Musculoskeletal complications of hemophilia

The most important clinical strategy for management of patients with hemophilia is the avoidance of recurrent hemarthroses by means of continuous, intravenous hematological prophylaxis. When only intravenous on-demand hematological treatment is available, frequent evaluations are necessary for the early diagnosis and treatment of episodes of intra-articular bleeding. The natural history of the disease in patients with poorly controlled intra-articular bleeding is the development of chronic synovitis and, later, multi-articular hemophilic arthropathy. Once arthropathy develops, the functional prognosis is poor. Treatment of these patients should be conducted through a comprehensive program by a multidisciplinary hemophilia unit. Although continuous prophylaxis can avoid the development of the orthopedic complications of hemophilia still seen in the twenty-first century, such a goal has not, so far, been achieved even in developed countries. Therefore, many different surgical procedures such as arthrocentesis, radiosynoviorthesis (radiosynovectomy) (yttrium-90, rhenium-186), tendon lengthenings, alignment osteotomies, joint arthroplasties, removal of pseudotumours, and fixation of fractures are still frequently needed in the care of these patients.

Instability following total knee arthroplasty

Background Knee prosthesis instability (KPI) is a frequent cause of failure of total knee arthroplasty. Moreover, the degree of constraint required to achieve immediate and long-term stability in total knee arthroplasty (TKA) is frequently debated. Questions This review aims to define the problem, analyze risk factors, and review strategies for prevention and treatment of KPI. Methods A PubMed (MEDLINE) search of the years 2000 to 2010 was performed using two key words: TKA and instability. One hundred and sixty-five initial articles were identified. The most important (17) articles as judged by the author were selected for this review. The main criteria for selection were that the articles addressed and provided solutions to the diagnosis and treatment of KPI. Results Patient-related risk factors predisposing to post-operative instability include deformity requiring a large surgical correction and aggressive ligament release, general or regional neuromuscular pathology, and hip or foot deformities. KPI can be prevented in most cases with appropriate selection of implants and good surgical technique. When ligament instability is anticipated post-operatively, the need for implants with a greater degree of constraint should be anticipated. In patients without significant varus or valgus malalignment and without significant flexion contracture, the posterior cruciate ligament (PCL) can be retained. However, the PCL should be sacrificed when deformity exists particularly in patients with rheumatoid arthritis, previous patellectomy, previous high tibial osteotomy or distal femoral osteotomy, and posttraumatic osteoarthritis with disruption of the PCL. In most cases, KPI requires revision surgery. Successful outcomes can only be obtained if the cause of KPI is identified and addressed. Conclusions Instability following TKA is a common cause of the need for revision. Typically, knees with deformity, rheumatoid arthritis, previous patellectomy or high tibial osteotomy, and posttraumatic arthritis carry higher risks of post-operative instability and are indications for more constrained TKA designs. Instability following TKA usually requires revision surgery which must address the cause of the instability for success.

Intra-articular Injections of Hyaluronic Acid and Other Drugs in the Knee Joint

BACKGROUND

Degenerative osteoarthritis of the knee (OA) affects 35% of persons older than 65 years. If pain persists after non-invasive treatment, some intra-articular drugs can be tried before surgical treatment.

QUESTIONS/PURPOSES

The purpose of this article is to review the literature after 2006 with the aim of answering two questions: (1) Are intra-articular injections of corticosteroids (CS), hyaluronic acid (HA) and platelet-rich plasma (PRP) effective in painful knee OA? and (2) Which of these drugs is more effective?

METHODS

The search engines were MedLine and the Cochrane Library. The keywords used were: knee, osteoarthritis, and intra-articular injections. Eight hundred and forty-four articles were found but only 142 had been published after 2006. Of those, only 14 were selected and reviewed because they were strictly focused on the topic and the questions of this article.

RESULTS

The clinical efficacy of intra-articular injections of HA and CS in patients with knee OA has been demonstrated. Pain reduction after three to five weekly injections of HA lasts between 5 to13 weeks (sometimes up to 1 year). Pain reduction is less durable after CS injections (2 to 3 weeks). Recent reports indicate that PRP could have a better performance than HA in younger patients.

