Utilization of Smartphone Technology and Wearable Technology Following TKA

The widespread adoption of smartphones and wearable technology has introduced innovative approaches in health care, particularly in postoperative rehabilitation. These technologies hold significant promise for improving recovery following lower extremity arthroplasty, especially total knee arthroplasty (TKA). Despite growing interest, the evidence on their effectiveness and long-term impact remains variable.This narrative review evaluates the utilization of smartphone applications, wearable devices, and their combined use in postoperative recovery after TKA. Key studies assessing adherence, functional outcomes, patient satisfaction, and health care utilization were analyzed to synthesize insights into their effectiveness compared to traditional rehabilitation approaches.Smartphone applications have demonstrated improvements in adherence to rehabilitation plans, pain management, and functional outcomes. For instance, interventions using text-based prompts or interactive platforms enhanced physical activity, reduced narcotic use, and improved patient-reported outcomes such as PROM adherence and range of motion (ROM). Similarly, wearable devices provided accurate feedback on activity levels and step counts, promoting early mobility and strength recovery. Combined approaches leveraging both technologies further enhanced adherence, functional recovery, and patient engagement while reducing health care utilization.The integration of smartphone and wearable technologies in TKA rehabilitation shows potential for improving recovery outcomes. While findings generally indicate noninferiority or superiority to conventional methods, limitations exist in standardization, data accuracy, and long-term benefits. Future research should focus on refining these technologies, establishing standardized guidelines, and evaluating their cost-effectiveness in diverse populations. Smartphone and wearable technologies represent safe and effective tools for enhancing postoperative outcomes in TKA patients. Their integration into clinical practice could optimize rehabilitation protocols, improve patient engagement, and potentially reduce health care costs.

Anatomical considerations, diagnosis, and treatment of medial and posterolateral elbow rotatory instability in athletes: an arthroscopic perspective and literature review

PURPOSE

Elbow joint instability results from the disruption of one or more stabilizing anatomical structures. The two most common forms of instability are posterolateral rotatory instability (PLRI) and medial elbow instability (MEI), particularly in athletes. This review aims to explore the anatomical foundations, diagnostic methods, and therapeutic approaches for PLRI and MEI in athletes.

METHODS

A comprehensive literature review was performed to investigate the study objective.

RESULTS

Regarding the anatomical background, the primary stabilizing structures of the elbow joint include the humeroulnar joint (trochlea, olecranon, and coronoid process), the medial collateral ligament (MCL), and the lateral ulnar collateral ligament (LUCL). PLRI is primarily caused by LUCL insufficiency, while MEI results from MCL dysfunction. A thorough clinical evaluation, combined with advanced imaging-magnetic resonance imaging (MRI) or MR arthrography is essential for an accurate diagnosis. For high-level athletes, surgical intervention is often required, with the timing and type of surgery tailored to the athlete's specific needs, expectations, and the chronicity of the injury.

CONCLUSION

PLRI and MEI present diagnostic and therapeutic challenges, especially in athletes. Advanced imaging and clinical evaluation are crucial for the diagnosis. Surgical intervention, particularly arthroscopy, is often required for optimal outcomes.

Decreased Association Between Patellar Axial Malalignment and Patellar Height and Increased Association Between Patellar Axial Malalignment and Tibial Tubercle-Trochlear Groove During Weightbearing

BACKGROUND

Nonweightbearing preoperative assessments avoid quadriceps contraction that tends to affect patellar motion and appear to be inaccurate in quantifying anatomic factors, which can lead to incorrect corrections and postoperative complications.

QUESTIONS/PURPOSES

(1) Does the relationship of patellar axial malalignment and other anatomic factors change during weightbearing? (2) What anatomic factor was most strongly correlated with recurrent patellar dislocation during weightbearing?

METHODS

This prospective, comparative, observational study recruited participants at our institution between January 2023 and September 2023. During this time, all patients with recurrent patellar dislocations received both weightbearing and nonweightbearing CT scans; control patients who received unilateral CT scans because of injuries or benign tumors received both weightbearing and nonweightbearing CT scans. Between January 2023 and September 2023, 52 patients were treated at our institution for patellar dislocation. We included those who had experienced at least two dislocations. The exclusion criteria were as follows: (1) traumatic dislocation, (2) prior knee surgery, (3) osteoarthritis (≥ Kellgren-Lawrence Grade 3), and (4) abnormal walking and standing postures confirmed by the orthopaedic surgeon and an inability to complete weightbearing CT with their body in a neutral position (meaning their body weight was evenly placed on both knees) because of severe pain. After applying prespecified exclusions, 63% (33 patients) of the original number were included, and data for 33 patients (65 knees) with weightbearing CT data and 28 patients (52 knees) with nonweightbearing CT data were obtained. Because of ethical requirements, the control group included patients who underwent unilateral CT scanning (for an injury or a benign tumor), and weightbearing CT and nonweightbearing CT covered both knees. Control knees were confirmed to have normal patellofemoral function by physical examination by an orthopaedic surgeon involved with the study. The control group consisted of the normal knees (52 knees underwent both weightbearing CT and nonweightbearing CT) and the affected but uninvolved knees (47 knees underwent weightbearing CT and 6 knees underwent nonweightbearing CT), and a total of 52 patients (99 knees) with weightbearing CT data and 31 patients (58 knees) with nonweightbearing CT data were included. There were no differences between the recurrent patellar dislocation and control groups in terms of gender, side, and BMI. Although the patients in the control group were older than those in the study group, most patients in both groups were at or at least near skeletal maturity. Patellofemoral measurements were evaluated with the Insall-Salvati ratio extension , Blackburne-Peel ratio extension , Caton-Deschamps ratio extension , bisect offset index, lateral patellar tilt angle, tibial tubercle-trochlear groove, lateral trochlear inclination, sulcus depth, and sulcus angle. Intraclass correlation coefficients (ICCs) for all these measurements were greater than or equal to 0.70 and so were considered adequate for reliability. The correlations between patellar axial malalignment and other anatomic factors during weightbearing and nonweightbearing were compared, and anatomic factors between weightbearing and nonweightbearing were compared to investigate the relationship of patellar axial malalignment and anatomic factors during weightbearing. The correlation between anatomic factors and recurrent patellar dislocation and the diagnostic performance of each factor for recurrent patellar dislocation were reported to find the anatomic factor that most strongly correlated with recurrent patellar dislocation during weightbearing.

RESULTS

We observed several changes in axial malalignment measurements that occurred with weightbearing. The correlation between bisect offset index and Blackburne-Peel ratio extension decreased with weightbearing compared with the nonweightbearing state (r = 0.12 [95% confidence interval (CI) -0.12 to 0.35] with weightbearing versus r = 0.58 [95% CI 0.36 to 0.75]; p = 0.003). The correlation between bisect offset index and Caton-Deschamps ratio extension decreased with weightbearing compared with the nonweightbearing state (r = 0.25 [95% CI 0.03 to 0.47] versus r = 0.68 [95% CI 0.49 to 0.82]; p = 0.002). The correlation between bisect offset index and tibial tubercle-trochlear groove distance increased with weightbearing compared with the nonweightbearing state (r = 0.63 [95% CI 0.43 to 0.78] versus r = 0.38 [95% CI 0.05 to 0.62]; p = 0.04). The correlation between lateral patellar tilt angle and Blackburne-Peel ratio extension decreased with weightbearing compared with the nonweightbearing state (r = 0.05 [95% CI -0.17 to 0.28] versus r = 0.44 [95% CI 0.21 to 0.63]; p = 0.02). The correlation between the lateral patellar tilt angle and Caton-Deschamps ratio extension decreased with the weightbearing compared with the nonweightbearing state (r = 0.16 [95% CI -0.09 to 0.40] versus r = 0.46 [95% CI 0.19 to 0.66]; p = 0.04). The correlation between lateral patellar tilt angle and tibial tubercle-trochlear groove distance increased with weightbearing compared with the nonweightbearing state (r = 0.64 [95% CI 0.48 to 0.76] versus r = 0.41 [95% CI 0.13 to 0.64]; p = 0.048). Several parameters changed with weightbearing. In both recurrent patellar dislocation and control groups, the Insall-Salvati ratio extension and the tibial tubercle-trochlear groove distance were lower with weightbearing compared with nonweightbearing (recurrent patellar dislocation/control: p = 0.001/p < 0.001 versus p = 0.006/p < 0.001); bisect offset index was higher with weightbearing compared with nonweightbearing (recurrent patellar dislocation/control: p < 0.001/p < 0.001). In the control group, the Blackburne-Peel ratio extension and the Caton-Deschamps ratio extension were lower with weightbearing compared with nonweightbearing (p = 0.01, p = 0.007). The anatomic factor most strongly correlated with recurrent patellar dislocation during weightbearing was the bisect offset index (r = 0.73 [95% CI 0.65 to 0.79]; p < 0.001). The anatomic factor most strongly correlated with recurrent patellar dislocation during nonweightbearing was the sulcus depth (r = -0.70 [95% CI -0.78 to -0.59]; p < 0.001). The ROC analysis showed that during weightbearing, the bisect offset index had the best diagnostic ability for recurrent patellar dislocation (area under the curve [AUC] 0.93 [95% CI 0.89 to 0.97]), whereas when the patient was nonweightbearing, sulcus depth was the best predictor (AUC 0.91 [95% CI 0.85 to 0.96]).

CONCLUSION

Evaluations based on nonweightbearing examinations underestimated the interaction between the tibial tubercle-trochlear groove and patellar axial alignment, thus surgeons could consider weightbearing preoperative assessments for tibial tuberosity osteotomy to avoid failing to restore normal patellar axial alignment. Bisect offset index was an important indicator to improve detecting possible recurrent patellar dislocation in the state of functional activation of soft tissues and can estimate patellar tilt to simplify the preoperative evaluation procedure. For patients who are at high risk but who have not yet developed a patellar dislocation, assessing the risk of recurrent patellar dislocation with the bisect offset index during weightbearing can inform them about the intensity and manner of their daily exercise.

LEVEL OF EVIDENCE

Level III, prognostic study.

Return to sport after shoulder arthroplasty: The role of fast-track rehabilitation in reverse shoulder arthroplasty

Introduction

Shoulder arthroplasty, encompassing Total Shoulder Arthroplasty (TSA) and Reverse Shoulder Arthroplasty (RSA), has become an essential treatment for severe glenohumeral arthritis and complex rotator cuff pathologies. This study evaluated and compared clinical outcomes and return-to-sport rates in TSA patients following standard rehabilitation protocol and RSA patients following fast rehabilitation protocol.

Material and Methods

This retrospective study analyzed 44 patients (TSA: 13; RSA: 31) treated between 2020 and 2023 with at least 12 months of follow-up. Participants engaged in regular upper-extremity sports preoperatively. Patients in the TSA group followed a standard rehabilitation protocol, whereas those in the RSA group were assigned a new standardized fast rehabilitation protocol. Clinical outcomes were assessed using the Constant-Murley Score (CS), Visual Analogue Scale (VAS) for pain, and return-to-sport rates.

