Archives of Bone and Joint Surgery
Year:2019 | Volume:7 | Issue:3|Papers Count:15

Knee osteoarthritis (OA) affects the joint beyond just the articular cartilage. Specifically, magnetic resonance imagingidentified bone marrow lesions (BML) in the subchondral bone have both clinical and pathophysiological significance. Compared to joint space narrowing on traditional radiographs, the presence of BMLs has been better correlated with severity of clinical symptoms as well as clinical deterioration. Presence of a BML increases the likelihood for progression to a total knee arthroplasty by up to nine fold. Histochemical analysis of BMLs has shown increased levels of tumor necrosis factor-alpha, matrix metalloproteinases and substance P, thought to stimulate pain receptors in osteoarthritis.

The preoperative care of patients undergoing orthopedic surgery and treated with biologic agents is of great significance. Perioperative use of biologic agents could lead to such complications as infection and delayed postoperative wound healing. This narrative review aimed to evaluate the current information on the use of biologic agents in patients undergoing orthopedic surgery, determine the rate of associated postoperative complications, and identify the appropriate time for the continuation or discontinuation of biologic therapy in these patients. It can be stated that all biologic agents increase the risk of infections depending on their half-lives. Biologic agents are suggested to be withheld for at least twice their half-lives before major surgeries. However, in case of minor operations, they can be continued given the low risk of infection and impaired wound healing in these cases.

Background: Allogeneic blood transfusion in patients undergoing total joint arthroplasty (TJA) has been shown to negatively affect patient outcomes. This study aimed to examine if there is a correlation between operative time and the need for allogeneic blood transfusions during TJA. Methods: We performed a retrospective review of 866 patients who underwent primary TJA during a one-year period at our institution. Logistic regression was performed to identify the association between operative time and need for allogeneic blood transfusion, controlling for other patient and surgical factors. Multiple linear regression analysis was also performed to see how the same factors affected CBL. Results: Of the 866 cases, 13%(115) were simultaneous bilateral. 52%(449) of patients received preoperative autologous blood donation. The average operative time for unilateral and bilateral patients was 74. 1± (33. 9) and 132. 6± (36. 0) minutes, respectively. Average CBL for unilateral patients was 2120mL± (1208) and 4051mL± (1311) for bilateral cases. The average number of allogeneic transfusions was also higher within the bilateral group (0. 49 vs 1. 15 units). Multivariate analysis indicated that duration of surgery (odds ratio [OR]: 1. 35 per 15 minutes) and bilateral TJA (OR: 2. 97) increase the risk of allogeneic blood transfusion, while patients having total knee arthroplasty are less likely to receive allogeneic blood transfusion (OR: 0. 50). CBL also increased significantly with surgical duration (211. 5 mL per 15 minutes). Conclusion: A subgroup analysis confirmed that there was a correlation between operative time and need for allogeneic transfusion following unilateral TJA. Expeditious surgery can minimize blood loss and subsequent need for blood transfusion and its associated adverse consequences.

Background: Distribution of radiographic images in the outpatient setting on compact discs-recordable (CD-R) is commonplace. Opening, manipulating and interpreting these can be challenging. This study evaluated the availability and ease of use of CD-R to evaluate digital images in an outpatient orthopedic setting. Methods: 118 CD-R containing diagnostic studies were evaluated by seven board certified orthopaedic surgeons. Surgeon age and self-perceived “ tech savvy” scores were tabulated using a visual analog scale (VAS). Surgeons evaluated: ability and number of computers to open, autorun, and specific reader software. Time to load was recorded in seconds, type of study, presence of “ not for diagnostic use” , and if the disc required additional software. Studies were graded using a VAS for ease of opening, ability to move from image to image and/or between series, to manipulate the image, and to zoom and pan. Results: There were 79 radiographs, 29 MRI’ s, and 10 CT scans. Seven (6%) had to be manually opened and four (3%) required software installation. Thirteen (11%) contained a warning that the studies should not be used for diagnostic purposes. Six (5%) of the studies could not be opened. For the opened studies, average time from disk insertion to image was 43. 7 seconds overall (range 3-350), 65. 3 seconds (range 21-191) for MRI and CT, and 35. 2 seconds (range 5-177) for radiographs. Conclusion: The present digital imaging systems include different software types and a variety of interfaces. Improving this would decrease time and effort necessary to open and evaluate these studies, and improve efficiency.