CONCLUSIONS

Three to five weekly intra-articular injections of HA are recommendable in patients with knee OA before surgical treatment. CS injections have a very short effect. The efficacy and duration of PRP injections require further studies.

Orthopedic disorders of the knee in hemophilia: A current concept review

The knee is frequently affected by severe orthopedic changes known as hemophilic arthropathy (HA) in patients with deficiency of coagulation factor VIII or IX and thus this manuscript seeks to present a current perspective of the role of the orthopedic surgeon in the management of these problems. Lifelong factor replacement therapy (FRT) is optimal to prevent HA, however adherence to this regerous treatment is challenging leading to breakthrough bleeding. In patients with chronic hemophilic synovitis, the prelude to HA, radiosynovectomy (RS) is the optimal to ameliorate bleeding. Surgery in people with hemophilia (PWH) is associated with a high risk of bleeding and infection, and must be performed with FRT. A coordinated effort including orthopedic surgeons, hematologists, physical medicine and rehabilitation physicians, physiotherapists and other team members is key to optimal outcomes. Ideally, orthopedic procedures should be performed in specialized hospitals with experienced teams. Until we are able to prevent orthopedic problems of the knee in PWH will have to continue performing orthopedic procedures (arthrocentesis, RS, arthroscopic synovectomy, hamstring release, arthroscopic debridement, alignment osteotomy, and total knee arthroplasty). By using the aforementioned procedures, the quality of life of PWH will be improved.

Analysis of the variables affecting outcome in fractures of the tibial pilon treated by open reduction and internal fixation

OBJECTIVE

To assess variables that could be related to outcomes in fractures of the tibial pilon treated by open reduction and internal fixation (ORIF).

DESIGN

Retrospective.

SETTING

University Hospital.

PATIENTS

A total 92 fractures of the tibial pilon treated by ORIF in a 5-year period. The minimum follow-up was 1 year (mean: 3.3 years; range: 1-5).

INTERVENTION

ORIF with LCP-LISS plate.

PRIMARY OUTCOME MEASUREMENTS

Age, sex, side, type of fracture, energy of the injury, provisional external fixation (EF), time until ORIF, stages of treatment (one or two), surgical approach, type of bone fixation, quality of reduction, bone graft, hardware removal, associated fractures (fibula and others), functional results (AOFAS scale), rates of infection, skin necrosis, flap coverage, non-union, and early posttraumatic ankle osteoarthritis (AOA).

RESULTS

According to AOFAS scale 30.5% of results were excellent, 46.7% good, 13.1% fair and 9.7% poor. Overall, the rate of infection was 13.04%, The rate of non-union was 10.86%. The rate of skin necrosis was 7.6% and the rate of flap coverage was 13.04%. The rate of early posttraumatic AOA was 13.04%. Type 43C3 fractures of the AO classification had a higher rate of skin necrosis and flap coverage. Open fractures were related to a higher prevalence of nonunion and flap coverage. The use of a bone graft was associated with a higher rate of nonunion and poor results. Infection was related to a higher prevalence of fair and poor results. EF was associated with a higher need for flap coverage. A suboptimal anatomic reduction was related to a higher rate of fair and poor results. The anteromedial approach was associated with a higher prevalence of skin necrosis and early posttraumatic AOA than the anterolateral approach. The use of an medial plate was related to a higher rate of nonunion than the use of a lateral plate.

CONCLUSIONS

The anteromedial approach was associated with a higher rate of skin necrosis and posttraumatic AOA than the anterolateral approach. Medial plating had a higher prevalence of nonunion than lateral plating.

LEVEL OF EVIDENCE

IV (case series).

The Influence of Obesity on the Outcome of TKR: Can the Impact of Obesity be justified from the Viewpoint of the Overall Health Care System?

BACKGROUND

There is controversy in the literature regarding the justification of performing total knee replacement (TKR) in obese patients in view of their increased risk of poor outcomes and how those poorer outcomes impact the health care system overall.

QUESTIONS/PURPOSES

Is TKR justifiable in the obese patient? Can the negative impact of continuing to perform TKR in the obese be quantified?

METHODS

A Cochrane Library, PubMed (MEDLINE), and Google Scholar search related to the justification of TKR in the obese patient and its impact on the health care system was analyzed. The main criteria for selection were that the articles were focused in the aforementioned questions.