Results

TSA patients showed a 100% return-to-sport rate, significantly higher than the 54.84% rate for RSA patients (p < 0.05). Functional outcomes were better in TSA (CS: 81 ± 13.18) compared to RSA (CS: 76.54 ± 8.3, p > 0.05). Within the RSA group, those who resumed sports had significantly higher CS scores (79.59 ± 7.41) than non-returners (73.21 ± 8.64, p < 0.05). Postoperative VAS was similarly low in both groups.

Conclusion

TSA patients exhibited superior return-to-sport rates and functional outcomes compared to RSA patients, highlighting TSA's biomechanical advantages.

Early postoperative gait characteristics after unicompartmental knee arthroplasty: results and clinical implications

BACKGROUND AND OBJECTIVE

Despite the established efficacy of unicompartmental knee arthroplasty (UKA), quantitative assessments of early postoperative changes in gait and stability remain limited. This study investigated preoperative and postoperative alterations in gait and stability following UKA.

METHODS

A cohort of 30 patients undergoing unilateral UKA at the Joint Surgery Department of the Affiliated Hospital of Xuzhou Medical University between May 2021 and 2022 was compared with a control group of 15 healthy elderly individuals without a history of hip or knee pathology. Evaluated parameters included Hospital for Special Surgery (HSS) scores, center of pressure path length, 95% confidence ellipse area, pace, stride length, stride frequency, gait cycle, and single support time percentage. Measurements were obtained preoperatively and at 1 and 3 months postoperatively for both groups.

RESULTS

Step frequency remained unchanged between preoperative and 1-month postoperative assessments (p > 0.05). Stability declined at 1 month postoperatively relative to baseline, whereas other gait parameters showed significant improvement (p < 0.05). By 3 months, HSS scores and all gait and stability metrics exhibited substantial enhancement compared to baseline (p < 0.05).

CONCLUSIONS

Early gait recovery following UKA demonstrated a positive trajectory; however, step frequency showed minimal improvement, and stability remained compromised at 1 month postoperatively. Quantitative gait analysis provides a robust framework for monitoring rehabilitation progress after UKA.

Anterolateral hip injection approach under portable ultrasound guidance: a prospective randomized controlled trial versus conventional ultrasound

PURPOSE

This study aimed to evaluate an innovative anterolateral approach using portable ultrasound, comparing the accuracy and safety of portable ultrasound-guided, conventional ultrasound-guided, and landmark-based blind injection techniques.

METHODS

In this single-centre, prospective, randomised controlled trial, 117 patients with hip pain were randomly assigned to three groups: landmark-based blind injection (n = 39), conventional ultrasound-guided injection (n = 39), and portable ultrasound-guided injection (n = 39). Each patient received a unilateral injection of 2.5 ml hyaluronic acid and 1 ml betamethasone via the anterolateral approach, using parameters optimized from previous research. Primary endpoints included success and accuracy rates, while secondary endpoints comprised post-injection visual analogue scale (VAS) pain scores, procedure time, puncture depth, and complications.

RESULTS

The portable ultrasound group achieved 100% success and accuracy rates, comparable to the conventional ultrasound group, whereas the blind group showed lower success (87.2%) and accuracy (79.4%) rates. Post-injection VAS pain scores were significantly lower in the portable ultrasound group (1.95, SD 0.99) compared with the blind group (2.95, SD 1.61; p = 0.007) and similar to those in the conventional ultrasound group (2.41, SD 1.27; p = 0.337). Procedure times were comparable across all groups, and no significant differences in puncture depth were observed. Importantly, no injection-related complications were reported.

CONCLUSION

Portable ultrasound-guided injections via the anterolateral approach demonstrate accuracy and safety comparable to conventional ultrasound-guided injections. Additionally, the portable device offers advantages in portability, reduced space requirements, and cost-effectiveness, thereby enhancing clinical utility in outpatient settings.

Diagnostic value of multiple projection angle X-ray and CT 3D reconstruction for long-term unreduced posterior hip dislocation

Background

Long-term unreduced posterior hip dislocation is a rare and diagnostically challenging condition, with imaging findings often indistinguishable from those of other end-stage hip diseases. It remains a great challenge to determine whether certain imaging characteristics can improve the clinical diagnosis rate of long-term unreduced posterior hip dislocation.

Methods

We retrospectively reviewed 24 patients from 2010 to 2022. The diagnostic values of multiple projection angle X-ray and CT 3D reconstruction for long-term unreduced posterior hip dislocation were evaluated.

Results

For aureole sign, 45.83% of patients (sensitivity = 45.83%, specificity = 81.52%, accuracy = 78.67%, Youden's index = 0.274, positive predictive value (PPV) = 17.74%, negative predictive value (NPV) = 94.54%, intraobserver consistency = 0.930, and interobserver consistency = 0.903) were diagnosed correctly. For obturator oblique radiograph of the pelvis, 58.33% of patients (sensitivity = 58.33%, specificity = 82.25%, accuracy = 80.33%, Youden's index = 0.406, PPV = 22.22%, NPV = 95.78%, intraobserver consistency = 0.923, and interobserver consistency = 0.900) were diagnosed correctly. For rhombus sign, 70.83% of patients (sensitivity = 70.83%, specificity = 90.94%, accuracy = 89.33%, Youden's index = 0.618, PPV = 40.48%, NPV = 97.29%, intraobserver consistency = 0.943, and interobserver consistency = 0.900) were diagnosed correctly. For CT 3D reconstruction, axial CT (sensitivity = 70.83%), coronal multiplanar reconstruction (sensitivity = 58.33%), and sagittal multiplanar reconstruction (sensitivity = 54.17%), all had high diagnostic values.

Conclusions

The signs, projection angle X-ray, and CT 3D reconstruction identified in this study are valuable in improving the diagnosis for long-term unreduced posterior hip dislocation.

No Short-Term Effects of Acromioclavicular Joint Augmentation in Acute Acromioclavicular Joint Stabilization Surgery: A Randomized Controlled Clinical Trial on 70 Patients

Background: Optimal treatment for high-grade acromioclavicular (AC) joint dislocations is still not unanimous. Improving horizontal AC stability has been emphasized in recent years. Biomechanical studies and computer simulations have demonstrated that adequate horizontal stability could be restored with an additional AC fixation. We aim to prospectively investigate if AC augmentation leads to better clinical and radiological results. Methods: A total of 70 patients with a mean (± SD) age of 42 ± 11 years with acute AC joint dislocation Rockwood type IIIb and V were prospectively randomized into two equal groups. All patients underwent arthroscopically assisted stabilization using a double coracoclavicular (CC) suspensory system. Group N (No-augmentation group) had no additional fixation across the AC joint, while group T (tape-augmentation group) had additional fixation with tape. Patients were evaluated at 3, 6, and 12 months postoperatively. Primary clinical outcome measures included the Constant-Murley score and the Specific AC Score (SACS). Secondary outcome measures included the Subjective Shoulder Value (SSV), the Simple Shoulder Test (SST), the Disabilities of the Arm, Shoulder, and Hand (DASH) outcome measure, and the AC Joint Instability (ACJI) Score. Horizontal stability was radiologically measured with overlapping length (OL) and overlapping area (OA). Vertical alignment was measured with the CC distance. All radiological measurements were compared to the uninjured side and expressed in percentages as relative values. Results: There were no significant differences found between groups regarding the Constant score (p = 0.664), SACS (p = 0.518), or any other outcome measure at the one-year follow-up. Pain level (p = 0.635) and strength (p = 0.217) at the one-year mark also showed no significant differences. Clinical drawer testing for residual horizontal instability was non-significant (p = 0.061), but showed a tendency for a more stable AC joint in group T. The CC distance was smaller in group T at 6 and 12 months (p = 0.047 and p = 0.046, respectively). A two-way mixed factorial ANOVA test showed significantly lower CC differences for group T (p = 0.032); however, the gradual increase in CC distance was similar for both groups over time (p = 0.869). No significant differences were found in OL (p = 0.619) or OA (p = 0.236). Conclusions: The results of our study show that both CC stabilization with the double suspensory system alone and with additional AC fixation are effective surgical treatment options for acute AC joint dislocations, without any important clinical differences. CC distance similarly increased over one year in both groups but was better retained in the AC-augmented group, which showed a tendency toward a more stable fixation.

Arthroscopic additional biceps augmentation and biceps superior capsular reconstruction yield similar clinical and radiological outcomes for patients with medium to large rotator cuff tears

Purpose: To compare the outcomes of additional biceps augmentation (ABA) and biceps superior capsule reconstruction (BSCR) in arthroscopic medium to large rotator cuff tear (RCT) repair. Hypothesis: Both ABA and BSCR yielded comparable clinical and radiological outcomes and retear rates at the 2-year follow-up in patients with medium to large RCTs. Methods: Patients undergoing ABA or BSCR for RCT repairs were included retrospectively between January 2019 and May 2020. The preoperative and postoperative Constant-Murley score (CMS), American Shoulder and Elbow Surgeons (ASES) score, subjective shoulder value (SSV), visual analog scale (VAS), and range of motion (ROM) were recorded, as well as the radiographic evaluation. Results: 67 patients (41 with ABA, 26 with BSCR) were included. There were no significant differences regarding preoperative patient demographics between groups unless forward flexion. In the ABA group, CMS, ASES, SSV, and VAS improved significantly from 33.9 ± 6.0, 37.3 ± 8.7, 24.9 ± 12.3, and 5.1 ± 1.1 to 79.3 ± 8.4, 82.7 ± 8.4, 77.5 ± 10.9, and 2.4 ± 0.6, at 2-year follow-up (all p < .001). In the BSCR group, the CMS, ASES, SSV, and VAS significantly improved from 33.9 ± 5.5, 33.5 ± 11.6, 20.8 ± 9.8, and 5.3 ± 1.5 to 72.8 ± 12.9, 79.6 ± 12.1, 73.1 ± 10.2, and 2.7 ± 0.8, at follow-up (all p < .001). All ROM improved at follow-up in both groups (all p < .001). No significant differences were found between the two groups regarding the postoperative clinical and radiological results. All patients reached minimal clinically important differences for CMS, ASES, SSV, and VAS at the final follow-up. The retear rates in the ABA and BSCR groups were 0% and 7.7%, respectively (p = .001). Conclusions: Both ABA and BSCR provided similar clinical and radiological outcomes in patients with medium to large RCTs. The BSCR group had a higher retear rate than the ABA group. Level of Evidence: Level III, Retrospective comparative therapeutic trial. Clinical Relevance: Both ABA and BSCR provided comparable clinical and radiological outcomes in patients with medium to large RCTs.

Exploring take-home opioid stewardship (ETHOS) in UK postoperative patients

Background

Surgery is one of the most common indications for a patient's first opioid prescription, with some patients progressing to unintended long-term use. There is no current data from the United Kingdom on how much patients use of the opioid medication dispensed at discharge from hospital. This study investigates discharge opioid prescribing and usage following common surgical procedures.

