the patient reported functional outcome and complications. Methods: A single center cohort study was performed. All patients operated through a deltoid split approach for PHFD between 2009 and 2016 were eligible for inclusion. The primary endpoint was subjective shoulder function measured with QuickDASH and subjective shoulder value (SSV). Secondary endpoints were complications and implant-related irritation. Results: 28 patients were included. The mean age was 49 (SD ± 10. 3). The mean follow-up was 48 months (SD ± 23. 7). The mean QuickDASH score was 6. 8 (SD ± 7. 8) and the mean SSV was 86 (SD ± 14. 6). Four patients had a conversion into a reversed arthroplasty (14%), one patient (4%) a shortening of secondary perforated screws, four patients an early re-osteosynthesis (14%), four patients (14%) developed an AVN and in one patient damage of the axillary nerve was observed. 21 patients (75%) had their implant removed. Conclusion: Patient reported functional results after humeral head preservation and internal fixation of PHFDs through an anterolateral deltoid spilt approach are promising. However, there is a high rate of re-operations either because of complications or for implant removal. Comparing our data to literature these rates are not depending on the approach chosen.

Background: The accuracy of reduction of ankle fractures using postoperative plain radiographies (x-ray) remains widely controversial. Some authors have demonstrated that postoperative computed tomography (CT) scan can be useful for these patients. In current study, the efficacy of x-rays after fixation of ankle fractures was investigated based on the CT scan findings. Methods: A total of 73 patients with ankle fractures who were subjected to open reduction internal fixation (ORIF) were enrolled. After surgery, if the reduction was acceptable based on the x-rays according to standard measurements, the patient was referred for CT scanning. Forty four patients were included in the study. Undesirable CT scan findings including malreduction of fragments or articular surfaces, device malpositioning, missed fractures, and undetected intra-articular fragments were documented. Results: Undesirable CT findings were seen in 25 patients (56. 8%). CT scan showed acceptable reduction without device malpositioning in 19 patients. The most prevalent findings in CT images were malreduction and device malpositioning in 17 and 16 patients, respectively. There was no abnormal finding in CT imaging of lateral malleolar fractures. In two thirds of the injured syndesmosis, device malpositioning, and malreduction were detected in CT scan. Conclusion: Despite acceptable postoperative x-rays, a considerable number of patients with ankle fractures had inappropriate reduction or undesirable findings in their postoperative CT scan. It seems necessary to use CT scan after ORIF of ankle fractures in order to examine the accuracy of reduction. Further validation of postoperative CT scan in ankle fracture surgery should be investigated.

Background: The present study was conducted to quantify the relationships between bone drilling process parameters (i. e., feed rate, resting time, exit rate, and drill bit diameter) and drilling outcome parameters (i. e., thrust force and maximum temperature). Methods: This study utilized 10-cm cortical bovine samples to evaluate the effects of four independent parameters, including drill bit diameters, six different feed rates, three various resting times, and three different exit rates on thrust force and maximum temperature (MT). A total of 28 stainless steel orthopedic drill bits with a diameter of 2. 5 and 3. 2 mm, as well as an orthopedic handpiece were attached to the 500N load cell and an accurate linear variable differential transformer to obtain forces. Moreover, two k-type thermocouples were utilized to record the temperature-time curve near the drilling site. The data were analyzed using the two-way analysis of variance and post hoc Tukey-Kramer Honest test. Results: Maximum thrust force (MTF) decreased by almost 230% as the drill bit diameter increased from 2. 5 to 3. 2 mm in the lowest feed rate. The MTF showed a 335% increase, whereas a decrease of 69% was observed as the feed rates rose from 0. 5 to 3 mm/sec. Moreover, the MT decreased to 67% with an increasing exit rate from 1 to 3 mm/sec. Furthermore, a slight increase was observed in MT when the resting time increased from 0 to 2 seconds (P>0. 05). Conclusion: The desired drilling is drilling with lower thrust force and lower final temperature of bone. Increasing feed rate can cause an increase and decline in thrust force and final temperature, respectively. The highest rates of MT were 0. 5 and 1 mm/min, and the optimum feed rate would be 1. 5 mm/min due to the averaged thrust force. Moreover, the resting time had no significant effects on the final temperature. Attentions to resting time would be useful to provide a more accurate, efficient, and uniform drill hole.

Background: Femoral head avascular necrosis is the cause of paralyzing status of youth population. Initial diagnosis is the main element in treating the disease. Bone grafting and core decompression are the approved cures at the early steps of the disease. Hip replacement in a total manner is the common cure in the final stages. The optimal treatment in the intermediate stages is partially disputable. We investigated several patients with femoral head osteonecrosis cured with impacted cancellous allograft and open core decompression using the lightbulb technique. Methods: A total of 46 patients (58 hips) suffering from femoral head osteonecrosis were evaluated in this crosssectional study. Patients were classified into two groups: A (stage 2B Ficat) and B (stage 3 Ficat) to be treated with the impaction of cancellous allograft and by open core decompression. Radiographic results, demographic data, and range of hip joint motions were recorded. The patients were assessed through employing the Harris hip score (HHS) and visual analogue scale (VAS) index prior to operation and over five years following surgery. We also studied radiographic alterations of femoral head. Results: The means of HHS and VAS were developed following the operation. Radiographic outcomes promoted in both groups, however, it was better in group A. 12 (40%) and six (22%) hips (40%) in groups A and B, respectively displayed developed stages following the operation. The hip ROM was enhanced with the mean of 15-20 degrees (P<0. 005). Conclusion: Open core decompression combined with allograft impaction sounds to be influential in the developing steps of femoral head necrosis and leads to joint discomfort and diminished pain improving ROM of the hip joint and meanwhile procrastinating the worsening of the disease.