RESULTS

Two thousand one hundred seventy-three articles were found, but only 50 were selected and reviewed because they were focused on the questions of this paper. Although some articles (with low grade of evidence) did not find that obesity adversely affected the outcome of TKR, most of them found that obesity adversely affected the results of TKR. Regarding complications rates and survival rates, obesity has shown to have a negative influence on outcome after TKR. The improvements in patient-reported outcome measures, however, were similar irrespective of body mass index. Regarding the impact of TKR in obese patients, an extra cost of US$3,050 has been reported per patient. Considering that 50% of the US population is obese and that 600,000 TKRs are implanted per year, the impact for the US health system could be as much as 915 million dollars (300,000 × 3,050).

CONCLUSION

TKR in obese patients may be justifiable because the functional improvements appear equivalent to those of patients with a lower BMI. However, in obese patients, the risk of complications is higher and the prosthetic survival is lower. Moreover, TKR in obese patients has a huge impact on the health system which should be considered.

Point-of-care Ultrasonography in Orthopedic Management of Hemophilia: Multiple Uses of an Effective Tool

Even in our current era of hemophilia prophylaxis, articular complications can arise and there is a growing need for strategies in the prevention, diagnosis, and treatment of hemophilic arthropathy, a significant contributor to disability in patients with hemophilia. One useful tool, point-of-care ultrasonography (POC-US), offers diverse diagnostic and therapeutic possibilities. This article reviews the literature on the uses of POC-US in hemophilia, including early diagnosis of joint damage, differential diagnosis of articular pain, follow-up of joint injury, and guidance for both arthrocentesis and intra-articular injection. Studies show that for patients with hemophilia, POC-US enhances diagnostic accuracy and targeted treatments. Further research is required into the most efficient use of POC-US and the training needed to develop clinicians' skills. The attributes of POC-US should be understood more fully to enable its widespread application.

Surgical treatment of isolated patellofemoral osteoarthritis

BACKGROUND

Isolated patellofemoral (PF) osteoarthritis (OA) affects 9% of persons older than 40 years. Nonoperative treatment should be exhausted fully before surgical treatment.

QUESTIONS/PURPOSES

The purpose of this article is to review the literature after 2008 with the aim of answering the following question: Which of the following surgical procedures has the highest survival rate and the lowest revision rate in advanced isolated PF OA: patellofemoral arthroplasty (PFA), total knee arthroplasty (TKA) or lateral facetectomy.

METHODS

The search engine was MedLine. The keywords used were: PF OA and PFA. Three hundred and fifty-three articles were found between 2008 and 25 July 2013. Of those, only 23 were selected and reviewed because they were strictly focused on the topic and the question of this article.

RESULTS

The types of studies reported so far have a low level of evidence (levels III and IV). Most of them are prospective case series (level IV). Some are systematic reviews of level III studies. Reported survival rate of lateral facetectomy is 85% at 5 years, 67% at 10 years and 47% at 20 years. Reported failure rate of lateral facetectomy is 26% at 10 years and 16% at 12 years. The reported average time of reoperation is 8 years and 37% of such procedures fail. Survival rate of PFA has been reported to be 87.5% on average (range, 60-100%). The revision rate of PFA is 20%. Recent improvements in PFA design have resulted in improvements in short-and medium-term results, similar to those of TKA.

CONCLUSIONS

There is still no gold standard for the surgical treatment of isolated PF OA. However, PFA or TKA appear to be the most recommendable treatment in cases that do not respond to conservative treatment.

Single Local Infiltration Analgesia (LIA) Aids Early Pain Management After Total Knee Replacement (TKR): An Evidence-Based Review and Commentary

BACKGROUND

There is controversy in the literature regarding the role of single local infiltration analgesia (LIA) after total knee replacement (TKR).

QUESTIONS/PURPOSES

Is single LIA really efficient in controlling pain after TKR?

METHODS

A Cochrane Library and PubMed (MEDLINE) search related to the justification LIA after TKR was analyzed. The main criteria for selection were that the articles were focused in the aforementioned question.