Methods

This cohort study was conducted at the Oxford University Hospitals NHS Foundation Trust and involved 20 of the most commonly performed adult surgical procedures. At least 20 patients per procedure were surveyed using a standardised telephone questionnaire 6-8 days after discharge to establish the amount of used and unused opioids. Opioid doses were converted to oral morphine equivalent (OME) for analysis.

Results

The amount of opioid given to patients after all types of surgery far exceeded requirement, with often large variations in prescribing practices for the same procedures, most notably in trauma and orthopaedics.For the cohort of 426 patients, a total of 55 080 mg OME was dispensed on discharge, with only 34.4% actually used by patients, leaving a total of 36 108.5 mg OME unused in the community, risking inappropriate opioid use, overdose, or diversion.

Conclusions

Opioid overprescribing is common after surgery and represents waste, expense, and risk to patients. There is a clear need to develop a procedure-specific evidence-base for discharge opioid prescribing, adopting an "enough but not too much" approach to ensure that patients have adequate analgesia to facilitate functional surgical recovery, but not more than is needed.

Computer-Assisted Navigation in Shoulder Arthroplasty: A Narrative Review

Shoulder arthroplasty, including total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA), is a well-established procedure for treating degenerative, post-traumatic, and inflammatory conditions of the shoulder joint. The success of these surgeries depends largely on the precise placement of implants, which helps restore proper joint mechanics, reduce complications, and extend the lifespan of the prosthesis. However, achieving accurate implant positioning can be challenging, especially in cases involving severe bone loss, anatomical deformities, or prior surgeries. Poor alignment can lead to instability, implant loosening, and the need for revision surgery. Computer-assisted navigation has become an important tool in shoulder arthroplasty, providing real-time intraoperative guidance to improve surgical accuracy and consistency. By integrating preoperative 3D imaging with intraoperative tracking, navigation technology allows surgeons to optimize glenoid component placement, reducing the risk of malalignment and mechanical failure. Research suggests that navigation-assisted techniques improve precision, enhance functional outcomes, and may even reduce complication rates by optimizing fixation strategies, such as using fewer but longer screws in RSA. Despite its benefits, navigation in shoulder arthroplasty is not without challenges. It requires additional surgical time, increases costs, and demands a learning curve for surgeons. However, with advancements in artificial intelligence, augmented reality, and robotic-assisted surgery, navigation is expected to become even more effective and accessible. This review explores the current impact of navigation on clinical outcomes, its role in complex cases, and the future potential of this technology. While early results are promising, further long-term studies are needed to fully assess its value and establish best practices for its routine use in shoulder arthroplasty.

Rate of Osteonecrosis After Femoral Lengthening with Intramedullary Lengthening Nails

BACKGROUND

There has been historical concern that the use of intramedullary nails could present undue risk of osteonecrosis of the femoral head due to compromise of the femoral blood supply. Intramedullary lengthening nails are rapidly becoming commonplace in lengthening procedures. As such, the primary objective of this study was to analyze the rates of osteonecrosis following femoral lengthening. The secondary objective was to characterize general trends in femoral lengthening.

METHODS

This retrospective cohort study evaluated patients who had undergone femoral lengthening at a single institution from 2012 to 2021. Retrospective chart review and radiographic evaluation of osteonecrosis were conducted. The primary end point was radiographic evidence of osteonecrosis. The secondary variables were the starting point of the femoral nail, the total amount of lengthening, and the time to consolidation.

RESULTS

Two hundred and forty-seven patients were included in the analysis, including 111 males and 136 females, with a mean age of 17 years. No patient had radiographic evidence of osteonecrosis (0%) or coxa valga (0%). The average amount of lengthening was 4.88 cm (range, 1.5 to 8.5 cm). No patient had any extensive complications, such as alterations in the proximal femoral anatomy.

CONCLUSIONS

This largest study to date investigating complications following femoral lengthening using intramedullary lengthening nails revealed that femoral lengthening is a well-tolerated procedure, and osteonecrosis is an infrequent complication.

LEVEL OF EVIDENCE

Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

No clinical relevant differences in early clinical outcomes, patient satisfaction and objective gait and posture analysis between a custom versus off-the-shelf total knee arthroplasty: a prospective controlled study

Osteoarthritis is one of the most frequent joint diseases in the world. Therefore, it is critical to develop sufficient therapy strategies to improve a patient's quality of life. The aim of this study was to evaluate the influence of an individualized (custTKA) vs. a conventional (convTKA) total knee arthroplasty (TKA) in regard to gait, posture and clinical outcome. Seventy-three patients (male: n = 32, female: n = 41; age: 66.5 ± 8.64 years; BMI: 32.2 ± 5.68 kg/m2; axis pre-operative: 174 ± 4.65°) were included in this prospective controlled trial study (examinations 1, 2 and 3: preoperative, 3 and 12 months postoperative). Two experienced senior surgeons performed the surgeries. Clinical results were measured using the Forgotten Knee Joint Score (FKJS) and Knee Society Score (KSS). Additionally, gait was measured with inertial sensor based mobile and treadmill based systems, while posture was measured with a posturographic system in order to assess gait patterns and postural stability, regulation and weight distribution. Radiographic evaluation was measured of the hip knee ankle (HKA)) at 3 and 12 months postoperative. There were no clinically significant interaction effects (time x group) for posture (e.g., stability indicator, postural subsystems) or gait (e.g., stride length, walking speed, double support). However, time effects were observed for the somatosensory system (p = 0.005, ηp2 = 0.08), medio-lateral weight distribution (p < 0.001, ηp2 = 0.31), stride length (p < 0.001, ηp2 = 0.21), walking speed (p < 0.001, ηp2 = 0.21), cadence (p < 0.001, ηp2 = 0.18), stance phase (p < 0.001, ηp2 = 0.20) and maximum toe force (p < 0.001, ηp2 = 0.24). No significant differences were found for KSS or FJS 3 and 12 months postoperative (custTKA/convTKA: KSS examination 2 179/189, p = 0.153; KSS examination 3 206/198, p = 0.246; FKJS examination 2 41.4/40.7, p = 0.900; FKJS examination 3 54.9/45.8, p = 0.149). Similarly, no significant differences were noted for flexion at 3 (113/119°, p = 0.062) and 12 months postoperative (121/122°, p = 0.615). Radiographic diagnostic (HKA) also displayed no significant-relevant interaction effects. In this prospective controlled study no clinical significant-relevant interaction effects (group x time) were found between both techniques regarding biomechanical and clinical parameters. Therefore, it can be concluded that custTKA provides no substantial clinical benefits compared to convTKA.

Good clinical and functional outcomes with low rates of recurrent instability and revision surgery following sternoclavicular reconstruction or repair for the treatment of instability: A systematic review

PURPOSE

The purpose of this systematic review was to evaluate clinical and functional outcomes after sternoclavicular joint (SCJ) reconstruction or repair and to calculate the rates of recurrent instability, revision surgery, return to sport (RTS), and return to work (RTW) after SCJ reconstruction or repair for the treatment of SCJ instability.

METHODS

A systematic review of the literature based on the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) was conducted using PubMed, Embase and Cochrane Library. Studies that evaluated the clinical and functional outcomes following SCJ reconstruction or repair for the treatment of SCJ instability were included. Data regarding study and patient characteristics, surgical management, clinical and functional outcomes as well as RTS and RTW were collected. Due to the heterogeneity of the studies included. patient-reported outcome measurements and complication rates were reported as ranges.

RESULTS

In total, ten studies (8x level three evidence, 2x level two evidence) with 150 patients were included for analysis, of which a reconstruction was performed in 8 studies and a repair was performed in two studies. Mean patient age ranged from 22.2 to 42 years (range, 11-73 years), and the mean follow-up time ranged from mean 28.2 to 94.5 months (range, 24 months - 13 years). A traumatic event was the most common source for SCJ instability across all studies (43.8-100%). Surgery was performed more often for anterior SCJ instability than for posterior SCJ instability. QuickDASH and ASES Score were the most commonly reported functional outcome parameters and improved from mean 44.2 to 2.3-12.1 and 44.8-50.0 to 70.8-94.8, respectively. Pain (assessed via VAS) decreased from mean 3.8-6.8 to 0-2.8 postoperatively. The recurrent instability rate was 0-10.0% and the revision SCJ surgery rate was 0-16.7%. Rates of RTS (44.4-100%) and RTW (57.2-75.0%) varied greatly among studies.

CONCLUSION

Reconstruction or repair of the SCJ for the treatment of SCJ instability is associated with good to excellent clinical and functional outcomes, low rates of instability recurrence and of revision SCJ surgery as well as moderate to high RTS and RTW rates.

LEVEL OF EVIDENCE

Level IV, systematic revie of Level III and IV studies.

The Evolution of Arthroscopic Shoulder Surgery: Current Trends and Future Perspectives

Arthroscopic shoulder surgery has undergone significant advancements over the past decades, transitioning from a primarily diagnostic tool to a comprehensive therapeutic approach. Technological innovations and refined surgical techniques have expanded the indications for arthroscopy, allowing minimally invasive management of shoulder instability and rotator cuff pathology. Methods: This narrative review explores the historical evolution, current trends, and future perspectives in arthroscopic shoulder surgery. Results: Key advancements in shoulder instability management include the evolution of the arthroscopic Bankart repair, the introduction of the remplissage technique for Hill-Sachs lesions, and the development of arthroscopic Latarjet procedures. Additionally, novel techniques such as Dynamic Anterior Stabilization (DAS) and bone block procedures have emerged as promising solutions for complex instability cases. In rotator cuff repair, innovations such as the suture-bridge double-row technique, superior capsular reconstruction (SCR), and biological augmentation strategies, including dermal allografts and bioinductive patches, have contributed to improving tendon healing and functional outcomes. The role of biologic augmentation, including biceps tendon autografts and subacromial bursa augmentation, is also gaining traction in enhancing repair durability. Conclusions: As arthroscopic techniques continue to evolve, the integration of biologic solutions and patient-specific surgical planning will likely define the future of shoulder surgery. This review provides a comprehensive assessment of current state-of-the-art techniques and discusses their clinical implications, with a focus on optimizing patient outcomes and minimizing surgical failure rates.

Audit of VTE prophylaxis prescribing preferences among orthopaedic consultants in Irish orthopaedic trauma centres

BACKGROUND

Thromboembolic complications are common in trauma orthopaedic practise. Despite extensive research, there remain a number of unanswered questions regarding the use of thromboprophylaxis.

AIMS

To establish the current practise among Irish consultant orthopaedic surgeons regarding thromboprophylaxis.

METHODS

A confidential online questionnaire regarding VTE prophylaxis was circulated to all consultant orthopaedic surgeons in training hospitals in the Republic of Ireland. Questions investigated surgeon awareness of local/national guidelines, inpatient and outpatient prescribing preferences and agreement/disagreement with the statement that defensive medicine, rather than evidence-based medicine, has driven increased emphasis on VTE prophylaxis in Ireland in recent years.