Background: Reconstructions of acute acromioclavicular (AC) dislocations have been thought to result in superior outcomes than chronic dislocations. The use of tendon graft in reconstructions has demonstrated favorable biomechanical properties. To determine whether utilizing tendon graft during repair of acute AC dislocations results in superior outcomes and lower complication rate. Methods: A retrospective review of AC reconstructions was conducted. Reconstructions performed within 3 weeks of injury were included. Inclusion criteria included age over 18, grade 3-5 AC joint separation, and no previous ipsilateral shoulder injury. Primary outcome measure was radiographic loss of reduction. Secondary outcomes included ASES and SANE scores. Results: Of 47 reconstructions of acute AC joint separations, 35 utilized fixation without a tendon graft, while 12 underwent an anatomic reconstruction with tendon graft. Repairs without the use of graft resulted in 8 (23%) cases of loss of reduction, while tendon graft augmented repairs resulted in 5 (42%). This difference was not statistically significant (P = 0. 22). No patients required reoperation. There was no statistical difference in the ASES and SANE scores between the two groups. Furthermore, we found no significant difference in ASES or SANE scores in patients who maintained reduction postoperatively versus those that lost reduction. Conclusion: A greater but not statistically significant rate of loss of reduction was observed in the group reconstructed with the use of a tendon graft. Further research is needed to determine whether the use of tendon graft is beneficial in the treatment of acute AC joint separations.

Background: Several studies have identified the radial nerve in arm using different anatomic landmarks, however, a controversy remains. Deltoid tuberosity (DT) and brachioradialis (BR) are reproducible landmarks that can be used to identify the radial nerve (RN) during fracture surgery. Methods: Dissection of RN was carried out in 17 fresh frozen adult cadavers. Using a calibrated caliper, we measured the distance between DT and the origin of BR. The distance between DT and where RN becomes lateral in its relationship with the humerus (DT-RN) and the distance between RN and BR (RN-BR) were subsequently measured. The ratio of DT-RN to DT-BR was calculated to see where the nerve lies in relationship to DT-BR. Results: Average DT-BR was 81. 8 (± 14. 86) mm, average DT-RN was 48. 9 (± 7. 83) mm, and average RN-BR was 33. 0 (± 10. 16) mm. RN was always found posterior to DT and was never found in the proximal third of DT-BR. The nerve was found in the middle third of DT-BR in 14 of 17 cadavers (82. 4 %) and in the distal third in 3 out of 17 cadavers (17. 6%). 16 of 17 cadavers (94%) had radial nerve in the distal half of DT-BR. Conclusion: Using the anatomic relationships between RN, DT, and the origin of BR, identification of RN is easily reproducible. These two structures can serve as the stationary landmarks during fracture surgery to find the radial nerve, which can be found in the distal 2/3 of the distance between the deltoid tuberosity and the origin of brachioradialis.

Background: The purpose of this retrospective study was to analyze the long-term results of revision ORIF, joint contracture release, and autogenous bone-grafting in the treatment of distal humerus frac-ture nonunions in older aged patients with poor bone quality or bone loss who would have been candidates for total elbow arthroplasty. Methods: Seven patients (average age at index procedure: 53. 3 years, range: 41-75) with a distal humerus fracture nonunion treated with revision ORIF, joint contracture release and autogenous bone grafting between 1989-2000 were available for follow-up. Radiographic union and arthrosis were assessed using the most recent radiograph. Pain-related outcomes were measured using PROMIS Pain Interference scores. Functional outcomes were evaluated using the Mayo Elbow Perfor-mance Index (MEPI). Results: After an average follow-up of 22 years (range: 19-27 years), all nonunions were healed after the index procedure and had an average arc of ulnohumeral motion of 80° , flexion of 112° , and flex-ion contracture of 32° . Average arthrosis grade was moderate joint-space narrowing with osteo-phyte formation. One patient had exertional discomfort but none required chronic pain medica-tions. PROMIS-Pain Interference scores were no different than the general population (mean [95%CI] = 49. 2 [41. 8, 56. 6], P=0. 83). Per the MEPI, the functional result was excellent in five patients, good in one, and poor in one. Conclusion: Despite older age and worse bone quality, distal humerus fracture nonunions can be treated using revision ORIF, joint contracture release and autogenous bone-grafting with acceptable long-term outcomes.