RESULTS

Two hundred ninety-nine articles were found until February 9, 2017, but only 27 were selected and reviewed because they were focused on clinical experience with LIA following TKR. Fifteen of them were considered level of evidence (I-II) while 12 had a lower level of evidence (III-IV). LIA reduced the amount of perioperative opioid administration and enabled adequate pain management in conjunction with oral medication without adverse effects. No clinically marked effects on the functional outcome after TKR were detected.

CONCLUSION

Single dose LIA provides effective analgesia in the initial postoperative period after TKR in most randomized clinical trials, systematic reviews, and meta-analyses.

Intra-articular Tranexamic Acid in Primary Total Knee Arthroplasty Decreases the Rate of Post-operative Blood Transfusions in People with Hemophilia: A Retrospective Case-Control Study

BACKGROUND

Blood transfusion rates after total knee arthroplasty (TKA) in patients without hemophilia have diminished with the use of a standardized multimodal blood loss prevention method (MBLPM) that includes intra-articular tranexamic acid (TXA) (MBLPM-TXA). However, the topic has not been addressed in people with hemophilia.

QUESTIONS/PURPOSES

Our aim was to investigate whether the MBLPM-TXA prevents blood loss in patients with hemophilia A who undergo TKA, thereby decreasing the need for post-operative blood transfusion.

METHODS

This retrospective case-control comparative study involved 30 TKA patients who had a severe degree of hemophilia A without inhibitions: one group treated with the MBLPM-TXA (n = 15) and a second group treated without it (n = 15). In all cases, the pre-operative hemoglobin level was greater than 13 g/dL.

RESULTS

The MBLPM-TXA group had a transfusion rate of zero, whereas 46.6% of the patients (seven of 15) in the non-MBLPM-TXA group needed transfusion.

CONCLUSION

This retrospective case-control study showed that the use of an MBLPM-TXA in patients with hemophilia A who underwent TKA was effective in reducing rates of transfusion. We recommend its use.

Opioid-Free Total Knee Arthroplasty? Local Infiltration Analgesia Plus Multimodal Blood-Loss Prevention Make it Possible

Opioids have been widely used in the USA for pain control after total knee arthroplasty (TKA). However, adverse effects, especially the possibility of addiction, have increased interest in opioid-free pain management after surgery. We therefore sought to review current pain management protocols after TKA, focusing especially on opioid-free alternatives. We reviewed the literature on pain management after TKA using Medline (PubMed), through June 30, 2018, using the keywords "TKA" and "analgesia." We found 388 articles but chose to analyze the 34 that presented high-quality (levels I and II) evidence. Local infiltration analgesia (LIA) is a good option for reducing the use of post-operative opioids; many reports have compared LIA against a nerve block or studied the synergies between two protocols of loco-regional anesthesia. Multimodal blood-loss prevention is sometimes recommended in combination with opioid-free analgesia. In most studies, however, no differences are reported or contradictory results exist. Post-operative pain management protocols vary so much that it is difficult to strongly favor a determined pathway.

Patient Satisfaction Following Primary Total Knee Arthroplasty: Contributing Factors

The reported dissatisfaction rate after primary total knee arthroplasty (TKA) ranges between 15% and 25%. The purpose of this article is to perform a narrative review of the literature with the aim of answering the following question: What are the main factors contributing to patient dissatisfaction after TKA? A review of the literature was performed on patient satisfaction after TKA. The search engines used were MedLine (PubMed) and the Cochrane Library. The keywords used were "TKA" and "satisfaction". The main reported preoperative factors positively contributing to patient satisfaction were the following: fulfilment of preoperative expectations, preoperative complete joint space collapse, increasing patellar and lateral compartment osteophyte size, and TKA communication checklist. The principal preoperative factors negatively contributing to patient satisfaction included female sex, comorbidities, and Hispanic race. The chief perioperative factor positively contributing to patient satisfaction was cosmetic closure, whereas the fundamental perioperative factors negatively contributing to patient satisfaction included joint laxity, anterior tibial component slope, and greater femoral component valgus angle. The principal postoperative factors positively contributing to patient satisfaction were the following: ameliorated walking distance, improved range of motion, and improvements in pain. The most important postoperative factors negatively contributing to patient satisfaction included poor postoperative knee stability and soft-tissue balance, functional limitation, surgical complication and reoperation, staff or quality of care issues, and increased stiffness.