RESULTS

The response rate was 72% (69/96). 72% (50/79) of surgeons were aware of local VTE prophylaxis guidelines. 38% (29/96) were aware of national guidelines. 89% (62/69) routinely used mechanical prophylaxis modalities. 73.9% (51/69) routinely used chemical prophylaxis for inpatients. However, this practise was z extremely heterogenous with five other pharmacological agents used by the remainder. 82.6% (57/69) routinely discharged patients on extended duration chemical prophylaxis. 67% (46/69) agreed that the recent increased emphasis on VTE prophylaxis was due to defensive medicine and not evidence-based medicine.

CONCLUSION

The results of this survey show that venous thromboembolism is regarded as a significant complication of orthopaedic surgery and most orthopaedic surgeons actively try to prevent it. There was a higher rate of intervention compared to previous surveys of Irish orthopaedic surgeons, possibly reflecting surgeon concerns regarding the high rate of litigation nationally. However, there is no consensus as to the optimum therapy which reflects the conflicting evidence available in the many publications on this subject.

Future advances in shoulder arthroplasty surgery

Shoulder arthroplasty has evolved significantly since the in 1950s when Charles Neer designed and implanted the first shoulder hemiarthroplasty. Various alterations in design and material properties over the decades have led us to the implants used today, with ever-improving longevity and patient outcomes. This narrative review aims to provide an overview of shoulder arthroplasty surgery, looking at the past, present and future advances in this rapidly evolving field of orthopaedics.

Influence of Tilt and Rotation on Coracoclavicular Distance Measurements and Rockwood Classification in Panorama View Radiographs in the Diagnosis of Acromioclavicular Dislocations

Background

The severity of acromioclavicular (AC) joint dislocation is evaluated through bilateral anterior-posterior radiographs of the AC joint. AC joint dislocations are graded based on the classification system of Rockwood, which is the foundation for further decision-making regarding therapy regimen.

Purpose/Hypothesis

The purpose of this study was to simulate technical irregularities in obtaining panoramic views and the effect they might have on the measured coracoclavicular (CC) distance. It was hypothesized that vertical tilt and horizontal rotation of the radiographic panoramic view of the AC joints affect the measured CC distance and, therefore, the Rockwood classification and reliability of the measurement method.

Study Design

Level IV, Diagnosis Study, Case Series.

Methods

A retrospective analysis including 14 patients with AC joint dislocations and available computed tomography scans of the upper body was conducted. Three-dimensional models of a simulated bilateral panoramic view were tilted and rotated from -15° to 15° in 5° increments around the vertical and horizontal axes. Three raters with different experience levels independently measured the CC distance and repeated this process with a minimum 6-week interval. The intra- and interclass correlation coefficients for intra- and interrater reliability were calculated. Changes in CC distance and Rockwood classification due to rotation or tilt were reported.

Results

The measurements of intra- and interclass correlation coefficients in the neutral (0° position) showed a high intra- and interrater reliability (0.878 and 0.952 for intrarater reliability; 0.851 and 0.952 for interrater reliability). By adding vertical tilt and horizontal rotation to simulated panoramic views, the intra- and interreliability of the 3 raters decreased. Vertical tilt showed a higher impact on the measurement reliability than horizontal rotation. In 10 of 14 cases, the initially determined Rockwood classification changed through adding tilt (9/14) or rotation (5/14). In 5 cases, the injury was graded more severe. In 3 cases, the classification was changed to a milder grade according to Rockwood. In 2 cases, the injury was changed to a higher or a lower type in the Rockwood classification, respectively, depending on the amount of tilt or rotation. Of the 10 cases that were reclassified by tilt and rotation, 5 were Rockwood type 3 injuries.

Conclusion

Vertical tilt and horizontal rotation in simulated panoramic views of the AC joints were demonstrated to have a significant influence on CC distances and Rockwood classification as well as intra- and interrater reliability. This effect was more pronounced with a higher degree of tilt/rotation. This may affect clinical decision-making, whether to treat this injury nonoperatively or operatively.

Clinical Relevance

The panoramic view is widely used as the gold standard for diagnosing and classifying AC joint dislocations according to Rockwood. Thus, it is a decisive criterion to choose the best treatment. This study investigates the reliability of the radiographic diagnosis of AC joint dislocations when adding tilt and rotation, which may occur in clinical practice while obtaining the panoramic view.

Minimizing Risk of Recurrent Instability Following Surgical Stabilization for Anterior Glenohumeral Instability

The most common surgical treatment options for anterior shoulder instability include the arthroscopic Bankart repair with or without adjunct procedures such as remplissage, the open Bankart repair, the Bristow-Latarjet procedure, and anterior free bone block transfers. The choice between non-operative treatment and 1 of the aforementioned procedures inherently impact the risk of recurrent instability. The purpose of this article is to discuss the timing of surgery in the in-season athlete, evaluate the evolving concept of glenoid and bipolar bone loss, and to discuss various surgical treatment options with a specific focus on minimizing recurrent instability rates following surgical stabilization.

Mobile app-based monitoring of recovery after knee osteotomy: Patients take approximately five months to return to preoperative step counts despite limited app uptake

INTRODUCTION

This study aimed to assess the feasibility of using mobile application (app) technology for monitoring recovery after knee osteotomy and to determine the time required for patients to return to their preoperative step counts.

METHODS

This retrospective study included 329 patients who underwent coronal realignment surgery, including high tibial osteotomy (HTO) or distal femoral osteotomy (DFO) with a minimum follow-up of 1 year. The patients were grouped based on the type of osteotomy performed, i.e., HTO and DFO groups. Step count data were collected using the myrecovery app and analyzed preoperatively and at 1 month, 3 months, 6 months, and 12 months postoperatively. Statistical analyses included univariate linear regression models to assess the relationship between step counts at each time point and the duration required to return to their preoperative step counts.

RESULTS

Of the 329 patients included in the study, a total of 62 patients (19%) downloaded the app and 24 patients (7%) had complete step count data. Of the 24 patients with complete data, 18 were included in the HTO group and 6 were included in the DFO group. It took patients an average of 153 ​± ​112 days to return to their preoperative step counts, with the patients in the HTO group taking 174 ​± ​121 days and those in the DFO group taking 113 ​± ​77 days. Step counts increased significantly over time, with percentages of preoperative step counts reaching 108% at 12 months postoperatively. A statistically significant correlation was found between step counts at 3 months postoperatively and the time to return to preoperative step counts (R2 ​= ​0.240, P ​= ​0.015).

DISCUSSION

This study found that patients took approximately 5 months to return to their preoperative step counts after knee osteotomy. However, the adoption of the app was limited, with only 19% of patients downloading the app and just 7% providing complete data, posing a significant barrier to the feasibility of mobile apps for tracking recovery.

CONCLUSION

The mobile app is effective for tracking recovery progress following knee osteotomy, but strategies to increase patient adoption are essential for enhancing its practical application.

LEVEL OF EVIDENCE

Level IV, Retrospective Case Series.

Do Superficial Drains Make a Difference After Lumbar Fusion Surgery? A Prospective, Randomized Trial

STUDY DESIGN

A prospective, randomized study.

OBJECTIVE

The goal of this study was to evaluate the impact that subcutaneous drains have on patient satisfaction and postoperative recovery after a lumbar fusion surgery.

SUMMARY OF BACKGROUND DATA

The use of drains following lumbar fusion surgery is controversial. Current literature shows that there are both benefits and drawbacks to using deep drains, however, there are no reports on the utility of superficial drains.

METHODS

One hundred ten patients undergoing a 1 to 3-level fusion by a single surgeon were randomly selected to receive either a subcutaneous drain (55 patients) or no drain (55 patients). Drain output was collected 1, 3, and 5 days after the procedure. Drains were removed 5 days after the surgery so long as the output was <50 ccs in a 24-hour period. Patient demographics, drain outputs, and questionnaire data from 10, 30, and 60 days after the procedure were compared.

RESULTS

Patients receiving a superficial drain were significantly less likely to have incisional drainage (P<0.01) and tended to be less anxious about their wound healing (P=0.06). There was no difference between drain and no drain groups in terms of postoperative complications, wound care satisfaction, level of independence, or need for outside medical assistance. Body mass index (BMI) and wound thickness did not impact the volume of drain output or other results.

CONCLUSIONS

Subcutaneous drains significantly decrease incisional leakage and tend to decrease patient anxiety regarding wound healing. The presence of a postoperative drain does not diminish patient satisfaction with wound healing.

Cracking the code of HBV persistence: cutting-edge approaches to targeting cccDNA in chronic hepatitis B with or without pyogenic liver Abscesses

Chronic Hepatitis B Virus (HBV) infection remains a formidable global health challenge, driving severe liver complications such as hepatocellular carcinoma (HCC) and pyogenic liver abscesses (PLA). At the core of HBV persistence lies covalently closed circular DNA (cccDNA), a viral reservoir that fuels ongoing infection despite antiviral treatments. This review highlights molecular mechanisms governing cccDNA formation, maintenance, and clearance, spotlighting innovative therapeutic strategies to disrupt this key viral element. We explore cutting-edge approaches, including epigenetic modulation to silence cccDNA, RNA interference (RNAi) for viral RNA degradation, and CRISPR/Cas genome editing to excise cccDNA directly. Additionally, emerging antiviral therapies and immunotherapies, such as therapeutic vaccines and immune checkpoint inhibitors, offer new avenues for enhanced treatment efficacy. Special attention is given to the clinical complexities of managing HBV in patients with co-morbid conditions like HCC and PLA, emphasizing the necessity of a multidisciplinary approach. The interplay between antibacterial and antiviral therapies in PLA-associated HBV cases is critically examined to prevent treatment antagonism, ensuring optimal patient outcomes. Advanced therapeutic strategies, including nucleos(t)ide analogs, interferon therapy, and novel genomic interventions, are explored in both isolated HBV infection and PLA co-infections. Personalized regimens remain pivotal in enhancing therapeutic efficacy and long-term disease control. Current review advocates for a shift toward precision medicine, highlighting the critical need for interdisciplinary collaboration to bridge molecular discoveries with clinical innovations. Ultimately, these advancements promise to revolutionize the management of chronic HBV, paving the way for potential cures and improved patient outcomes.

Use and safety of corticosteroid injections in joints and musculoskeletal soft tissue: guidelines from the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, the American Society of Interventional Pain Physicians, and the International Pain and Spine Intervention Society

BACKGROUND

Intra-articular corticosteroid (IACS) injection and peri-articular corticosteroid injection are commonly used to treat musculoskeletal conditions. Results vary by musculoskeletal region, but most studies report short-term benefit with mixed results on long-term relief. Publications showed adverse events from single corticosteroid injections. Recommended effective doses were lower than those currently used by clinicians.