Background: The purpose of this study was to assess the incidence and importance of bony bridge that covers the supra scapular notch during posterior approach to transfer accessory nerve to suprascapular nerve. Methods: Between 2010 and 2015, the frequency and importance of suprascapular bony bridge instead of transverse ligament was assessed among patients with brachial plexus injury candidate to shoulder function restoration by accessory to suprascapular nerve transfer through posterior approach. Results: Forty three patients, 41 male and 2 female, (mean age: 32. 5 years, range 14 to 36) were included in this study. Five male patients (11. 6%) had a complete bony rim on the superior scapular notch. Suprascapular nerve release needed osteotomy of the bony bridge and related equipment. Conclusion: Although all previous cadaveric studies among different ethnic groups had reported the prevalence between 0. 3 to 30% of suprascapular canal, this in vivo study showed the incidence of 11. 6%. Preoperative alertness about this variation could make the exploration and release of the suprascapular nerve easier and reduce the risk of nerve injury or failing to anatomize it.

Background: The alternative surgery for massive and irreparable shoulder rotator cuff tears in older patients is the debridement of subacromial bursa, biceps tenotomy, and tuberoplasty (reverse acromioplasty). This study aimed to report the effectiveness of such a treatment performed arthroscopically in a small group of patients for a short period of time. Methods: This prospective study was conducted on 12 patients with massive irreparable rotator cuff tear during 2014-2017. Participants with the mean age of 65 were subjected to arthroscopic debridement of subacromial bursa, necrotic rotator cuff tendon remnants, and tuberoplasty without coracoacromial ligament excision. The sign and symptoms of patients before and after the surgery were evaluated based on Modified-University of California at Los Angeles (UCLA) Shoulder Score. Results: With the mean follow-up of 18 months (12-24 months), the mean of the modified UCLA score improved from 9. 2 to 27. 5. The obtained results of the study revealed that the pain and range of motion improved to near normal in the participants. The functional outcome was good although there were a decrease of acromiohumeral distance from 5 to 4 mm and a slight increase in degenerative changes. Conclusion: This simple arthroscopic procedure is recommended for massive irreparable rotator cuff tear, especially in elderly patients.

Background: One of the major challenges in orthopedic surgery is the prevention of arthrofibrosis, which can be successfully alleviated in its early stages. Many studies suggest the administration of methylene blue (MB) as an accessible and effective agent for the prevention of post-operation adhesions. The purpose of this study was to evaluate the efficacy of MB in the prevention of arthrofibrosis. Methods: This study was conducted on 18 New Zealand white female mature rabbits. The anterior cruciate ligament of the left stifle joint of each animal was cut during aseptic surgery. In the next step, the rabbits were divided into three groups based on their treatments. The rabbits in the first, second, and third groups were subjected to the injection of normal saline, 1% MB solution, and 2% MB solution into their synovial space, respectively. The postoperative stifle range of motion was measured every week. After 4 weeks, the animals were euthanized and all joints were dissected for histopathology. Results: The histopathological evaluation of tissues indicated the presence of fibrotic connective tissue as a sign of fibrosis in all groups. The fibrosis rate, inflammatory rate, tissue disarrangement, fibroblastic cellularity, and granulation tissue formation were at their highest levels in the 1% MB group. The integrity of articular cartilage in the 2% MB group was lower than the other groups. The level of bone degeneration was similar in both MB groups; however, it was more than the control saline group. The range of motion was reduced during the first week, then increased in the second and third weeks, and finally decreased in the fourth week. Conclusion: The MB was not an effective method regarding the prevention or treatment of arthofibrosis and the subsequent osteoarthritis. In contrast with previous studies, fibrosis was lower in the high dose MB group, compared to the low dose MB group. The alterations in the range of motion were related to the reduced movement caused by the pain and stiffness of the operated joints. The current study can be considered as the first report addressing the adverse effect of MB on synovial components.

Background: Hamstring tendons are secondary hip extensors. Their harvest for graft in anterior cruciate ligament (ACL) reconstruction may create deleterious effect on hip extension strength. This is of particular importance in sports that need powerful hip extension force like climbing and sprinting. Due to scarcity of a comprehensive study in this area, we designed this prospective study to evaluate hip extension strength following ACL reconstruction using different types of grafts. Methods: Fifty eight patients were enrolled in this prospective non-randomized case control study to compare isokinetic hip extension strength following ACL reconstruction with different graft types. Twenty patients in group A (both Semitendinosus and Gracilis tendons autograft (ST-G)), 14 patients in group B (Tibialis Posterior tendon allograft (Allograft)), 12 patients in group C (bone-patellar tendon-bone autograft (BPTB)) and 12 patients in group D (only semitendinosus autograft (ST)) were studied. Hip extension strength was tested post-operatively at three-and six-month periods using a Biodex isokinetic testing machine at a speed of 30 degree per second in operated (cases) and non-operated (controls) limbs. Results: There was a significant increase in hip extension force between three and six month intervals in all four groups and in both operated (case) and non-operated (control) limbs (P<0. 05, 95% CI). However, there was more increase in case limbs in comparison to control limbs. There was no significant difference in hip extension strength among all four groups (both in case and control limbs) in the third-and the sixth-month post-operative tests. Conclusion: Graft type had no effect on hip extension strength following ACL reconstruction, and the harvest of one or both hamstrings had no deleterious effect on hip extension force.