Orthobiologics: Current role in Orthopedic Surgery and Traumatology

Orthobiologics are organic and synthetic materials that help in the cure of musculo-skeletal problems and are utilized in Orthopaedic Surgery, both in and out of the surgical theater, to augment the possibilities of curing bone and soft tissue lesions. Taking into account that their effect is frequently multifactorial and, in some occasions not entirely comprehended, together with the insufficient clinical information, orthobiologics should be scrupulously assessed against other secure and clinically accepted options. The fundamental orthobiologics today ready for use in Orthopedic Surgery are the following: osseous hollow fillers, extracellular matrix (ECM) substances, platelet-rich plasma (PRP), bone morphogenetic protein-2 (BMP-2), bone marrow aspirate (BMA), bone marrow aspirate concentrate (BMAC), and mesenchymal stem cells (MSCs). It is predictable that in the time to come we will have more secure and more efficacious orthobiologics. Meanwhile, it is paramount that orthopedic surgeons have appropriate information of contemporary orthobiologics (biological adjuvants) so that they can utilize them correctly.

Return to Sport Activities and Risk of Reinjury Following Primary Anterior Cruciate Ligament Reconstruction

This article examines the elements that affect the return to sport (RTS) and the risk and percentages of reinjury following a prior primary anterior cruciate ligament reconstruction (ACLR). The prevalence of RTS following ACLR ranges from 71% to 83%. Concerning elements affecting RTS, a limb symmetry index score of 90 or more duplicates the likelihood of RTS and triplicates it when the International Knee Documentation Committee (IKDC) score is 95 or more, irrespective of age. Other elements recognized to be preindicative of RTS at 1 year include complete rehabilitation, age ≤25, and higher IKDC scores. The prevalence of reinjury following ACLR ranges from 1.5% to 37.5% (between 9% and 29% in the majority of reports). It has been published that 1 in 5 individuals suffers reinjury to either knee, and that male individuals are more prone to reinjure following ACLR. The highest percentage of ACLR reinjury happens in younger male (<18 years), being substantially higher than in female of the same age. Passing a combination of functional tests with predetermined cut-off points utilized as RTS criteria are related diminished ACLR reinjury percentages.

Knee Osteoarthritis Following Anterior Cruciate Ligament Reconstruction: Frequency, Contributory Elements, and Recent Interventions to Modify the Route of Degeneration

Half of the individuals who experience an anterior cruciate ligament reconstruction (ACLR) suffer from knee osteoarthritis (OA) 12-14 years later. Elements that make a contribution to the appearance of OA following ACLR are anomalous anterior tibial displacement and anomalous tibial rotation in the course of the stance phase of walking (exhibited in 85% of operated knees). Individuals who undergo an early ACLR (5 days on average following anterior cruciate ligament [ACL] breakage) have an inferior frequency of radiographically apparent tibiofemoral OA at 32-37 years of follow-up than individuals with ACL rupture who did not experience the procedure. Nevertheless, the percentage of symptomatic OA, radiographically apparent patellofemoral OA and knee symptoms are alike in both groups. At 15 years of follow-up, 23% of knees that experienced an anatomic ACLR suffer from OA, while this percentage augments to 44% if the ACLR was non-anatomic. Knees of individuals who experience ACLR need total knee arthroplasty at an earlier age than healthy knees. Intra-articular injections of interleukin-1 receptor antagonist and corticosteroids may reduce the risk of OA after ACLR.

The Current Role of Ankle Arthrodesis in Hemophilic Patients

There are several manners to take care of the hemophilic ankle in the initial phases of degeneration of the articular cartilage, in the event that hematologic prophylaxis is unsuccessful in accomplishing no bleeds. Some of these are nonoperative, with which management must start. These are Physical and Rehabilitation Medicine protocols and the utilization of orthoses (patellar tendon bearing). When these are unsuccessful, more aggressive types of treatment can be utilized, such as radiosynovectomy and some surgical operations (open or arthroscopic removal of anterior osteophyte of the distal part of the tibia, arthroscopic ankle debridement). Nonetheless, in the late phases of degeneration of the articular cartilage (advanced arthropathy), the solely options are surgical: ankle fusion or total ankle arthroplasty. The review of the literature has shown that the percentage of consolidation is between 90% and 100%, and that the percentage of postoperative infection is between 0% and 10%%. When the Ilizarov external fixator is utilized for ankle fusion, the percentage of pin tract infection is around 14%. Ankle fusion is a secure surgical technique that meliorates articular pain and improves the quality of life of hemophilic patients.