METHODS

Development of the practice guideline for joint injections was approved by the Board of Directors of the American Society of Regional Anesthesia and Pain Medicine and the participating societies. A Corticosteroid Safety Work Group coordinated the development of three guidelines: peripheral nerve blocks and trigger points; joints; and neuraxial, facet, and sacroiliac joint injections. The topics included safety of the technique in relation to landmark-guided, ultrasound-guided, or radiology-aided injections; effect of the addition of the corticosteroid on the efficacy of the injectate; and adverse events related to the injection. Experts on the topics were assigned to extensively review the literature and initially develop consensus statements and recommendations. A modified version of the US Preventive Services Task Force grading of evidence and strength of recommendation was followed. A modified Delphi process was adhered to in arriving at a consensus.

RESULTS

This guideline focuses on the safety and efficacy of corticosteroid joint injections for managing joint chronic pain in adults. The joints that were addressed included the shoulder, elbow, hand, wrist, hip, knee, and small joints of the hands and feet. All the statements and recommendations were approved by all participants and the Board of Directors of the participating societies after four rounds of discussion. There is little evidence to guide the selection of one corticosteroid over another. Ultrasound guidance increases the accuracy of injections and reduces procedural pain. A dose of 20 mg triamcinolone is as effective as 40 mg for both shoulder IACS and subacromial subdeltoid bursa corticosteroid injections. The commonly used dose for hip IACS is 40 mg triamcinolone or methylprednisolone. Triamcinolone 40 mg is as effective as 80 mg for knee IACS. Overall, IACS injections result in short-term pain relief from a few weeks to a few months. The adverse events include an increase in blood glucose, adrenal suppression, detrimental effect on cartilage lining the joint, reduction of bone mineral density, and postoperative joint infection.

CONCLUSIONS

In this practice guideline, we provided specific recommendations on the role of corticosteroids in joint, bursa, and peritendon injections for musculoskeletal pain.

Combined Repair and Reconstruction of Coracoclavicular and Acromioclavicular Ligaments for Acute and Chronic AC Joint Dislocations: A Technical Note and Prospective Case Series

Background/Objectives: Dislocation of the acromioclavicular joint (ACJ) is a common injury for which numerous operative fixation and reconstructive techniques have been described. This technique combines a coracoclavicular ligament (CC) repair with an acromioclavicular ligament (AC) and CC reconstruction with an additional ACJ internal brace to address both horizontal and vertical instability. Methods: The surgery is performed through a superior approach in the following sequence: (1) CC ligaments are repaired using a TightRope construct, (2) CC reconstruction is performed using a peroneus longus tendon allograft, (3) AC ligaments are repaired using an internal brace, and (4) AC reconstruction is performed with a second peroneus longus tendon allograft. The results of consecutive patients with grade IIIB, IV, and V AC joint dislocations were included. Results: Six patients with acute and six patients with chronic injuries were eligible for inclusion. The Constant-Murley Score improved significantly from 27.6 (8.0-56.5) to 61.5 (42.0-92.0) (p = 0.006 paired t-test) at 12 months of follow-up. There was one complication (frozen shoulder) from which the patient recovered spontaneously; no other complications were observed with this technique. The coracoclavicular distance (CCD) was reduced from 18.7 mm (13.0-24.0) to 10.0 mm (6.0-16.0, p < 0.001) and 10.5 mm (8.0-14.0, p = 0.002) at 12 weeks and 12 months, respectively. Conclusions: This study describes a new technique to treat acute and chronic Rockwood stage IIIB-V ACJ dislocations with promising short-term clinical and radiological results. The results suggest that the combined repair and reconstruction of the AC and CC ligaments is a safe procedure with low complication risk in experienced hands. Addressing the vertical and horizontal stability in ACJ dislocation is key to achieving optimal long-term results. Further, follow-up is required to investigate the long-term outcomes.

Arthroscopic Humeral Head Hill-Sachs Grafting With Talus Allograft

The presence of a Hill-Sachs lesion is a known risk factor for recurrent shoulder instability. Many procedures have been described for the treatment of off-track Hill-Sachs lesions; however, each of these techniques is fraught with potential disadvantages and complications. In this Technical Note and accompanying video, we describe our technique for arthroscopic treatment of a Hill-Sachs lesion with talus osteochondral allograft. This technique recreates native humeral head anatomy with a highly congruent graft without altering the biomechanics of the glenohumeral joint.

Viability and Functional Prognosis in Mangled Hand Casualties Depending on Their Etiological Factors. A Study of 31 Cases

Purpose

Mangled hands refer to disfiguring severe injuries that affect many anatomical components. These injuries are evaluated using various scoring systems. In addition to these ratings, we need to include critical aspects relating to the patient, such as the trauma origin, prognosis, and procedure. We examined the significance of accident etiology in assessing trauma and predicting outcomes, as well as their value in guiding decisions for trauma treatment.

Methods

Thirty-one patients, from 6 to 73 years, have been treated for upper limb compound injuries at our hospital between 2004 and 2009. We registered 10 blast injuries, 10 work accidents, six motor vehicle accidents, and five gunshot injuries. The severity, anatomy, topography, and type assessment method was used to evaluate the prognosis on viability and functionality. Additionally, we studied the influence of the etiological factor on injury prognosis. The functional results have been assessed by the manual muscle testing grading system, whereas the results of the limb usefulness have been evaluated by Disabilities of Arm, Shoulder and Hand (DASH) score test (patients' self-questionnaire).

Results

Seventeen cases involved major vascular lesions that required emergency reconstruction or amputation. Our findings indicate that cases with blast injuries managed by partial or total amputations or using flaps to close stumps had poor prognoses. For cases with work-related injuries, we performed revascularization or flaps where the likelihood of saving the limbs was deemed higher than the potential risks of postoperative complications. In cases with gunshot injuries, despite the low overall functioning seen, our primary approach was to repair rather than amputating because of the potential feasibility of achieving viability.

Conclusions

Further investigation is needed to determine if the cause of trauma has an important impact on trauma evaluation scores and predicting trauma outcomes, furthermore, helping decision making in emergencies.

Type of study/level of evidence

Prognosis IIa.

[Translated article] Rivaroxaban versus enoxaparin for thromboprophylaxis in orthopedic surgery: A meta-analysis

INTRODUCTION

Venous thromboembolism is highly associated with orthopedic surgery, so thromboprophylaxis is an important consideration for orthopedic surgeons. The new oral anticoagulants have clear advantages for clinical practice.

OBJECTIVES

To analyze the efficacy and safety of rivaroxaban versus enoxaparin for thromboprophylaxis in different orthopedic surgeries.

MATERIAL AND METHODS

Systematic electronic search of clinical trials was carried out. Data extraction of efficacy outcomes (deep venous thrombosis, pulmonary embolism and death) and safety outcomes (major bleeding and clinically relevant bleeding) was realized.

RESULTS

Six randomized and controlled clinical trials were included in this meta-analysis. Compared with enoxaparin the risk of venous thromboembolism was lower with rivaroxaban both in different orthopedic surgeries (RR: 0.51; 95% CI: 0.36-0.73; p=.0002). This result was even better and more homogeneous in the analysis of symptomatic deep venous thrombosis outcome (RR: 0.43; 95% CI: 0.28-0.65; p<.0001; I2=0%; p=.49). The risk of bleeding was not significantly higher with rivaroxaban (RR: 1.20; 95% CI: 0.97-1.49; p=.09).

CONCLUSIONS

Rivaroxaban should be considerate such as a more effective alternative for thromboprophylaxis in orthopedic surgery.

Ultrasound- Versus Landmark-Guided Corticosteroid Injections in Patients With Shoulder Pain: A Meta-Analysis and Systematic Review

This meta-analysis evaluated the effects of ultrasound-guided (USG) and landmark-guided (LMG) injections of corticosteroids into the shoulder joint cavity of patients with shoulder pain. The PubMed database was searched for articles (January 1, 2004-December 31, 2023) comparing USG and LMG injections of corticosteroids for the treatment of adult shoulder pain. Two authors independently performed data extraction and appraisal. The outcome measures collected were visual analogue scale (VAS) score and VAS score change at 1 and 6 weeks postinjection and range of motion (ROM) at 6 weeks postinjection. Thirteen studies including 656 patients were reviewed (USG and LMG groups, 328 patients each). The VAS score at 1 week postinjection and the ROM in abduction at 6 weeks postinjection were statistically different, but there were no statistically significant differences in other outcomes. This meta-analysis indicated that USG corticosteroid injection may have a better effect than LMG corticosteroid injection for early-stage shoulder pain and abduction in the mid- to long-term, but does not affect later shoulder pain or other ROMs.

The (T) thrombosis (I) in patients with (L) lower (L) limb (I) injuries (R) requiring (I) immobilisation (TILLIRI) study

BACKGROUND

Patients requiring lower limb immobilization after injury have an increased venous thromboembolism (VTE) risk. The extent of this risk in published studies varies. The Thrombosis Risk Prediction for Patients with Cast Immobilization (TRiP[cast]) model quantifies VTE risk using clinical parameters. Delineating low-risk from high-risk patients remains challenging.

OBJECTIVES

Determine the 90-day incidence of symptomatic VTE following temporary lower limb immobilization after injury in an unselected cohort. Prospectively collect data on risk factors, including those incorporated in the TRiP(cast) model, to calculate TRiP(cast) scores.

METHODS

TILLIRI is a multicenter, pragmatic, observational cohort study including 10 sites within the Irish Network for VTE Research. Patients aged ≥18 years with an immobilized injured lower limb were included. Twenty-one clinical variables were collected at presentation. Thromboprophylaxis was prescribed according to clinical gestalt. Patients were followed up at 90 days to determine if VTE occurred.

RESULTS

Between November 2018 and February 2023, 1242 patients were recruited. Follow-up was complete for 1199 patients (96.5%). Forty-three patients (3.5%) were lost to follow-up. Forty-four (3.6%) patients and 125 (10%) patients were prescribed anticoagulation and aspirin, respectively. Twenty-one patients receiving regular anticoagulation were removed from the final analysis. VTE incidence at 90-day follow-up was 6/1179 (0.51%; 95% CI, 0.1%-0.92%). TRiP(cast) scores were calculated for 1176/1221 patients. A total of 846 patients (71.9%) had a TRiP(cast) score < 7, received no prophylaxis, and had no VTE.

CONCLUSION

TILLIRI indicates a low VTE incidence in an unselected cohort following lower limb immobilization with low rates of prophylaxis use. The proportion of patients with low TRiP(cast) scores and no symptomatic VTE suggests that thromboprophylaxis may be avoided in patients with TRiP(cast) scores < 7 with a low 90-day VTE risk.

Autologous Tendon "Bamboo Raft" Graft for Reconstruction of Massive Irreparable Rotator Cuff Tears

Superior capsular reconstruction has shown long-term clinical effectiveness in treating massive irreparable rotator cuff tears, playing a key role in reducing humeral head translation and restoring the force-couple balance. Various graft techniques involving different types of grafts, such as autologous fascia lata, allogeneic dermal patches, and autologous long head of the biceps tendon, have been described. However, these approaches were often limited by factors such as extensive surgical trauma, high donor-site morbidity, and insufficient mechanical strength of the grafts. We describe autologous tendons, such as the hamstring tendon, fashioned into a "bamboo raft" configuration to create a graft for massive irreparable rotator cuff tears. This technique offers several advantages, including minimal surgical trauma, low donor-site complication rates, and superior mechanical strength of the graft.