Background: Recently, in approach to spinal pathologies, the whole spine should be considered as a biomechanical unit. Studies have shown the great importance of sagittal and coronal balance and the relationship between the various parts of spine together and pelvis. Former studies have shown a close relationship between spinopelvic parameters and sagittal balance. A complete understanding of sagittal balance basics is needed to achieve the best outcome and avoiding future complications after treatment of spinal deformities. In this study, the normal range of spinopelvic parameters among healthy volunteers in Iran has been evaluated. Methods: This cross-sectional study was conducted on healthy volunteers in 2017. The lateral whole-spine X-ray was obtained under the standard conditions. Two spine surgeons measured the parameters including pelvic incidence, pelvic tilt, sacral slope and lumbar lordosis. Results: In this study 100 volunteers were studied; out of whom, 41 participants were male and the mean age was 47. 5± 11. 7 years. The average pelvic incidence, pelvic tilt, and sacral slope were 51. 5± 10. 9, 17. 4± 9. 9, and 34. 8± 8. 8 degrees, respectively. The pelvic tilt was significantly lower in women. It was found that with increasing age, the pelvic incidence and pelvic tilt increases while lumbar lordosis decreases (P<0. 05). Conclusion: This study is the first study on the normal range of spinopelvic parameters in healthy individuals in Iran. . Our data showed that PT and PI-LL are significantly lower in women, while, PT, PI and PI-LL increase and LL decreases in older ages.

Background: Recently, patient-specific instrumentation (PSI) systems have been developed in order to increase the accuracy of component positioning during total knee arthroplasty (TKA); however, the findings of previous studies are controversial in this regard. In the current randomized clinical study, the outcomes of computer tomography (CT)-based PS (patient specific)-guided TKA were compared to the results of conventional instrumentation (CVI) TKA. The guides were designed on the basis of distal femoral and proximal tibial pin orientation of the conventional related guides. Methods: The present study was carried out on 24 TKA candidates randomly assigned to two PSI (n=12) and CVI (n=12) groups. The patients were postoperatively followed for 2 years. Then, the hip-knee-ankle angle (HKAA), femoral component flexion, and orientation of components in the coronal plane were measured. In addition, the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) Index and Knee Society Score (KSS) questionnaire were completed for all the patients. Results: The rate of the outliers of the HKAA was higher in the CVI group (41. 7% and 8. 3%; P=0. 077); nevertheless, the difference was not significant in this regard. The rate of the outliers of other radiographic measurements and operational time were similar in both groups. Furthermore, there was no significant difference between the two groups in terms of the WOMAC and KSS. Conclusion: The CT-based PS-guided TKA may result in the improved postoperative mechanical alignment of the limb and should be considered in complicated TKAs. However, future studies should investigate whether the results of PSI TKA support the considerably higher costs of this technique.

Background: The purpose of this study was to evaluate the treatment outcomes of perilunate dislocations (PLDs) and transscaphoid perilunate fracture dislocations (TSPLDs) treated with operative volar approach without ligament repair or reconstruction. Methods: A total of seven patients (10 hands) were studied during 2017-2018. We fixed scaphoid fractures thorough a volar approach and 3 k-wires were inserted to stabilize the scaphoid to the adjacent bones. We evaluated patients’ range of motion by VAS and grip strength, sensitivity assessment, and radiographs. Mayo and DASH scores were also recorded for wrist evaluation. Results: All fractures united well. The mean Mayo wrist score was 81. 5. Five patients scored good and excellent results (90-100). Excellent DASH scores (˂ 20) were observed in 4 patients and there was no poor DASH score (˃ 50). Conclusion: Treatment of PLDs and TSPLDs with k-wire and screw fixation using a volar approach and without any ligament repair or reconstruction results in minimal manipulation and has favorable short-term outcomes.

Patellar tendon moment arm length (PTma) changes at different knee flexion angles have not been determined in in vivo studies. We aimed to determine PTma in four different knee angles using Magnetic Resonance Imaging (MRI) to predict in vivo changes in the moment arm length from different knee angles during running. PTma was measured as the perpendicular distance from muscle– tendon line of action to the knee joint axis of rotation at 0° (full extension), 20° , 40° , and 60° flexion of knee by using MRI method. Repeated measure ANOVA method was applied to compare the moment arm length among four degrees of knee flexion (P<0. 05). A regression analysis was used to predict the PTma during different knee joint angles. The PTma in the four angles at 0° , 20° , 40° , and 60° of knee flexion were 42. 55± 4. 20, 39. 91± 2. 98, 37. 73± 2. 87, and 36. 18± 2. 90 mm, respectively (P<0. 05). The regression analysis provided an equation to predict the PTma from different knee joint angles during running. PTma values decreased from knee extension to flexion in a linear manner. These findings have important implications for estimating PTma using a regression equation model from different knee joint angles.