Correction to: Opioid-Free Total Knee Arthroplasty? Local Infiltration Analgesia Plus Multimodal Blood-Loss Prevention Make it Possible

[This corrects the article DOI: 10.1007/s11420-018-9636-2.].

Comparing the Results of Total Ankle Arthroplasty Vs Tibiotalar Fusion (Ankle Arthrodesis) in Patients with Ankle Osteoarthritis since 2006 to 2020- A Systematic Review

BACKGROUND

This study compares the outcomes of patients undergoing total ankle arthroplasty (TAA) and tibiotalar fusion (ankle arthrodesis) in patients with end-stage osteoarthritis. The primary outcome assessed was Patient Reported Outcome Measures (PROMS); secondary outcomes included the incidence of revision, re-operation, and complications.

METHODS

A systematic review of studies examining the outcomes of patients undergoing TAA and/or tibiotalar fusion from 2006 to 2020 was conducted. Individual cohort studies and randomized control trials were included. Outcomes were assessed at two and five years.

RESULTS

21 studies were included: 16 arthroplasty (2,016 patients) and 5 arthrodesis (256 patients) studies. No significant difference in PROMS was evident two years post-surgery - American Orthopaedic Foot and Ankle Society (AOFAS) scores were 78.8 (95% CI-confidence interval: 76.6-80.8; n=1548) and 80.8 (95% CI: 80.1-81.5; n=206 patients) for the arthroplasty and arthrodesis groups respectively. Two years post-surgery the revision rates for the arthroplasty and arthrodesis groups were similar - 3.5% (n=9) and 3.7% (n=61) respectively (OR-odds ratio: 1.05; 95% CI: 0.51-2.13); however, the re-operation rate was 2.5 times higher for the arthroplasty group (12.2%) in comparison to the arthrodesis group (5.1%) (OR: 2.57; 95% CI: 1.43-4.62). Documented complications in the arthroplasty group were half those documented in the arthrodesis group two years post-surgery (OR: 0.53; 95% CI: 0.37-0.77). No arthrodesis studies were found which contained mean 5-year follow-up data within the study period.

CONCLUSION

Despite recent developments in TAA design, we found no clear evidence as to their superiority over ankle arthrodesis when considering patient outcomes two years postoperatively. However, this conclusion could be debatable in some types of patients such as diabetic patients, posttraumatic patients and patients with stiff hindfoot and midfoot.

Elbow Arthroplasty: A Concise Literature Update

Total elbow arthroplasty (TEA) is increasingly used, especially in patients with rheumatoid arthritis (RA) and distal humerus fractures (DHFs). This narrative review of the recent literature published in 2022 reached the following conclusions: 1) Age greater than 80 is not a contraindication for TEA. 2) The estimated 10-year survival reported for linked TEAs is 92%, and unlinked TEAs 84%. 3) For DHFs in the elderly, regarding the flexion/extension arc, TEA gives substantially better results than open reduction and internal fixation (ORIF). The reoperation and elbow stiffness rates are substantially lower in TEA than in ORIF. 4) Comparing distal humeral hemiarthroplasty (DHH) vs. TEA in individuals over 65 years with a non-reconstructable DHF favors DHH regarding the range of motion but with a similarly high rate of adverse events in the two surgical techniques. 5) The rate of eradication of periprosthetic joint infection (PJI) is 69-76% with two-stage, 71% with resection arthroplasty, 67% with one-stage, 58% with DAIR, and 40% with elbow arthrodesis.