Rivaroxaban versus enoxaparin for thromboprophylaxis in orthopedic surgery: A meta-analysis

INTRODUCTION

Venous thromboembolism is highly associated with orthopedic surgery, so thromboprophylaxis is an important consideration for orthopedic surgeons. The new oral anticoagulants have clear advantages for clinical practice.

OBJECTIVES

To analyze the efficacy and safety of rivaroxaban versus enoxaparin for thromboprophylaxis in different orthopedic surgeries.

MATERIAL AND METHODS

Systematic electronic search of clinical trials was carried out. Data extraction of efficacy outcomes (deep venous thrombosis, pulmonary embolism and death) and safety outcomes (major bleeding and clinical relevant bleeding) was realized.

RESULTS

Six randomized and controlled clinical trials were included in this meta-analysis. Compared with enoxaparin the risk of venous thromboembolism was lower with rivaroxaban both in different orthopedic surgeries (RR: 0.51; 95% CI: 0.36-0.73; P=.0002). This result was even better and more homogeneous in the analysis of symptomatic deep venous thrombosis outcome (RR: 0.43; 95% CI: 0.28-0.65; P<.0001; I2=0%; P=.49). The risk of bleeding was not significantly higher with rivaroxaban (RR: 1.20; 95% CI: 0.97-1.49; P=.09).

CONCLUSIONS

Rivaroxaban should be considerate such as a more effective alternative for thromboprophylaxis in orthopedic surgery.

Remplissage May Decrease the Redislocation Rate After Arthroscopic Bankart Repair in Patients With an Engaging Hill-Sachs Defect: A Systematic Review and Meta-analysis of Studies With Minimal 2-Year Follow-up

BACKGROUND

The redislocation rate after arthroscopic Bankart repair (BR) among patients with a Hill-Sachs lesion (HSL) may be reduced with the use of remplissage.

PURPOSE

To investigate the outcomes of adding remplissage to an arthroscopic BR in patients with concomitant HSL.

STUDY DESIGN

Meta-analysis; Level of evidence, 3.

METHODS

PubMed and ScienceDirect databases were searched between February 2022 and April 2023 with the terms "remplissage" and "shoulder instability" according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The inclusion criteria were formed using the population, intervention, control, and outcome method; the investigation included studies that compared BR with and without remplissage and had ≥24 months of follow-up.

RESULTS

From 802 articles found during the initial search, 7 studies with a total of 837 patients-558 receiving isolated BR (BR group) and 279 receiving BR with remplissage (BR+REMP)-were included. The probability of recurrence of instability among patients with an engaging HSL was significantly diminished in the BR+REMP group compared with the BR group (odds ratio, 0.11; 95% CI, 0.05 to 0.24; P < .001). Regarding shoulder range of motion, the BR+REMP group achieved increased forward flexion (mean difference [MD], 1.97°; 95% CI, 1.49° to 2.46°; P < .001) and decreased external rotation in adduction (MD, -1.43°; 95% CI, -2.40° to -0.46°; P = .004) compared with the BR group. Regarding patient-reported outcome measures, the BR+REMP group had Rowe (MD, 2.53; 95% CI, -1.48 to 6.54; P = .21) and Western Ontario Shoulder Instability Index (WOSI) (MD, -61.60; 95% CI, -148.03 to 24.82; P = .162) scores that were comparable with those of the BR group.

CONCLUSION

Remplissage resulted in a 9-fold decrease in the recurrence of instability after arthroscopic BR in patients with HSL. Remplissage not only led to an increase in forward flexion but also only slightly limited patients' external rotation in adduction. WOSI and Rowe scores after remplissage at the final 24-month follow-up were comparable with those obtained after isolated Bankart repair.

Gender-Based Differences in Biomechanical Walking Patterns of Athletes Using Inertial Sensors

Background: Wearable inertial sensors are essential tools in biomechanics and sports science for assessing gait in real-world conditions. This study explored gender-based differences in biomechanical walking patterns among healthy Greek athletes using the BTS G-Walk system, focusing on key gait parameters to inform gender-specific training and rehabilitation strategies. Methods: Ninety-five healthy athletes (55 men, 40 women), aged 18 to 30 years, participated in this study. Each athlete performed a standardized 14 m walk while 17 biomechanical gait parameters were recorded using the BTS G-Walk inertial sensor. Statistical analyses were conducted using SPSS to assess gender differences and left-right foot symmetry. Results: No significant asymmetry was found between the left and right feet for most gait parameters. Men exhibited longer stride lengths (left: p = 0.005, Cohen's d = 0.61; right: p = 0.009, Cohen's d = 0.53) and longer stride and gait cycle durations (left: p = 0.025, Cohen's d = 0.52; right: p = 0.025, Cohen's d = 0.53). Women showed a higher cadence (p = 0.022, Cohen's d = -0.52) and greater propulsion index (left: p = 0.001, Cohen's d = -0.71; right: p = 0.001, Cohen's d = -0.73), as well as a higher percentage of first double support (p = 0.030, Cohen's d = -0.44). Conclusions: These findings highlight the impact of biological and biomechanical differences on walking patterns, emphasizing the need for gender-specific training and rehabilitation. The BTS G-Walk system proved reliable for gait analysis, with potential for optimizing performance, injury prevention, and rehabilitation in athletes. Future research should explore larger, more diverse populations with multi-sensor setups.

Physeal-Sparing Soft Tissue Realignment in Pediatric Patellofemoral Instability Patients: A Review of Treatment Options and Outcomes

Patellofemoral instability is a common condition in children, with an annual incidence of approximately 50 cases per 100,000 children. Instability of the patella involves a number of structures, such as the medial patellofemoral ligament and the vastus medialis obliquus, which can be used for patellar realignment in soft tissue, physeal-sparing procedures. In this rapid review, we aim to review the surgical interventions, post-operative outcomes, and associated surgical complications of global soft tissue procedures in the management of patellofemoral instability. A search of the Medline database was conducted to identify studies evaluating the treatment and outcomes of global treatment of pediatric patellofemoral instability. The included studies analyzed the surgical management of patellofemoral instability in pediatric patients, utilizing soft tissue global procedures and reported functional outcomes, return to sport or play, and post-operative complications. A total of eight studies were included, comprising a cohort of 270 pediatric and adolescent patients and 334 knees. The average patient age was 10.6 years, with 60.4% (163/270) patients being female, and the mean follow-up duration was 58.4 months. Of the eight studies, two examined the three-in-one procedure, three examined the four-in-one procedure, one examined a combination of medial and lateral release, and two examined the Galeazzi procedure. This review underscores the variety of global physeal-sparing surgical procedures available for treating patellofemoral instability. While outcomes are generally favorable, with high rates of return to sport, recurrent residual instability and recurrent dislocation remain significant challenges, with residual instability affecting nearly half of patients. Future research should focus on exploring long-term outcomes, optimizing patient selection, and identifying the causes of recurrent instability to further enhance patient outcomes and reduce complication rates.

Arthroscopic-Controlled Reduction of Hill-Sachs Lesions: Treatment Option for Off-Track Lesions in Young Patients?

Large Hill-Sachs lesions (HSL) are currently treated via a remplissage procedure. Although the good stabilizing properties of this surgery are apparent, there are some disadvantages in terms of the functional outcome. In the following Technical Note, we present a method of arthroscopic-controlled reduction of HSL for anatomical restoration of the humeral head without functional limitations. For HSL reduction, we place a 1.6-mm K-wire in the central lesion under arthroscopic and fluoroscopic control from posterior to anterior in lateral drilling direction. Then, a 7-mm cannulated drill is used for preparing the reduction canal. Afterward, the HSL is reduced via bone tamp, also under arthroscopic and fluoroscopic control. No bone substitution material is used to fill the canal; only a standard wound closure is performed. Arthroscopic-controlled reduction of impacted humeral head fractures seems to be a possible and relatively easy way to perform an anatomical restoration of HSLs. Because the exact location of HSLs can vary slightly, the exact surgical setting might be slightly different each time. Biomechanical studies already show similar stabilizing properties of this procedure compared with established techniques but without losing external rotation. Further studies need to review the potential rate of humeral head necrosis or secondary loss of reduction.

Similar patient-reported outcomes but lower redislocation and higher revision rates following primary Latarjet vs. primary arthroscopic Bankart repair in patients with 10%-20% glenoid bone loss at a minimum 2-year follow-up

BACKGROUND

The amount of glenoid bone loss is closely related to the success rate of surgical treatment following anterior shoulder dislocations. There is an ongoing debate on the most successful treatment in patients with a subcritical amount (10%-20%) of glenoid bone loss (GBL). This study aimed to compare patient-reported outcome measures (PROMs) following primary open Latarjet procedure and primary arthroscopic Bankart repair (ABR) in patients with 10%-20% GBL at a minimum 2-year follow-up.

METHODS

This multicenter retrospective cohort study included 53 patients with traumatic anterior shoulder dislocations treated with Latarjet or ABR between 2011 and 2019. PROMs included the Western Ontario Shoulder Instability Index (WOSI) and Oxford Shoulder Instability Score (OSIS). Secondary outcomes included recurrence, complications, revision surgery, patient satisfaction, and return to sport (RTS).

RESULTS

The mean follow-up was 77 ± 31.7 months. Baseline characteristics were similar between ABR and Latarjet, except for time to follow-up (91 ± 30 vs. 61 ± 26 months, P < .001) and percentage GBL (15 ± 3 vs. 17 ± 3, P = .024). WOSI scores were higher in Latarjet patients compared with ABR; however, this difference was not statistically significant (220 vs. 457, P = .10). OSIS scores were similar following ABR and Latarjet (42 vs. 45, P = .33). Recurrence rates were higher in ABR patients (7 [24%] vs. 0 [0%] recurrences, P = .01), whereas revision rates were higher in Latarjet patients (4 vs. 0 revisions, P = .04). Patient satisfaction and complications were not different between the 2 procedures and neither achieved RTS and RTS to preinjury level.

CONCLUSION

The null hypothesis in which Latarjet and ABR show similar patient-reported outcomes could not be rejected based on the underpowered analysis. Patients treated with Latarjet did not have any recurrences vs. 7 in the ABR group (P = .01). However, revision rates were higher in Latarjet patients (4 vs. 0 revisions, P = .04).

Effects of Biceps Rerouting on In Vivo Glenohumeral Kinematics in the Treatment of Large-to-Massive Rotator Cuff Tears

BACKGROUND

Arthroscopic repair with the biceps rerouting (BR) technique has been determined to lead to promising clinical and biomechanical outcomes for treating large-to-massive rotator cuff tears (LMRCTs). However, the in vivo effects of BR on glenohumeral kinematics during functional shoulder movements have not been fully elucidated.

PURPOSE

To investigate whether BR provides a better restoration of shoulder kinematics compared with conventional rotator cuff repair (RCR).