Background: The pelvic ring fractures (PRF) and acetabular fractures (AF) are among the major orthopedic injuries associated with high rates of morbidity and mortality. Open surgical stabilization is the standard treatment for the majority of these complications. Percutaneous minimally invasive surgical stabilization of the fractures has become an accepted treatment method for the past several years. This study investigated the outcomes of percutaneous fixation of pelvic and acetabular fractures. Methods: Totally, 143 patients with PRF or AF of whom 95 cases were males underwent percutaneous fixation between February 2015 and September 2016. All the operations were performed by a single surgeon in a supine position and under C-arm fluoroscopy visualization. The patients were followed up for one year. Results: All the fractures healed in all of the patients within the first postoperative three months. The patients could bear weight completely on both lower limbs. Out of 143 patients, 133 cases could get back to their preoperative work (93%). The mean amount of intraoperative blood loss was 29± 19 cc. Of the total patients, seven cases required oral analgesics because of moderate pain (4. 9%). The means of operation time and length of incision were 32± 8 min and 3. 2± 2. 4 cm, respectively. There was one screw back out and one deep infection. No neurovascular injury was reported in this study. Conclusion: Closed reduction and percutaneous minimally invasive screw fixation for a pelvic ring or acetabular fractures is a useful surgical treatment option with low complication rates.

Background: Foot function index (FFI) is a worthy subjective patient reported outcome measures (PROM) tool for evaluation of the outcomes of medical interventions on foot and ankle. This study was conducted to assess the validity of the Persian version of the foot function index (FFI). Methods: After translating the original FFI into Persian, back-translation was performed on the agreed Persian version and the final version was established. A total of 113 Persian-speaking patients with foot and ankle problems were enrolled in this study and were asked to fill in the FFI. Results: The Cronbach’ s alpha for subsections of FFI and MOXFQ was above 0. 8 and 0. 7, respectively, while it was 0. 95 and 0. 93 for total FFI and MOXFQ, respectively. The ICC for all subsections of MOXFQ and FFI was above 0. 7. The Pearson’ s correlation coefficient for all subsections of FFI and MOXFQ was significant (P<0. 01). Conclusion: The Persian version of FFI is valid and reproducible in Persian speaking population.

Background: Anterior cruciate ligament (ACL) reconstruction using tendon or ligament autograft is the current gold standard surgical technique for acute ACL ruptures. However, ACL repair surgical procedures are reappearing as an optimistic treatment alternative for acute proximal ruptures. The purpose of this annotation is to review the current role of primary repair of the ACL. Methods: A Cochrane Library and PubMed (MEDLINE) search related to the role of ACL repair in acute ACL rupture was analyzed. Results: Arthroscopic ACL repair can accomplish good short-run outcomes with knee stability and resumption of sport activity in children, with proximal ACL avulsion tear. Reported results of open primary repair in adult patients with proximal tears are excellent, which ratifies there may be a possible role for primary repair as management for proximal ACL tears. Conclusion: Recent reports suggest that refixation of the ACL is a possible treatment alternative in selected patients. Only time will tell whether the long-run results are similar to those obtained following ACL reconstruction.

Dear Editor Technology is quickly progressing; accordingly, social media, web, and mobile technologies are increasingly used by physicians and healthcare employers. Today, social networks, including Facebook, Twitter, and Instagram, are widely used by people from all different walks of life. Moreover, these increasingly popular social networks are used by the public, professionals, and medical students to acquire and share information. Based on studies in the United States, the prevalence rate of social network application was approximately 78% among the internet users in 2016. Smartphones and social networks are highly popular in developing countries similar to other parts of the world. Social networks have a huge impact on the perception of health system problems, acquisition and exchange of health-related information, and personal experience sharing...