Intraosseous Regional Administration of Vancomycin Prophylaxis for Primary and Revision Total Knee Arthroplasty

The advantages of prophylaxis with intraosseous regional administration (IORA) of vancomycin for periprosthetic joint infection (PJI) in primary and revision total knee arthroplasty (TKA) include the ability to deliver antibiotics directly to the surgical bed and avert systemic delivery; the ability to precisely time and quickly administer vancomycin to achieve the highest concentrations at the beginning and throughout the surgical procedure; and the ability to avert several common and potentially serious adverse effects of intravenous vancomycin. Indications for IORA of vancomycin prophylaxis include the following clinical scenarios: revision TKA; obesity; diabetes; beta-lactam allergy; known colonization with methicillin-resistant Staphylococcus aureus (MRSA); individuals coming from institutions with a high MRSA incidence; previous ligamentous surgical procedure or osteotomy; current or recent smokers; in the primary TKA setting if the individual is considered high-risk as defined by the criteria above; and during reimplantation following 2-stage exchange for PJI.

The Role of Intraarticular Injections of Hyaluronic Acid and Platelet Rich Plasma for the Treatment of Articular Pain in Knee Osteoarthritis

The purpose of this in brief article was to determine the current role of intraarticular injections of hyaluronic acid (HA) and platelet-rich plasma (PRP) for the treatment of painful KOA. It has been reported that the average duration of effectiveness (pain relief) of one injection of extended-release HA is around one year. Kellgren-Lawrence grade (I-II versus III-IV), male gender, and older age are associated with a longer duration of effectiveness. Cartilage degeneration might be improved with a higher number of injections of HA. Intraarticular injections of HA alleviate pain, function, and diminish non-steroidal anti-inflammatory drugs (NSAIDs) consumption. In addition, several studies have indicated that the combination of HA and PRP is more effective than HA alone. Finally, other studies seemed to demonstrate that PRP was more effective than HA.

The Effect of Biomechanical Footwear on Pain from Knee Osteoarthritis

The effect of biomechanical footwear on pain from knee osteoarthritis (OA) is still unclear and controversial. The purpose of this article is to review the literature with the aim of answering the following question: What is the impact of biomechanical footwear on pain from knee OA? A Cochrane Library and PubMed (MEDLINE) search related to the effect of biomechanical footwear on pain from knee OA was performed. Several authors have reported knee pain alleviation in people with knee OA using biomechanical footwear. However, many of them have also stated that further investigation was required to evaluate its long-run effectiveness and safety, as well as replication, prior to reaching conclusions about the clinical value of this treatment. The cost of biomechanical footwear treatment is around 5,000 US dollars. Considering the weak evidence currently available on the efficacy of biomechanical footwear and its high cost, we do not advise the routine use of that treatment until it can be unequivocally confirmed that it is truly effective for pain alleviation in patients with knee OA.

Total Wrist Arthrodesis: An Update on Indications, Technique and Outcomes

Painful end-stage wrist osteoarthritis (OA) unresponsive to conservative treatment is frequently managed with total wrist arthrodesis (TWA), which might render pain alleviation and ameliorate function, pain, and grip strength. Usual indications for TWA include inflammatory arthritis, idiopathic degenerative OA and posttraumatic OA, Kienböck's illness, brachial plexus palsy, cerebral paralysis, infraclavicular brachial plexus blocks and other spastic and contracture base illnesses, scapholunate advanced collapse, scaphoid nonunion advanced collapse, and failure of other surgical techniques such as after failed total wrist arthroplasty, four-corner fusion, proximal row carpectomy and severe ligament injuries (this procedure is carried out when all other treatment alternatives have failed to control the individual's symptoms). TWA is commonly carried out with a dorsal plate fixed from the distal radius to the third metacarpal. However, other surgical procedures have been reported, including intramedullary fixation and new implants that do not cross the third carpometacarpal joint or some procedures without utilizing hardware for example using a vascularized fibular grafting In individuals with rheumatoid arthritis. TWA has been shown to give persistent and painless stability for 20 years or more. The rate of adverse events for TWA ranges from 0.1% to 6.1%, though some authors have published that it can be as high as 27%. The most common adverse events are tendon ruptures, peri-implant fractures of the third metacarpal, the need for hardware removal, and constant pain at the third carpometacarpal joint. In idiopathic degenerative OA, the reoperation rate following TWA has been reported as high as 63%. While TWA can render foreseeable pain alleviation and ameliorate function, orthopedic surgeons should remember that this surgical technique is not without its risks and that the accessibility of many surgical procedures requires orthopedic surgeons to scrupulously contemplate the risks and benefits of each alternative for the individual in front of them.