STUDY DESIGN

Controlled laboratory study.

METHODS

Patients who underwent either repair with the BR technique (BR group) or RCR alone (RCR group) for treating LMRCTs between January 2021 and May 2022 were enrolled. They underwent a 1-year postoperative kinematic evaluation of bilateral shoulders by performing scapular-plane abduction with a dual fluoroscopic imaging system. Glenohumeral translation in the superior-inferior (S-I) and anterior-posterior (A-P) directions was assessed in shoulder abduction at 10° increments. Moreover, the mean, maximum, minimum, and range of glenohumeral translation were calculated throughout the entire movement.

RESULTS

A total of 9 patients were enrolled in each group for final analysis, and baseline characteristics were comparable between the groups. In the RCR group, compared with contralateral shoulders, the operative shoulders showed increased superior humeral head translation during lower abduction angles of 30° to 50° (all P≤ .004), with a greater maximum (P = .014) and a larger range (P = .002) for S-I translation throughout the entire movement. In the BR group, no significant differences between operative and contralateral shoulders were detected in any kinematic variables for S-I translation (all P≥ .132); however, the operative shoulders exhibited a larger maximum (P = .031), a smaller minimum (P = .008), and a larger range (P < .001) for A-P translation throughout the entire movement compared with the contralateral shoulders.

CONCLUSION

BR successfully reduced residual superior humeral head translation compared with conventional RCR and restored normal S-I glenohumeral kinematics in the treatment of LMRCTs. However, A-P glenohumeral kinematics was not fully restored after BR, and its effect on long-term clinical outcomes requires further investigation.

CLINICAL RELEVANCE

BR can be a promising technique to treat LMRCTs. However, its potential adverse effects on A-P glenohumeral kinematics should not be ignored, requiring further clinical evidence to determine long-term outcomes.

Automatic measurement of X-ray radiographic parameters based on cascaded HRNet model from the supraspinatus outlet radiographs

Background

Rotator cuff injury is a common cause of shoulder pain. Precise and efficient measurement of morphological parameters is necessary in the clinical diagnosis and evaluation of shoulder disorders. However, manual measurement is a time-consuming and labor-intensive task, with low inter-observer reliability. The automatic measurement of radiographic parameters in supraspinatus outlet radiographs has not been reported yet. Thus, the objective of this study was to use a cascaded High-Resolution Net (HRNet) model based on deep learning (DL) algorithms to automatically measure morphological parameters from supraspinatus outlet radiographs and assess its performance. It was intended for use in early screening of patients with rotator cuff disease and to guide them to further consultation.

Methods

This cross-sectional study collected 1,668 supraspinatus outlet radiographs from the picture archiving and communication system of Gansu Provincial Hospital of Traditional Chinese Medicine and the Affiliated Hospital of Gansu University of Chinese Medicine. Among them, 521 images were provided for test datasets and 1,147 images were provided for a model training dataset and validation dataset. Landmarks were annotated for acromio-humeral interval (AHI), acromial tilt (AT), and 3 lines in Park's acromial classification (line huo-acrf, line acro-acro1, and line huo-acro1). R4 radiologist reviewed the means of 3 radiologists as a reference standard. Model performance was assessed by calculating the percentage of correct key points (PCK), intra-class correlation coefficients (ICCs), Pearson's correlation coefficients, mean absolute error, and root mean square error. The reliability of R1, R2, R3, AI with R4 and inter-observer reliability of R1, R2, and R3 for acromial morphology classification were assessed by Cohen's kappa coefficient.

Results

Within the 3-mm threshold, the PCK of the model ranged from 74% to 100%. Compared to the reference standard, the model had reliable measurement of AHI, AT, line huo-acrf, line acro-acro1, line huo-acro1 (ICC =0.73-0.94) and moderate reliability of acromial morphology classification (k=0.50-0.56).

Conclusions

The cascaded HRNet developed in this study can automatically measure morphological parameters of the shoulder. It may aid early clinical screening for shoulder disorders and assist physicians in treatment decisions.

Risk factors for increased external rotation deficit after combined Bankart repair and remplissage for recurrent anterior shoulder instability

BACKGROUND

External rotation (ER) deficit following Bankart repair and remplissage (BRR) is reported to be a major concern. The purpose of this study was to identify potential risk factors that correlate with increased postoperative ER deficit in a population that underwent BRR for recurrent anterior shoulder instability and glenoid bone loss (<20%).

METHODS

A retrospective analysis of prospectively collected data was performed on 41 patients who underwent BRR for anterior shoulder instability with glenoid bone loss of <20%. Inclusion criteria were a minimum of 2-year postoperative follow-up with available pre- and postoperative functional scores (American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES] score and Western Ontario Shoulder Instability Index [WOSI]) and preoperative magnetic resonance imaging. Regression analysis was conducted to detect risk factors for postoperative ER deficit, including age, sex, number of dislocations, length of follow-up, Hill-Sachs interval (HSI), Hill-Sachs depth (HSD), sport participation, number of anchors used for remplissage, and hand dominance. A subanalysis was undertaken after dividing patients into 2 groups (deficit <20% and ≥20%). Correlation between postoperative scores and ER deficit was performed.

RESULTS

All patients showed marked improvement in postoperative WOSI and ASES compared to preoperative by a mean difference of 46.2 ± 19.9 and 29.6 ± 14.4, respectively. Compared with the opposite side, the mean reduction in external rotation at the side (ERs), external rotation in abduction (ERa), forward flexion, and internal rotation in abduction were 21.9% ± 15.5%, 14.3% ± 9.9%, 2.7% ± 1.9%, and 10% ± 6.2%, respectively. Univariate regression analysis showed that shorter postoperative time, larger HSI, and the use of 2 anchors were significantly associated with increased limitation of both ERs and ERa. Participation in sports was significantly associated with less ERs limitation. HSD was significantly associated with increased ERa limitation. Multivariate regression analysis revealed that larger HSI was significantly associated with increases in both ERs and ERa limitation. Time of final follow-up and number of anchors were significantly associated with ERs and ERa limitation, respectively. ER deficit ≥20% was significantly associated with a lower number of preoperative dislocations, shorter time of final follow-up, HSI, and 2 anchors used in remplissage. No correlations exist between functional scores and ER deficit. There were no recurrent dislocations.

CONCLUSION

The results show that postoperative ER deficit improves over time. Risk factors for increased postoperative ER deficit are larger HSI and use of more than 1 anchor for capsulotenodesis. There was no correlation between functional scores and ER deficit.

Randomized Controlled Studies on Smartphone Applications and Wearable Devices for Postoperative Rehabilitation After Total Knee Arthroplasty: A Systematic Review

INTRODUCTION

Smartphone and wearable technologies are novel devices for monitoring postoperative mobility and recovery in total knee arthroplasty (TKA) patients. This systematic review of the highest-level evidence studies evaluated the advantages of these technologies in postoperative care, specifically focusing on 1) smartphone applications, 2) wearable devices, and 3) their combined use.

METHODS

A systematic literature search from July 26, 2015, to June 13, 2024, identified Level-1 and -2 published studies investigating smartphone applications and wearables for monitoring post-TKA recovery. A total of 3,131 studies were screened, with 31 meeting inclusion criteria: 18 focused on applications, eight on wearables, and five on both. Study quality was evaluated using the Coleman Methodology Scoring. Key metrics analyzed included patient satisfaction scores and adherences, functional outcomes, and pain scores, ranges of motion and gait analyses, and measurements and comparison tools.

RESULTS

Among the Level 1 and 2 publications, 17 of 18 studies on smartphone applications for postoperative recovery in TKA highlighted benefits including patient satisfaction, improved gait, optimized pain management through medication scheduling guidance, cost savings, and better functional outcomes. Among the eight studies focused solely on wearable technologies, seven exhibited positive outcomes and demonstrated accuracy in monitoring and effectiveness in gait and motion analysis. Additional benefits included improved recovery outcomes, enhanced return to function, cost reduction, and better pain management through patient interaction and guidance. The five studies, which integrated both applications and wearables, corroborated these findings, emphasizing patient satisfaction and overall mobility enhancement at three months post-surgery.

DISCUSSION

Smartphone applications and wearable devices offer enhancements in postoperative rehabilitation following TKA. Randomized trials validate their accuracy, effectiveness, and utility in this context. Improved adherence to care plans and medication schedules emerged as recurrent findings. These technologies and resultant data not only provide direct patient benefits, but also promise potential cost savings.

A ten-year prospective randomized trial comparing non-operative treatment to hook plate fixation for Rockwood III acromio-clavicular dislocation

BACKGROUND

Despite new modern surgical techniques, no short-term functional differences have been demonstrated between operative and non-operative treatment for acute acromio-clavicular (AC) dislocations Rockwood III-V. Few studies describe the long-term clinical and radiological results of these lesions. We aim to compare the one- and ten-year outcome of patients either treated non-operatively or with hook plate fixation for Rockwood III AC lesions.

HYPOTHESIS

Non-operative treatment is not inferior to surgical treatment at short and long-term follow-up when considering patient function and radiological degenerative changes.

PATIENTS AND METHODS

Prospective randomized trial including 56 consecutive patients aged between 18 and 60, admitted to a level one trauma center for an acute Rockwood III AC joint dislocation. Patients were randomized to two groups: non-operative or surgical treatment with hook plate. Outcome measures were obtained by an independent examiner and included Constant score, DASH score, complications, and radiological results at one and minimum ten years (last visit delayed due to COVID-19 pandemia). Data analysis with a 5% alpha error.

RESULTS

We observed no difference between the two groups for the Constant score at one year (non-operative 93.3 ± 7.4 vs surgical 92.7 ± 6.7, p = 0,41) and ten years (93.3 ± 10 vs 98.2 ± 5.2, p = 0,08). Similar results for all other clinical outcomes were censed. The reoperation rate was higher in the surgical group (88.5 vs 3.3%, p < 0,01), but consisted of hardware removal in most cases. Radiological degenerative changes were present in both groups at ten years (non-operative 33.3% vs surgical 50%, p = 0,24).

DISCUSSION

This study confirmed that non-operative treatment was not inferior to surgical treatment with a hook plate for acute Rockwood III AC joint lesion at both short and long-term follow-up periods. Patients treated non-operatively achieved very high clinical scores, nearly equivalent to normal function. Further research should identify the patient-specific risk factors associated with the rare cases of failed non-operative treatment.

LEVEL OF EVIDENCE

I; randomized controlled study, therapeutic.

Patient-reported outcomes, postoperative pain and pain relief after day case surgery (POPPY): methodology for a prospective, multicentre observational study

BACKGROUND

In the UK, approximately 70% of surgical procedures are undertaken as day-cases. Little information exists about recovery from day-case surgery, yet international data highlights patients are at risk of developing significant longer-term health problems including chronic post-surgical pain and persistent postoperative opioid use. The Patient-reported Outcomes, Postoperative Pain and pain relief after daY case surgery (POPPY) study was a national prospective multicentre observational study, measuring short- and longer-term patient-reported outcomes, postoperative pain and pain relief after day-case surgery.

METHODS

This was a collaborative project led by resident anaesthetists under the Research and Audit Federation of Trainees umbrella. Adult day-case surgical patients were recruited on the day of surgery. Baseline data including patient characteristics; procedure details; pre-operative analgesic use; pre-existing pain; and quality of life scores were recorded. Patients were followed up through automated short message service messages. Short-term (postoperative days 1, 3 and 7) outcomes included: quality of recovery; pain severity; impact of pain on function; and analgesic use. Longer-term outcomes (postoperative day 97) included: quality of life; analgesic use; incidence of chronic post-surgical pain; and incidence persistent postoperative opioid use. Additional outcomes were completed by those patients with chronic post-surgical pain and persistent postoperative opioid use, with 30 patients recruited to a qualitative semi-structured interview study exploring postoperative expectations, recovery, postoperative pain and opioid use.

RESULTS

An embedded pilot study at four sites recruited 129 patients. Responses to the automated short message service were gained from 129 patients (100%) at day 1; 116 (89.9%) at day 3; 108 (83.7%) at day 7; and 77 (59.7%) at day 97 postoperatively. The pilot enabled refinement of the methods and processes before the national roll out.

CONCLUSION

This paper outlines the methods for the POPPY study, the largest UK multicentre prospective observational study considering short- and longer-term outcomes following day-case surgery.

Surgeons consider Rockwood classification the most important factor for decision-making in acute, high-grade acromioclavicular dislocations

Purpose

The aim of this study is to investigate the influence of patient-specific factors, including age, lifestyle considerations as well as the extent of injury according to the Rockwood classification (RW), on the surgeon's decision-making in the choice between operative and nonoperative treatment for acute, high-grade acromioclavicular (AC) joint dislocations.

Methods

Orthopaedic and trauma surgeons were requested to complete an online questionnaire consisting of closed and open questions regarding the treatment of acute, high-grade AC joint dislocations and 24 fictive clinical scenarios.

Results

A total of 133 answered questionnaires were collected. 27 different nationalities from five continents were represented. The included participants had a median experience of 12 years (interquartile range: 2-41). Overall, the treatment option for surgery (answer: YES) was chosen in 2426 answers (76% of cases) compared to 'NO' in 766 (24% of cases). RW classification was considered the most important factor influencing surgical decision-making for most surgeons (69%). Two thirds of the participants answered that smoking does not impact their decision towards surgery and as to the influence of body mass index (BMI) on decision-making, half of the respondents would not alter their preferred treatment based on BMI. Finally, there were no significant differences in decision-making regarding the influence of the participant's demographics.

Conclusion

This study highlights that RW classification is the most important factor to consider in the surgeon's decision-making between operative and nonoperative treatment in acute, high-grade AC joint dislocations. Participants preferred operative treatment over nonoperative treatment in acute, high-grade AC joint dislocation in 76% of case scenarios, increasing up to 90% when RW Grade III lesions were not taken into account. These findings contrast with recent studies reporting good functional outcomes of conservatively treated acute, high-grade AC injuries and highlight the need to bridge the gap between evidence and practice.

Level of Evidence

Level V.

Protocol for the Catheter-Related Early Thromboprophylaxis With Enoxaparin (CRETE) Studies

OBJECTIVES

In post hoc analyses of our previous phase 2b Bayesian randomized clinical trial (RCT), prophylaxis with enoxaparin reduced central venous catheter (CVC)-associated deep venous thrombosis (CADVT) in critically ill older children but not in infants. The goal of the Catheter-Related Early Thromboprophylaxis with Enoxaparin (CRETE) Studies is to investigate this newly identified age-dependent heterogeneity in the efficacy of prophylaxis with enoxaparin against CADVT in critically ill children.

DESIGN

Two parallel, multicenter Bayesian superiority explanatory RCTs, that is, phase 3 for older children and phase 2b for infants, and an exploratory mechanistic nested case-control study (Trial Registration ClinicalTrials.gov NCT04924322, June 7, 2021).

SETTING

At least 15 PICUs across the United States.

PATIENTS

Older children 1-17 years old ( n = 90) and infants older than 36 weeks corrected gestational age younger than 1 year old ( n = 168) admitted to the PICU with an untunneled CVC inserted in the prior 24 hours. Subjects with or at high risk of clinically relevant bleeding will be excluded.

INTERVENTIONS

Prophylactic dose of enoxaparin starting at 0.5 mg/kg then adjusted to anti-Xa range of 0.2-0.5 international units (IU)/mL for older children and therapeutic dose of enoxaparin starting at 1.5 mg/kg then adjusted to anti-Xa range of greater than 0.5-1.0 IU/mL or 0.2-0.5 IU/mL for infants while CVC is in situ.

MEASUREMENTS AND MAIN RESULTS

Randomization is 2:1 to enoxaparin or usual care (no enoxaparin) for older children and 1:1:1 to either of 2 anti-Xa ranges of enoxaparin or usual care for infants. Ultrasonography will be performed after removal of CVC to assess for CADVT. Subjects will be monitored for bleeding. Platelet poor plasma will be analyzed for markers of thrombin generation. Samples from subjects with CADVT will be counter-matched 1:1 to subjects without CADVT from the opposite trial arm. Institutional Review Board approved the "CRETE Studies" on July 1, 2021. Enrollment is ongoing with planned completion in July 2025 for older children and July 2026 for infants.

Superior suspensory complex of the shoulder reconstruction for acute and chronic acromioclavicular joint dislocations: the Queensland Unit for Advanced Shoulder Research 3-tunnel technique

Background

Management of acromioclavicular joint (ACJ) injuries have wide variety of classification systems, surgical indications and operative techniques. Our study describes the Queensland Unit for Advanced Shoulder Research (QUASR) 3-Tunnel Technique with Ligament Augmentation and Reconstruction System (LARS; Surgical Implants and Devices, Arc sur Tille, France) artificial ligament to reconstruct the superior shoulder suspensory complex in acute, chronic, and revision ACJ dislocations and lateral clavicle fractures.

Methods

Our prospective cohort series of patients undergoing the QUASR 3-Tunnel Technique using LARS artificial ligament. This technique reconstructs the superior shoulder suspensory complex using 2 4-mm clavicle tunnels, 1 acromion tunnel, and is arthroscopically assisted to pass the artificial ligament under the coracoid. The ligament is secured with braided composite sutures and no interference screw is used. Preoperative and postoperative functional outcome scores were compared in patients with minimum 12-months follow-up.

Results

Of 26 patients in this series, 7 (27%) were operated within 4 weeks of injury, 2 (8%) were revision cases, and 6 (23%) were lateral clavicle fractures. Mean time to surgery was 14 weeks (2-650). Mean postoperative scores with associated 95% confidence interval were Specific Acromioclavicular Score 87.38 (confidence interval 75.38-99.37), American Shoulder and Elbow Surgeons score 94.60 (87.85-101.35), Constant 79.47 (71.87-87.07), simple shoulder test 85.44 (72.34-98.54) and visual analog score 0.50 (-0.15 to 1.15). There were 2 infections and 1 atraumatic loss of reduction; however, there were no tunnel fractures.

Conclusion

The QUASR 3-Tunnel Technique with LARS artificial ligament is a safe and efficient technique for both acute and chronic ACJ reconstruction, lateral clavicle fractures with coracoclavicular ligament disruption and complex revision cases with favorable outcomes at the mid-term follow-up.

Clinical results of carpal tunnel Re-release revision surgery and synovial wrap for recurrent carpal tunnel syndrome

Introduction

Carpal tunnel syndrome is a challenging condition when conventional carpal tunnel revision surgery fails to alleviate symptoms. This study aims to assess the outcomes of combining carpal tunnel revision surgery with a synovial wrap for cases of recurrent carpal tunnel syndrome in patients who had adhered median nerve, with a minimum 1-year follow-up.

Patients and methods

A retrospective analysis was conducted on 10 patients (mean age: 73.7 years, nine females and one male) who underwent treatment for recurrent carpal tunnel syndrome. The approach involved carpal tunnel revision surgery coupled with a median nerve synovial wrap. Patients were followed up for a minimum of 1 year. The procedure involved harvesting a 3.5 cm × 4 cm section of the flexor synovial membrane with a distal ulnar pedicle, which was then wrapped around the adherent site of the median nerve. Physical assessments included the pain visual analogue scale (VAS), Tinel sign in the carpal tunnel, thenar muscle atrophy, the Semmes-Weinstein monofilament test (SW test), manual muscle test (MMT) as assessed on the 5-point British Medical Research Council Scale (5/5, normal; 0/5, absent), and the Disabilities of the Arm, Shoulder, and Hand (Quick DASH) questionnaire. The physical variables were compared before surgery and at final follow-up.

Results

All patients showed some improvement in SW test. The MMT for the abductor pollicis brevis showed significant improvement at final follow-up (3 for four patients, 4 for four patients, and 5 for two patients) compared to pre-surgery assessments (2 for six patients, 3 for two patients, and 4 for two patients). The mean VAS score and DASH score at final follow-up (13.0 ± 10.3, 19.3 ± 12.7, respectively) were significantly lower than those recorded before surgery (76.5 ± 11.1, 52.4 ± 17.1, respectively). The Tinel sign and the thenar muscle atrophy significantly improved from before surgery to final follow-up.

Conclusion

Carpal tunnel release with a synovial wrap demonstrated significant improvements in muscle strength, pain relief and function. The synovial wrap method is an effective procedure for treating recurrent carpal tunnel syndrome.

Special Issue "Working Group in Sports Medicine"

The Special Issue "Working Group in Sports Medicine" has been successfully concluded, offering significant contributions to the growing discourse on sports medicine as a dynamic and interdisciplinary field [...].

Acetabular osteophyte formation in dysplastic hip osteoarthritis

The growth of periacetabular osteophytes with developmental dysplasia of the hip (DDH) remains unclear. This study aimed to perform a three-dimensional assessment of periacetabular osteophytes and the effects of superiorization (SP) and lateralization (LT) of the femoral head on osteophyte formation. Female (n = 105) with unilateral hip osteoarthritis due to DDH who underwent total hip arthroplasty between 2016 and 2022 were included. The SP and LT of the femoral head were assessed using anteroposterior radiographs. We measured the periacetabular osteophyte using computed tomography. The correlation coefficient between SP or LT and the length of each osteophyte were investigated. Furthermore, multiple regression analyses with SP and LT as explanatory variables and each osteophyte as an objective variable were performed to evaluate the effect of SP and LT on osteophyte formation. The longest osteophyte was the anterior osteophyte (20.48 mm ± 11.8 mm). Acetabular osteophytes correlated with LT as follows: anterior (r = 0.55), posterosuperior (r = 0.51), and inferior (r = 0.48). Multiple regression analysis showed that all acetabular osteophytes were influenced by LT (p < 0.05 for all factors). Hip surgeons may need to be aware that cases with marked lateralization of the femoral head require treatment of the periacetabular osteophytes.